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Evidence-Based Medicine Comes to Neurorehabilitation Brain Rehabilitation Research Center: A VA Rehabilitation R&D Center of Excellence Malcolm Randall VAMC (151- A) 1601 S.W. Archer Road Gainesville, Florida 32608 352-374-6181 Fax 352-379-2332 www.va.gov/brrc
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Welcome Presenters: Stephen E. Nadeau, MD. Medical Director BRRC, Chief of Neurology Malcom Randal NF/SG VAMC University of Florida Neurology snadeau@ufl.edu Sandra E. Davis, Research P.T. BRRC University of Florida Physical Therapy sandra.davis2@va.gov Lorie G. Richards, OTR/L, PhD Research Scientist BRRC University of Florida Occupational Therapy lrichard@phhp.ufl.edu
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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
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Introduction to Constraint Induced Movement Therapy CIMT
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EXCITE TRIAL Wolf 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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EXCITE Trial
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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 al1999 Minimum 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 goal Example: reach - to grasp - to lift a glass – to drink Task Practice: Functionally based activities performed continuously 15-20 minutes or until the task is attained. Example: fix a sandwich & eat lunch More general feedback & graded progression To 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 & Quality Box and Blocks Fugl Meyer Wolf Motor Function Kinematics Actual Amount Use Test Accelerometry Quality of Motion QoL- SIS Caregiver Strain
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Compliance Measures Translational Package Morris,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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Constraint Induced Movement Therapy Developed to improve motor skill and to decrease learned non-use Injury Unsuccessful attempts to move Punishment (pain, can’t) Behavioral suppression Positive Reinforcement Compensatory behavior strengthened Compensatory Behavior patterns
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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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Page, et al., 2005 ACUTE STROKE Traditional therapy: Compensatory ADLs, ROM, strengthening, dexterity practice mCIMT – 1/2 hrs/d 3x/wk shaping, 5 hr/d mitt
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Dromerick, et al., 2009 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
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(Kleim et al, 2004) Cortical Map Reorganization Proximal Distal
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Is there evidence that CIMT changes the brain? 2 most common methods: –Transcranial Magnetic Stimulation (TMS) –Functional Magnetic Resonance Imaging (fMRI)
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Is there evidence that CIMT changes the brain? (Hamzei, et al., 2006) Participants with lesioned M1 and disturbed MEPs at baseline Participants with intact M1 and 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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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
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CE Credit For any questions about the monthly GRECC Audio Conference Series please contact Tim Foley at tim.foley@va.gov 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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