1. 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

2. 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

3. 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

4. Introduction to Constraint Induced Movement Therapy CIMT

5. 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.

6. EXCITE Trial

7. 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

8. 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

9. 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

10. Choose CIMT tasks to match the Individual

11. 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

12. Creative Considerations for CIMT and modified mCIMT *Setting *Acuity *Length of Stay *Staffing *Support *Modifications *Home Program *Charge and Reimbursement *Legal and Ethical considerations

13. 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

14. 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

15. 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

16. 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

17. (Sterr, et al., 2002)

18. (Dettmers, et al., 2005) Does it need to be given 6 hours every day?

19. 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

20. 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

21. (Kleim et al, 2004) Cortical Map Reorganization Proximal Distal

22. Is there evidence that CIMT changes the brain? 2 most common methods: –Transcranial Magnetic Stimulation (TMS) –Functional Magnetic Resonance Imaging (fMRI)

23. 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

24. CIMT now Paired With other Therapies: * Drugs * Strengthening * Rhythm Cues

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

26. 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

27. 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