1. Co-researchers: Sue Hunter & Nicky Edelstyn
Implementing constraint induced movement therapy: a mixed methods study
Kathryn Jarvis
Thank you for inviting me to speak
Would like to take opportunity to talk about a mixed methods study looking at the implementation of CIMT
Co-researchers: Sue Hunter & Nicky Edelstyn

2. Background-what is it all about?
Constraint induced movement therapy (CIMT)
Core components:
Constraint of less affected UL
Training of more affected UL
CIMT intervention used to address hemiparesis
Involves 2 core components
Been around since early 90s
In late 90s the consultant I was working with went to a conference came back and asked why are we not using it?
When I started my PhD in 2008, questions still existed relating to implementation of CIMT
“Why are we not using it?”

3. CIMT a complex intervention…
Background
CIMT a complex intervention…
…therapeutic interventions encompassing a number of potentially interacting components
(Medical Research Council, 2008)

4. Developing and evaluating complex interventions
Feasibility/piloting
Evaluation
Implementation
Development
Development-some not undertaken eg core components
(Medical Research Council, 2008)

5. CIMT Context Feasibility/piloting Development Evaluation
Limited qualitative evidence
Which protocol?
Development
Animal studies
Active ingredients?
Evaluation
Systematic reviews of effectiveness
Implementation
Not part of routine practice
Feasibility & acceptability?
Facilitators & barriers?
Development-some not undertaken eg core components
(Medical Research Council, 2008)

6. Research Questions What did we set out to find out?
What are stroke survivors’ expectations, experiences and responses to receiving CIMT?
Is it feasible to provide CIMT protocols in a UK NHS sub-acute stroke service?

7. Study Design Screening measures Selection of protocol Interviews
Mood
Sensation
Resilience
Cognition
Selection of protocol
Outcome Measures
Grip strength
Wolf Motor Function Test (WMFT)
Nottingham Extended Activities of Daily Living Scale (NEADL)
Canadian Occupational Performance Measure (COPM)
Interviews
Pre-CIMT
Post-CIMT
Mixed method case study design
4 participants

8. Results: protocols selected
Number of Participants
Training
Constraint 3
3hrs
6 hrs 1
4hrs
90% of waking hours

9. Results: quantitative outcomes
Janet
Tina
Margaret
Tony
Post FU
WMFT
(functional score)
(performance time)
Grip
NEADL
COPM
(performance)
(satisfaction)

10. I want to be doing things again
…because you think to yourself, well I drive a car, I go there and there. And suddenly that all stops, you think to yourself, well, is there any point in doing this and going for that…I have no interest
Pre-CIMT
Tony
Post-CIMT
Tony
…I feel a lot better. I know that I am going somewhere, I mean I’m heading somewhere, you know. It’s just I want to be active and training and doing things again here, you know. It’s just I want to be active and training and doing things again
More around house
Considering driving

11. I’ve enjoyed coming back out
Post-CIMT
Janet
It gives me the will to want to get out and do the work now, whereas I w It gives me the will to want to get out and do the work now, whereas I wasn't really bothered. But I've enjoyed coming back
bothered. But I've enjoyed coming back out
It gives me the will to want to get out and do the work now, whereas I wasn't really bothered. But I've enjoyed coming back out
More household tasks
Playing/grooming dogs
Applying for jobs

12. It’s like a job Janet Tony
Well, just a job, like, it's made me get up more. Like, I'd most probably stay in bed 'til about three o'clock otherwise. I think that's why I'm brighter because I'm doing more, not only is my brain but my body is using more energy, isn't it?
Post-CIMT
Janet
Post-CIMT
Tony
...to get up in the morning, to go to work … And it was like a mechanism, you know that you work in the morning, that’s what you’ve got to do. You’ve got a purpose. It’s
More around house
Considering driving

13. Interpretation through MOHO
What I expected...
Focus on how occupations are performed
What I heard...
How CIMT impacted on how occupations were both motivated and patterned
Volition
Habituation
Performance

14. Training CIMT Hope Routine
What are the core components/active ingredients?
Constraint
Training
CIMT
Role of therapist
Hope
In addition there were qualitative findings that made me reflect on the active ingredients of CIMT
Context
Evidence
Routine

15. Implications for Practice
Stroke survivors selected, tolerated and benefitted from 3 hrs training and 3 additional hrs constraint
Evidenced protocols were feasible…but there are barriers to implementing these protocols into practice
Active ingredients of CIMT still need exploring
We need to consider the complexity of OT interventions when evaluating and implementing...
…mixed method studies rock
Mixed methods opened up more questions for future investigation
Who benefits most? Is it people with low mood/depression indicators

16. Final bits… Wouldn’t be possible without:
Participants: stroke survivors & therapists
Funders: Vreeburg Bursary & Constance Owens Trust
Reference:
Medical Research Council (2008) Developing and evaluating complex interventions: new guidance. London.
Contact: