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Evidence-Based Medicine Comes to Neurorehabilitation

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Evidence based medicine comes to neurorehabilitation l.jpg

Evidence-Based Medicine Comes to Neurorehabilitation

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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]

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  • 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

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Introduction to Constraint Induced Movement TherapyCIMT

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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.

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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

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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

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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

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Choose CIMT tasks to match the Individual

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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

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Creative Considerations for CIMT and modified mCIMT

*Setting*Acuity*Length of Stay*Staffing*Support*Modifications*Home Program*Charge and Reimbursement*Legal and Ethical considerations

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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

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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

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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

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to move


(pain, can’t)









Constraint Induced Movement Therapy

  • Developed to improve motor skill and to decrease learned non-use


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(Sterr, et al., 2002)

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(Dettmers, et al., 2005)

Does it need to be given 6 hours every day?

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Traditional therapy: Compensatory ADLs, ROM, strengthening, dexterity practice

mCIMT – 1/2 hrs/d 3x/wk shaping, 5 hr/d mitt

Page, et al., 2005

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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

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Cortical Map Reorganization



(Kleim et al, 2004)

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Is there evidence that CIMT changes the brain?

2 most common methods:

Transcranial Magnetic Stimulation


Functional Magnetic Resonance Imaging (fMRI)

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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

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CIMT now Paired

  • With other Therapies:* Drugs* Strengthening* Rhythm Cues

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Remaining Questions

  • Future Research Needs to Demonstrate* What is the Best CIMT Schedule:- Distributed versus Massed- # of Hours- Maintenance of the gains

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  • 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

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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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