EvidenceBased Medicine Comes to Neurorehabilitation Brain Rehabilitation Research

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

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. davis 2@va. gov Lorie G. Richards, OTR/L, Ph. D Research Scientist BRRC University of Florida Occupational Therapy lrichard@phhp. ufl. edu

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

Introduction to Constraint Induced Movement Therapy CIMT

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.

EXCITE Trial

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 al 1999 Minimum Motor Criteria: Active extension must be repeated 3 x 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 • 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? • 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

Choose CIMT tasks to match the Individual

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

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 Qo. L- SIS Caregiver Strain

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

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 Therapy • Developed to improve motor skill and to decrease learned non-use Injury Compensatory Behavior patterns Unsuccessful attempts to move Positive Reinforcement Punishment (pain, can’t) Behavioral suppression Compensatory behavior strengthened

(Sterr, et al. , 2002)

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

ACUTE STROKE Traditional therapy: Compensatory ADLs, ROM, strengthening, dexterity practice m. CIMT – 1/2 hrs/d 3 x/wk shaping, 5 hr/d mitt Page, et al. , 2005

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 Proximal Distal (Kleim et al, 2004)

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

Is there evidence that CIMT changes the brain? (Hamzei, et al. , 2006) Participants with intact M 1 and MEPs at baseline Participants with lesioned M 1 and disturbed MEPs at baseline

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

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

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 • 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