Examining the use of constraint-induced movement therapy in canadian neurological occupational and physical therapy

Interventions to Promote Bimanual Activities and Participation in Daily Life Activities in Children with Cerebral Palsy: A Scoping Review

AIMS

To identify rehabilitation interventions and outcome measures that target bimanual activities and autonomy in activities of daily living (ADLs) in children with cerebral palsy.

METHODS

This scoping review followed the Arksey and O'Malley framework. The literature search was conducted in five medical databases. Inclusion criteria were studies of children with cerebral palsy that delivered rehabilitation interventions targeting upper limb function and used valid outcome measures assessing bimanual activities or ADLs. The exclusion criteria were pharmacological or surgical interventions, reviews, expert opinions, protocols and qualitative studies. Two independent researchers screened titles/abstracts and full texts. Data related to the study participants, interventions, outcome measures and results were extracted.

RESULTS

Eighty-nine publications were included in this review. Out of the 17 interventions identified, the most frequent were constraint-induced movement therapy (n = 29), virtual reality (n = 22), hand-arm bimanual intensive training (n = 12), bimanual intensive training (n = 11) and action observation (n = 6). All five interventions showed significant improvements on bimanual function, whereas all but action observation showed improvements in autonomy in ADLs. We identified 15 outcome measures capturing bimanual activities and 6 capturing autonomy in ADLs.

CONCLUSION

This scoping review provides essential information for the improvement of rehabilitation interventions for children with cerebral palsy.

Effectiveness of modified constraint-induced movement therapy on upper limb function of stroke survivors in inpatient hospital settings: a systematic review and meta-analysis

PURPOSE

To synthesise evidence on the effectiveness of modified constraint-induced movement therapy on upper limb function in stroke survivors within inpatient hospital settings.

METHODS

A systematic review was pre-registered in PROSPERO (CRD42023421715b) and searched six databases (EMBASE, AMED, MEDLINE, CINAHL, Cochrane Library, OTseeker) up to November 2024.

Articles included adults with stroke undergoing modified constraint-induced movement therapy in inpatient hospital settings. Article quality was assessed using the Physiotherapy Evidence Database (PEDro) scale. Homogenous data was synthesised in a meta-analysis and assessed using the Grading of Recommendation, Assessment, Development and Evaluation (GRADE) approach. Remaining data was synthesised descriptively.

RESULTS

Ten randomised controlled trials (364 participants) were included. Four (191 participants) were analysed in a meta-analysis, showing modified constraint-induced movement therapy improved upper limb function (standardised mean difference (SMD) 0.94, 95% confidence interval (CI) 0.40 to 1.48), based on low-quality evidence. Five articles included follow-up, with two (90 participants) reporting sustained improvements. Five articles assessed activities of daily living, with two (136 participants) reporting positive effects.

CONCLUSION

Modified constraint-induced movement therapy improves upper limb function in the acute and sub-acute stages of stroke recovery within inpatient hospital settings. Sustainability of improvements and the impact on activities of daily living remains uncertain.

Translating acceptability to sustained delivery: Clinician and manager perspectives on implementing modified constraint-induced movement therapy in an early-supported discharge rehabilitation service

BACKGROUND

Modified constraint-induced movement therapy (mCIMT) improves upper limb (UL) function after stroke. Despite up to one-third of stroke survivors being eligible, clinical uptake remains poor. To address this, a multi-modal behaviour change intervention was implemented across a large seven-site early-supported discharge (ESD) rehabilitation service. This study investigated the acceptability of mCIMT implementation within this ESD service and identified adaptations required for sustained delivery.

METHODS

This qualitative study was nested within a mixed-methods process evaluation of mCIMT implementation. Four focus groups (n = 24) comprising therapists (two groups), therapy assistants (one group), and allied health managers (one group) were conducted. Data were analysed using reflexive thematic analysis and mapped to the Theoretical Domains Framework (TDF).

CONSUMER AND COMMUNITY INVOLVEMENT

Consumers were not directly involved in this study; however, lived experience research partners have helped shape the larger mixed-methods implementation study.

FINDINGS

Four themes were generated and mapped to the TDF. Factors related to acceptability included interdisciplinary practice in sharing workloads (belief about capabilities), practice opportunities across a range of UL presentations (skills), clinician attitudes influencing patient engagement (optimism), time constraints (belief about consequences), and cognitive overload from multiple systems and processes (memory, attention, and decision-making processes). Factors facilitating sustained delivery included improving stroke survivor education (knowledge), sharing success stories across teams (reinforcement), manager facilitation (social/professional role and identity), and the perception that the ESD setting was optimal for mCIMT delivery (social influences).

CONCLUSION

mCIMT was acceptable in the ESD service, with clinicians feeling a responsibility to provide it. Key adaptations for sustained delivery included ongoing training, resource adaptation, and enhanced patient and carer engagement. Successful implementation and sustained delivery of mCIMT in the ESD service could enhance UL function and reduce the burden of care for potentially hundreds of stroke survivors and their carers.

PLAIN LANGUAGE SUMMARY

Modified constraint-induced movement therapy (mCIMT) helps improve arm movement after a stroke. However, many stroke survivors do not get this therapy. To fix this, we started a program in a large home-based rehabilitation service. This study looked at how well mCIMT could fit into this service. We also wanted to know what changes were needed to make sure it was regularly provided. We held four group discussions with therapists, therapy assistants, and health managers. A total of 24 people took part. From these discussions, we found several important points. Therapists needed to work together as a team. They also needed to practice mCIMT to get better at delivering it. Therapists having a positive attitude would encourage more stroke survivors to take part. For long-term success, stroke survivors need better education about mCIMT. Managers need to encourage therapists to provide mCIMT. The rehabilitation service should also share their success stories about this therapy to encourage therapists to deliver it and stroke survivors to ask for it. Therapists enjoyed delivering mCIMT in the rehabilitation service. It worked better than other therapies to improve a stroke survivor's arm function. Because of this, they also felt it was their duty to offer mCIMT. Having ongoing training and better resources would help keep mCIMT going. If mCIMT can be provided regularly in this service, it could lead to better arm function and less care needed for many stroke survivors and their carers.

Nineteen years of constraint-induced movement therapy: A practice-based, retrospective, observational study

BACKGROUND

Despite its proven efficacy and recommendations in national clinical guidelines, Constraint-Induced Movement Therapy (CIMT) is rarely implemented, sustained over time, nor evaluated in regular clinical practice.

AIMS

To evaluate the effects of CIMT that has been delivered in a clinical setting over a sustained period of time, and to study the relationship between patient characteristics and outcomes.

MATERIAL AND METHODS

This practice-based, retrospective, observational study utilised a before-and-after design. Eighty-seven patients with neurological disorders participated. Outcome measures, including the Patient-Specific Functional Scale (PSFS), Motor Activity Log, the Box and Block Test, BL Motor Assessment, active range of motion and modified Ashworth Scale, were recorded before treatment, after treatment, and six months post-intervention.

RESULTS

Significant improvements with effect sizes r = 0.24-0.61 were observed across all variables at follow up, with 71% of patients demonstrating clinically relevant progress in activity performance (PSFS). Time since injury, rather than age, sex, diagnosis or initial function, influenced outcomes.

CONCLUSIONS

CIMT in a clinical setting is effective for a wide range of patients, and manageable to deliver over a sustained period of time.

SIGNIFICANCE

Therapists engaged in neurological rehabilitation should consider this evidence-based method to enhance patients' activity performance in areas of importance.

Pediatric Constraint-Induced Movement Therapy: Current Practices and Implementation Barriers

Hemiplegic Cerebral Palsy (CP) is the most common pediatric motor disability, characterized by unilateral motor weakness. Pediatric Constraint-Induced Movement Therapy (pCIMT) improves affected extremity function but faces variable clinical integration. This study assessed U.S. providers' awareness and use of pCIMT, educational practices, and barriers to broader implementation for more eligible children. Overall, 148 providers specializing in pediatric stroke or hemiplegic CP completed surveys on pCIMT familiarity, implementation challenges, and support for evidence-based practices (EBP). Participants indicated high pCIMT competency. Although 75% reported regional pCIMT availability, only 14% indicated that pCIMT is accessible to all children who could benefit. Reported barriers included therapist and family availability, cost, and institutional limitations. Despite valuing EBP, participants reported minimal workplace support for its use. The study revealed significant barriers to pCIMT accessibility and implementation. Further research is needed to address these challenges and improve clinical adoption of EBP, such as pCIMT.

Implementing constraint-induced movement therapy into practice in sub-acute stroke: Experiences and perceptions of stroke survivors and therapists

Introduction

Constraint-induced movement therapy has been shown to be effective in a sub-group of sub-acute stroke survivors but has not been widely implemented in the United Kingdom. This study explored therapist and stroke survivor perceptions and experiences of constraint-induced movement therapy and explored the non-agreement (incongruence) and agreement (congruence) of these perspectives.

Method

Consenting occupational therapists (n = 3) and physiotherapist (n = 5) participated in a focus group discussion. Four-stroke survivors undertook pre- and post-constraint-induced movement therapy interviews. Stroke survivor participants selected and undertook an evidence-based constraint-induced movement therapy protocol. Focus groups and interview audio recordings were independently analysed thematically. Therapist and stroke survivor views were subsequently synthesised using meta-ethnographic principles.

Findings

Four over-arching themes were identified: motivation and determination to participate in constraint-induced movement therapy; who benefits; which protocol; making constraint-induced movement therapy feasible. The final over-arching theme comprised five sub-themes: fatigue and sleep; pain; transport; need for support; training, support and mentorship for therapists. Stroke survivors and therapists held contrasting views on three themes.

Conclusion

Participating stroke survivors successfully undertook a self-selected, evidence-based constraint-induced movement therapy protocol. The identified enablers and barriers should inform future constraint-induced movement therapy protocol development. The contrasting views held by therapists and stroke survivors reinforce the need for collaborative communication and opportunity for choice during constraint-induced movement therapy.

Development of a behaviour change intervention to increase the delivery of upper limb constraint-induced movement therapy programs to people with stroke and traumatic brain injury

PURPOSE

Constraint-induced movement therapy (CIMT) is a recommended intervention for arm recovery after acquired brain injury but is underutilised in practice. The purpose of this study is to describe the development of a behaviour change intervention targeted at therapists, to increase delivery of CIMT.

METHODS

A theoretically-informed approach for designing behaviour change interventions was used including identification of which behaviours needed to change (Step 1), barriers and enablers that needed to be addressed (Step 2), and intervention components to target those barriers and enablers (Step 3). Data collection methods included file audits and therapist interviews. Quantitative data (file audits) were analysed using descriptive statistics. Qualitative data analysis (interviews) was informed by the Theoretical Domains Framework (TDF) and Behaviour Change Wheel.

RESULTS

Fifty two occupational therapists, physiotherapists and allied health assistants participated in focus groups (n = 7) or individual interviews (n = 6). Key barriers (n = 20) and enablers (n = 10) were identified across 11 domains of the TDF and perceived to influence CIMT implementation. The subsequent behaviour change intervention included training workshops, nominated team champions, community of practice meetings, three-monthly file audit feedback cycles, poster reminders and drop-in support during CIMT.

CONCLUSION

This study describes the development of a behaviour change intervention to increase CIMT delivery by clinicians.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, Trial ID: ACTRN12617001147370.

Is non-invasive neuromodulation a viable technique to improve neuroplasticity in individuals with acquired brain injury? A review

Objective

This study aimed to explore and evaluate the efficacy of non-invasive brain stimulation (NIBS) as a standalone or coupled intervention and understand its mechanisms to produce positive alterations in neuroplasticity and behavioral outcomes after acquired brain injury (ABI).

Data sources

Cochrane Library, Web of Science, PubMed, and Google Scholar databases were searched from January 2013 to January 2024.

Study selection

Using the PICO framework, transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS) randomized controlled trials (RCTs), retrospective, pilot, open-label, and observational large group and single-participant case studies were included. Two authors reviewed articles according to pre-established inclusion criteria.

Data extraction

Data related to participant and intervention characteristics, mechanisms of change, methods, and outcomes were extracted by two authors. The two authors performed quality assessments using SORT.

Results

Twenty-two studies involving 657 participants diagnosed with ABIs were included. Two studies reported that NIBS was ineffective in producing positive alterations or behavioral outcomes. Twenty studies reported at least one, or a combination of, positively altered neuroplasticity and improved neuropsychological, neuropsychiatric, motor, or somatic symptoms. Twenty-eight current articles between 2020 and 2024 have been studied to elucidate potential mechanisms of change related to NIBS and other mediating or confounding variables.

Discussion

tDCS and TMS may be efficacious as standalone interventions or coupled with neurorehabilitation therapies to positively alter maladaptive brain physiology and improve behavioral symptomology resulting from ABI. Based on postintervention and follow-up results, evidence suggests NIBS may offer a direct or mediatory contribution to improving behavioral outcomes post-ABI.

Conclusion

More research is needed to better understand the extent of rTMS and tDCS application in affecting changes in symptoms after ABI.

Requirements for home-based upper extremity rehabilitation using wearable motion sensors for stroke patients: a user-centred approach

PURPOSE

Telerehabilitation systems have the potential to enable therapists to monitor and assist stroke patients in achieving high-intensity upper extremity exercise in the home environment. We adopted an iterative user-centred approach, including multiple data sources and meetings with end-users and stakeholders to define the user requirements for home-based upper extremity rehabilitation using wearable motion sensors for subacute stroke patients.

METHODS

We performed a requirement analysis consisting of the following steps: 1) context & groundwork; 2) eliciting requirements; 3) modelling & analysis; 4) agreeing requirements. During these steps, a pragmatic literature search, interviews and focus groups with stroke patients, physiotherapists and occupational therapists were performed. The results were systematically analysed and prioritised into "must-haves", "should-haves", and "could-haves".

RESULTS

We formulated 33 functional requirements: eighteen must-have requirements related to blended care (2), exercise principles (7), exercise delivery (3), exercise evaluation (4), and usability (2); ten should-haves; and five could-haves. Six movement components, including twelve exercises and five combination exercises, are required. For each exercise, appropriate exercise measures were defined.

CONCLUSION

This study provides an overview of functional requirements, required exercises, and required exercise measures for home-based upper extremity rehabilitation using wearable motion sensors for stroke patients, which can be used to develop home-based upper extremity rehabilitation interventions. Moreover, the comprehensive and systematic requirement analysis used in this study can be applied by other researchers and developers when extracting requirements for designing a system or intervention in a medical context.

Unlocking the restraint-Development of a behaviour change intervention to increase the provision of modified constraint-induced movement therapy in stroke rehabilitation

BACKGROUND

Strong evidence supports the provision of modified constraint-induced movement therapy (mCIMT) to improve upper limb function after stroke. A service audit identified that very few patients received mCIMT in a large subacute, early-supported discharge rehabilitation service. A behaviour change intervention was developed to increase the provision of mCIMT following an unsuccessful 'education only' attempt. This paper aims to systematically document the steps undertaken and to provide practical guidance to clinicians and rehabilitation services to implement this complex, yet effective, rehabilitation intervention.

METHODS

This clinician behaviour change intervention was developed over five stages and led by a working group of neurological experts (n = 3). Data collection methods included informal discussions with clinicians and an online survey (n = 35). The staged process included reflection on why the first attempt did not improve the provision of mCIMT (stage 1), mapping barriers and enablers to the Theoretical Domains Framework (TDF) and behaviour change wheel (BCW) to guide the behaviour change techniques (stages 2 and 3), developing a suitable mCIMT protocol (stage 4), and delivering the behaviour change intervention (stage 5).

RESULTS

Reflection among the working group identified the need for upskilling in mCIMT delivery and the use of a behaviour change framework to guide the implementation program. Key determinants of behaviour change operated within the TDF domains of knowledge, skills, environmental context and resources, social role and identity, and social influences. Following the development of a context-specific mCIMT protocol, the BCW guided the behaviour change intervention, which included education, training, persuasion, environmental restructuring, and modelling.

CONCLUSION

This paper provides an example of using the TDF and BCW to support the implementation of mCIMT in a large early-supported discharge service. It outlines the suite of behaviour change techniques used to influence clinician behaviour. The success of this behaviour change intervention will be explored in future research.

Delivering constraint-induced movement therapy in stroke rehabilitation requires informed stakeholders, sufficient resources and organisational buy-in: a mixed-methods systematic review

OBJECTIVE

To summarise and synthesise the qualitative literature relating to constraint-induced movement therapy (CIMT) among stroke survivors, carers, therapists and rehabilitation service managers.

DESIGN

Systematic review of qualitative studies. Quantitative studies using survey data were also included if they investigated perceptions and/or experiences related to CIMT.

DATA SOURCES

Cochrane Library, Medline, JBI, Emcare, Embase, PsycInfo, CINAHL, PEDro, OT Seeker and NICE from inception to January 2022.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently extracted data from the included studies and assessed comprehensiveness of reporting using established tools. Thematic synthesis was undertaken to synthesise findings for studies using focus groups and interviews. A summary of themes from quantitative studies using survey data was compiled to complement the qualitative synthesis.

RESULTS

Searches yielded 1,450 titles after removal of duplicates; 60 full-text articles were assessed for eligibility and 14 studies were included (1,570 total participants). Thematic synthesis identified nine descriptive themes from which four analytical themes were developed: CIMT is challenging but support at all levels helps; therapists need the know-how, resources and staffing; CIMT is different to other interventions, and there are positives and negatives to this; and functional outcomes do not always meet high expectations. Quantitative survey themes included: knowledge, skills and confidence in delivering CIMT programs; patient factors; and institutional factors.

CONCLUSIONS

This review identified several determinants of implementation related to CIMT. Rehabilitation therapists need to develop their knowledge and skills to deliver CIMT, engage with organisational leaders, and develop CIMT protocols to fit the local clinical context in order to sustainably deliver CIMT in stroke rehabilitation services. Stroke survivors and carers require improved education to increase their engagement and participation. After addressing these determinants, future research should evaluate population-level outcomes and policy-level implementation in establishing CIMT as global standard rehabilitation practice.

REGISTRATION

CRD42021237757.

Adult experiences of constraint-induced movement therapy programmes: a qualitative study using the Theoretical Domains Framework and Capability, Opportunity, Motivation - Behaviour system

AIM

To explore the experiences of adults who completed a constraint-induced movement therapy (CIMT) programme, and the barriers and enablers to their participation.

METHODS

Qualitative design using semi-structured interviews. Stroke and brain injury survivors (n = 45) who had completed CIMT as part of their usual rehabilitation were interviewed 1 month post-CIMT. Interviews were audio-recorded, transcribed and imported into Nvivo for analysis. Inductive coding was used to identify initial themes. Themes were then deductively mapped to the Capability, Opportunity, Motivation - Behaviour system, a behaviour change model, to identify barriers and enablers to CIMT programme adherence and engagement.

RESULTS

Enablers influencing participation included being provided with education about the programme (Capability - psychological), seeing improvements in arm function (Motivation - reflective), being committed to the programme (Motivation - reflective) and having strong social support from staff, family and allied health students (Opportunity - social). The structured programme was a motivator and offered a way to fill the time, particularly during inpatient rehabilitation (Opportunity - physical). Barriers to participation included experiencing physical and mental fatigue (Capability - physical) and frustration early in the CIMT programme (Motivation - automatic), and finding exercises boring and repetitive (Motivation - automatic).

CONCLUSION

Therapist provision of educational supports for CIMT participants and their families is important to maximise CIMT programme uptake. During CIMT delivery, we recommend the provision of positive feedback and coaching in alignment with CIMT principles, and the inclusion of social supports such as group-based programmes to enhance participant adherence.

Remote constraint induced therapy of the upper extremity (ReCITE): A feasibility study protocol

Background

Difficulty using the upper extremity in everyday activities is common after stroke. Constraint-induced movement therapy (CIMT) has been shown to be effective in both sub-acute and chronic phases of stroke recovery and is recommended in clinical practice guidelines for stroke internationally. Despite reports of equivalence of outcome when stroke rehabilitation interventions are delivered using telehealth, there has been limited evaluation of CIMT when using this mode of delivery. ReCITE will (a) evaluate the feasibility and acceptability of CIMT when delivered via telehealth to stroke survivors (TeleCIMT) and (b) explore therapists' experiences and use of an online support package inclusive of training, mentoring and resources to support TeleCIMT delivery in clinical practice.

Methods

A prospective single-group, single blinded, study design with embedded process evaluation will be conducted. The study will be conducted at three outpatient services in Sydney, Australia. A multi-faceted therapist support package, informed by the Capabilities, Opportunity, Motivation- Behaviour model (COM-B), will be used to support occupational therapists to implement TeleCIMT as part of routine care to stroke survivors. Each service will recruit 10 stroke survivor participants (n = 30) with mild to moderate upper extremity impairment. Upper extremity and quality of life outcomes of stroke survivor participants will be collected at baseline, post-intervention and at a 4 week follow-up appointment. Feasibility of TeleCIMT will be evaluated by assessing the number of stroke participants who complete 80% of intensive arm practice prescribed during their 3 week program (i.e., at least 24 h of intensive arm practice). Acceptability will be investigated through qualitative interviews and surveys with stroke survivors, supporter surveys and therapist focus groups. Qualitative interviews with therapists will provide additional data to explore their experiences and use of the online support package.

Discussion

The COVID-19 pandemic resulted in a rapid transition to delivering telehealth. The proposed study will investigate the feasibility and acceptability of delivering a complex intervention via telehealth to stroke survivors at home, and the support that therapists and patients require for delivery. The findings of the study will be used to inform whether a larger, randomized controlled trial is feasible.

Effects of constraint-induced movement therapy for the lower extremity among individuals post-stroke: A randomized controlled clinical trial

BACKGROUND: Stroke often leads to lower extremity impairments that significantly hinders functional recovery. OBJECTIVE: To investigate the effectiveness of constraint-induced movement therapy for the lower extremity (CIMT-LE) for improving balance and ambulation among people post-stroke. METHODS: A randomized controlled, single-blinded clinical trial was conducted. Participants were recruited and randomized into one of two groups: CIMT-LE group and control. Outcome measures were the Fugl-Meyer assessment of lower extremity, Berg balance scale, ten-meter walk test and six-minute walk test. Outcome measures were collected at baseline, following the conclusion of the therapeutic programs and after three months. RESULTS: 38 participants were enrolled in the study (19 in each group). No significant differences were found between groups at baseline. At the conclusion of therapeutic programs, both groups showed significant changes compared to baseline. However, changes seen in the CIMT-LE were clinically significant. Further, at three months following the conclusion of the program, the recorded improvements were retained by participants. CONCLUSION: A CIMT-LE program compared to an intensity-matched conventional program yielded significant clinical improvements among people post-stroke. These improvements were seen in lower extremity motor recovery, postural balance and gait speed. Furthermore, these improvements were retained three months following the conclusion of the therapeutic program.

Cost-Effectiveness of Constraint-Induced Movement Therapy Implementation in Neurorehabilitation: The ACTIveARM Project

BACKGROUND

Constraint-induced movement therapy (CIMT) is a recommended intervention for improving arm recovery following stroke and traumatic brain injury; however, delivery in practice remains rare.

PURPOSE

The aim of this study was to investigate the costs and cost effectiveness of CIMT delivery, and the use of a CIMT implementation package designed to improve CIMT uptake and delivery by therapists in Sydney, Australia.

METHODS

This economic evaluation was conducted with a subset of CIMT programmes (n = 20) delivered by neurological rehabilitation teams at five varied hospitals within a mixed methods implementation study (ACTIveARM). The costs of delivering the CIMT implementation package and publicly funded CIMT were calculated using a bottom-up approach. A cost-effectiveness analysis was conducted, using decision analytic modelling. We compared the uptake and outcomes of people who received CIMT from health services that had received a CIMT implementation package, with those receiving standard upper limb therapy. An Australian health care system perspective was used in the model, over a 3-week time horizon (the average timeframe of a CIMT programme). All costs were calculated in Australian dollars (AUD). Inputs were derived from the ACTIveARM study and relevant literature. The Action Research Arm Test was used to measure arm outcomes. Sensitivity analyses assessed the impact of improving CIMT uptake, scale-up of the implementation package and resource adjustment, including a 'best-case' scenario analysis.

RESULTS

The total cost of delivering the implementation package to nine teams across five hospitals was $110,336.43 AUD over 18 months. The mean cost of delivering an individual CIMT programme was $1233.38 AUD per participant, and $936.03 AUD per participant for group-based programmes. The incremental cost-effectiveness ratio (ICER) of individual CIMT programmes was $8052 AUD per additional person achieving meaningful improvement in arm function, and $6045 AUD for group-based CIMT. The ICER was most sensitive to reductions in staffing costs. In the 'best-case' scenario, the ICER for both individual and group-based CIMT was $245 AUD per additional person gaining a meaningful change in function.

CONCLUSION

Therapists improved CIMT uptake and delivery with the support of an implementation package, however cost effectiveness was unclear.

CLINICAL TRIAL REGISTRATION

https://anzctr.org.au/Trial ID: ACTRN12617001147370.

Acceptability of constraint induced movement therapy: influence of perceived difficulty and expected treatment outcome

BACKGROUND

Constraint-Induced Movement (CI) Therapy has evidence of efficaciously rehabilitating upper-extremity hemiparesis after stroke. Yet, it is not widely used in the United States. One barrier appears to be the perception of its difficulty among stroke care consumers, as reported by two published studies in which the participants had little or no apparent direct exposure to CI Therapy.

OBJECTIVES

Assess the perception of difficulty of CI Therapy by individuals with chronic stroke who have actually undergone CI Therapy.

METHODS

A secondary analysis was conducted of data from two randomized controlled trials of CI Therapy. Participants had chronic, mild-to-moderate upper-extremity hemiparesis after stroke. The Motor Activity Log and Wolf Motor Function Test were used to measure motor function of the more-affected arm. A Patient Opinion Survey assessed participants' perception of difficulty and satisfaction with treatment.

RESULTS

The participants (N = 40) showed large improvements in motor function of their more-affected arm after treatment, p's <001. CI Therapy was perceived to be of only moderate difficulty by participants before treatment (mean = 4.4 out of 7). Perception of its difficulty decreased afterward (mean = 3.7, p = .002). Moreover, participants were highly satisfied with their outcomes (mean = 6.3 out of 7). Satisfaction was positively related to the improvements in more-affected arm use in everyday life, ΔR² = .3, p < .001.

CONCLUSIONS

Chronic stroke survivors who have actually had CI Therapy perceive it to be of only moderate difficulty and are highly satisfied. Negative views about its acceptability warrant reconsideration.

[Effectiveness of constraint-induced movement therapy in upper extremity rehabilitation in patients with cerebral palsy: A systematic review]

BACKGROUND AND OBJECTIVE

In hemiplegic cerebral palsy, learned non-use may appear. This phenomenon can be reversed by constraint-induced movement therapy in the healthy side. The aim of this article was to review the evidence of the effectiveness of this therapy on upper extremity functioning, the performance of activities of daily living and quality of life.

PATIENTS AND METHODS

We performed a systematic review between January and April 2019 in the PubMed, COCHRANE, PEDro and TRIPDATABASE databases. We included 14 clinical studies describing their characteristics.

RESULTS

Most of the studies found significant improvements compared with control groups. Only one article investigated quality of life.

CONCLUSIONS

Constraint-induced movement therapy seems to have positive effects in the motor rehabilitation of the upper extremity in patients with hemiplegic cerebral palsy. Further studies are needed to assess the individual factors of greatest influence in rehabilitation.

Upper Extremity Task-Specific Training: Manual Development and Implementation Research within Inpatient Rehabilitation

A structured program of manualization and implementation of neurologic upper extremity task-specific training was developed at an inpatient rehabilitation hospital. The study used the Consolidated Framework for Implementation Research and engaged 31 stakeholders in manual refinement and examination of barriers after a year of training and use. Occupational therapists, occupational therapy assistants, and clinical educators provided input for manual revisions until consensus was achieved on usability, applicability, and implementation. Practitioners reported barriers such as intervention complexity, insufficient idea sharing for implementation, and a lack of motivators outside of the organization. The results can inform future implementation research in occupational therapy.Supplemental data for this article is available online at https://doi.org/10.1080/07380577.2021.1938338 .

Canadian Platform for Trials in Noninvasive Brain Stimulation (CanStim) Consensus Recommendations for Repetitive Transcranial Magnetic Stimulation in Upper Extremity Motor Stroke Rehabilitation Trials

Objective. To develop consensus recommendations for the use of repetitive transcranial magnetic stimulation (rTMS) as an adjunct intervention for upper extremity motor recovery in stroke rehabilitation clinical trials. Participants. The Canadian Platform for Trials in Non-Invasive Brain Stimulation (CanStim) convened a multidisciplinary team of clinicians and researchers from institutions across Canada to form the CanStim Consensus Expert Working Group. Consensus Process. Four consensus themes were identified: (1) patient population, (2) rehabilitation interventions, (3) outcome measures, and (4) stimulation parameters. Theme leaders conducted comprehensive evidence reviews for each theme, and during a 2-day Consensus Meeting, the Expert Working Group used a weighted dot-voting consensus procedure to achieve consensus on recommendations for the use of rTMS as an adjunct intervention in motor stroke recovery rehabilitation clinical trials. Results. Based on best available evidence, consensus was achieved for recommendations identifying the target poststroke population, rehabilitation intervention, objective and subjective outcomes, and specific rTMS parameters for rehabilitation trials evaluating the efficacy of rTMS as an adjunct therapy for upper extremity motor stroke recovery. Conclusions. The establishment of the CanStim platform and development of these consensus recommendations is a first step toward the translation of noninvasive brain stimulation technologies from the laboratory to clinic to enhance stroke recovery.

Implementation and sustainability of upper limb constraint-induced movement therapy programs for adults with neurological conditions: an international qualitative study

Purpose

Constraint-induced movement therapy (CIMT) is an effective intervention for arm recovery following acquired brain injury; however, there is an evidence-practice gap between research and CIMT use in practice. The aim of this study was to identify individual, organisational and social factors enabling implementation and sustained delivery of CIMT programs internationally.

Design/methodology/approach

Descriptive qualitative design. Purposive sampling was used to recruit occupational therapists and physiotherapists with previous experience delivering CIMT. Semi- structured interviews were conducted, using an interview schedule informed by the Theoretical Domains Framework (TDF) to explore individual factors (such as knowledge, skills and beliefs), organisational factors (such as organisational culture and resources) and social factors (such as leadership) influencing CIMT implementation. Interviews were audio-recorded, transcribed and managed using NVivo. The TDF guided data analysis and identification of key influences on CIMT implementation and sustainability.

Findings

Eleven participants (n = 7 [63.6%] occupational therapists and n = 4 [36.4%] physiotherapists) were interviewed from six countries, working across public (n = 6, 54.6%) and private health (n = 5, 45.5%). Six key domains influenced CIMT implementation and sustainability. Clinicians needed knowledge and opportunities to apply their skills, and confidence in their ability to implement CIMT. Within their workplace, supportive social influences (including broader team support), the environmental context (including organisational culture and resources) and reinforcement from seeing positive outcomes contributed to implementation and sustainability. Other important influences included community demand and tailoring of programs to meet individual needs.

Originality/value

This is the first study to examine therapists' experiences of CIMT implementation and sustainability across multiple countries. Factors related to capacity building, social and organisational support and resources enabled CIMT program implementation and ongoing sustainability. These findings can be used to design behaviour change interventions to support CIMT use in practice.

Exploration of barriers and enablers for evidence-based interventions for upper limb rehabilitation following a stroke: Use of Constraint Induced Movement Therapy and Robot Assisted Therapy in NHS Scotland

Introduction

The routine use of evidence-based upper limb rehabilitation interventions after stroke has the potential to improve function and increase independence. Two such interventions are Constraint Induced Movement Therapy and Robot Assisted Therapy. Despite evidence to support both interventions, their use within the National Health Service appears, anecdotally, to be low. We sought to understand user perceptions in order to explain low uptake in clinical practice.

Methods

A combination of a cross-sectional online survey with therapists and semi-structured interviews with stroke patients was used to explore uptake and user opinions on the benefits, enablers and barriers to each intervention.

Findings

The therapists surveyed reported low use of Constraint Induced Movement Therapy and Robot Assisted Therapy in clinical practice within the Scottish National Health Service. Barriers identified by therapists were inadequate staffing, and a lack of training and resources. Interviews with stroke patients identified themes that may help us to understand the acceptability of each intervention, such as the impact of motivation.

Conclusion

Barriers to the uptake of Constraint Induced Movement Therapy and Robot Assisted Therapy within the clinical setting were found to be similar. Further qualitative research should be completed in order to help us understand the role patient motivation plays in uptake.

Structuring community-based adapted dance programs for persons post-stroke: a qualitative study

PURPOSE

Dance improves physical, psychosocial, and cognitive function, while increasing community participation among community-dwelling individuals post-stroke. Yet little is known about how to structure community-based dance classes to optimize benefits and participation. This study aims to gain stakeholders' perspectives about how to optimally structure community-based dance classes for individuals with chronic stroke.

METHODS

A qualitative descriptive approach utilizing focus group methods was implemented. Two focus groups were undertaken with each of three stakeholder groups: persons post-stroke (n = 9), rehabilitation therapists (n = 6), and dance instructors (n = 8). Focus groups were audio-recorded and transcribed verbatim, providing the raw data. Analysis of the focus group transcripts were completed using the DEPICT model of collaborative qualitative analysis.

RESULTS

This study identified three main themes/topics requiring consideration when structuring community-based dance programs: the environment, flow of the class, and qualities of the dance instructor. The study findings highlight that the pedagogical skills and teaching philosophy of the dance instructor are integral for a successful dance program, as the dance instructor directly mediates both the environment and flow of classes.

CONCLUSION

Recommendations generated from our study can inform the development of community-based dance programs that are practical, optimize health benefits, and meet the needs and interests of people post-stroke.IMPLICATIONS FOR REHABILITATIONDance is an effective way to improve physical, psychosocial, and cognitive function for persons post-stroke while also promoting meaningful social relationships within the community.A dance instructor who is a skilled communicator and is willing to adapt to the needs of the class, is the most important factor for a successful dance class.Creating a safe and inviting environment for a dance program, includes both the physical and emotional aspects of environment facilitating individuals to create connections with others and feel more confident in themselves.The structure of a dance class, based on the abilities, interests, and goals of dancers, should include elements of predictability and variability to keep dancers progressing and motivated, and be two times a week for 3 months lasting 1-2 h.

Post-stroke motor recovery and cortical organization following Constraint-Induced Movement Therapies: a literature review

[Purpose] This review synthesizes findings from studies on two forms of Constraint-Induced Movement Therapies: the original Constraint-Induced Movement Therapy and the modified Constraint-Induced Movement Therapy, in adult stroke patients including the evidence, current limitations and future directions. [Methods] We critically reviewed studies evaluating the effectiveness of Constraint-Induced Movement Therapies in chronic stoke focusing on the functional (i.e. motor recovery) and the neural (i.e. cortical organization) levels. [Results] Constraint-Induced Movement Therapies seemed to improve the upper limb functional usage in chronic stoke with no reliable neurophysiological underlying mechanisms. The Motor Activity Log was the common outcome measuring motor recovery. The work that has been done on modified Constraint-Induced Movement Therapy was far less than the work done on the original Constraint-Induced Movement Therapy. [Conclusion] Evident lack of understanding of the association between changes in motor recovery and the underlying neural mechanisms in-terms of measures of assessing and defining functional recovery (i.e Motor Activity Log) that lacks sufficient sensitivity to characterize changes in movement strategies and thereby lack of distinction between recovery and behavioral compensation. Future studies should employ using kinematic metrics to quantify and explain the training-related changes in behavior following Constraint-Induced Movement Therapies in chronic stroke.

Constraint-induced movement therapy for upper limb recovery in adult neurorehabilitation: An international survey of current knowledge and experience

INTRODUCTION

Constraint-induced movement therapy (CIMT) is an effective intervention for upper limb recovery following stroke and traumatic brain injury. Despite strong evidence, the use of CIMT in practice is limited. The aim of this study was to investigate clinician knowledge and experience of delivering CIMT protocols internationally in neurorehabilitation.

METHODS

A cross-sectional survey was conducted online. The survey was distributed through occupational therapy and physiotherapy associations, neurological interest groups and list serves in 11 countries. Passive snowball sampling was used to recruit participants. Descriptive and inferential statistics were used for analysis.

RESULTS

Complete surveys were returned by 169 respondents (64.5% occupational therapists; 34.3% physiotherapists; 1.2% other). Most respondents were from the United Kingdom (36.1%), Australia (28.4%) and Denmark (7.7%). Most participants delivered CIMT to individuals (79.3%) rather than in groups. A modified version of CIMT was used most often (74.6%), with one hour sessions per day (30.2%), provided to stroke survivors (96.4%) and people with traumatic brain injury (37.3%). Most respondents (88.8%) used intensive graded practice as a component of a CIMT program, but only 43.2% reported using a mitt restraint for most waking hours, and only 38.5% used a transfer package.

CONCLUSION

These findings suggest that CIMT is being used globally but not always with fidelity to the original trials. A range of strategies are needed for improving clinicians' knowledge and skills to increase the frequency of program delivery and enhance program delivery with fidelity.

Effects of Number of Repetitions and Number of Hours of Shaping Practice during Constraint-Induced Movement Therapy: A Randomized Controlled Trial

Background

Constraint-induced movement therapy (CIMT) is effective in improving motor outcomes after stroke. However, its existing protocols are resource-intensive and difficult to implement. The aim of this study is to design an easier CIMT protocol using number of repetitions of shaping practice.

Method

The study design was randomized controlled trial. Participants within 4 weeks after stroke were recruited at Murtala Muhammad Specialist Hospital. They were randomly assigned to groups A, B, C, and D. Group A received 3 hours of traditional therapy. Groups B, C, and D received modified CIMT consisting of 3 hours of shaping practice per session, 300 repetitions of shaping practice in 3 sessions, and 600 repetitions of shaping practice in 3 sessions per day, respectively, and constraint for 90% of the waking hours. All treatment protocols were administered 5 times per week for 4 weeks. The primary outcome was measured using upper limb Fugl-Meyer assessment, while the secondary outcome was measured using motor activity log, Wolf Motor Function Test, and upper limb self-efficacy test at baseline, 2 weeks, and 4 weeks after intervention.

Result

There were 48 participants 4 weeks after intervention. The result showed that there was no significant difference between groups at baseline (p > 0.05). Within-group improvements attained minimal clinically important difference (MCID) in modified CIMT and 300 repetitions and 600 repetitions groups.

Conclusion

Number of repetitions of shaping practice significantly improved motor function, real-world arm use, and upper limb self-efficacy after stroke. Therefore, it seems to be a simple alternative for the use of number of hours.

Trial Registration

This trial is registered with Pan African Clinical Trial Registry (registration number: PACTR201610001828172) (date of registration: 21/10/2016).

Exercise Training Inhibits the Nogo-A/NgR1/Rho-A Signals in the Cortical Peri-infarct Area in Hypertensive Stroke Rats

OBJECTIVE

The aim of this study was to test the hypothesis that exercise training promotes motor recovery after stroke by facilitating axonal remodeling via inhibition of the Nogo-A/NgR1 and Rho-A pathway.

DESIGN

A distal middle cerebral artery occlusion model was generated in stroke-prone renovascular hypertensive rats. Stroke-prone renovascular hypertensive rats were randomly divided into a control group, an exercise training group, and a sham group. Motor function was measured using the grip strength test. Axon and myelin remodeling markers, growth-associated protein 43, myelin basic protein, Tau, and amyloid precursor protein were detected by immunofluorescence. The expression of Nogo-A, NgR1, and Rho-A was demonstrated by immunofluorescence and Western blotting in the peri-infarction area at 7, 14, 28, and 52 days after distal middle cerebral artery occlusion.

RESULTS

Grip strength was higher in the exercise training group (P < 0.05). Exercise training increased the expression of growth-associated protein 43, myelin basic protein (at 7, 14, and 28 days), and Tau (at 7 and 14 days), and decreased the expression of axonal damage amyloid precursor protein (at 7 and 14 days), compared with the control group. The protein levels of Nogo-A (at 7 and 14 days), NgR1 (at 7, 14, and 28 days), and Rho-A (at 14 and 28 days) were reduced after exercise training.

CONCLUSIONS

Exercise training promotes axonal recovery, which is associated with functional improvement after cerebral infarction. Down-regulation of the Nogo-A/NgR1/Rho-A may mediate the axonal remodeling induced by exercise training.

The practice of OTC counseling by community pharmacists in Parana, Brazil

BACKGROUND

In order to provide appropriate advice to the patient at the time of dispensing and over-the-counter (OTC) medication counseling, community pharmacists need access to current and reliable information about medicines. Brazilian pharmacists have assumed new functions such as prescribing medication, in a dependent model, based in protocols.

OBJECTIVE

To examine the practice of community pharmacists in a Brazilian State, focusing on OTC recommendation.

METHOD

A cross-sectional survey of community pharmacists in a state of Brazil was conducted from October 2013 to January 2014, with data collection through a pre-piloted self-administered anonymous survey via Survey Monkey(®) platform. Following ethical approval, the online instrument was sent to 8,885 pharmacists registered in Parana State, Brazil, focusing on professionals working in community pharmacies. The questionnaire assessed the community pharmacy setting, the search for information, the knowledge of the evidence-based practice, the important factors to consider when recommending an OTC medicine, and the pharmacist prescribing. Responses were imported into SPSS(®) (version 22.0) for analysis. Nonparametric tests were used to assess the association between responses and demographic information with a significance level less than 5% (p<0.05).

RESULTS

Of the pharmacists, 97.4% dispensed medications and counseled patients for a median of six hours per day. Product's efficacy (97%) and adverse effects (62.3%) were the most important factors taken into account when counseling a nonprescription medicine. Few pharmacists knew the meaning of terms related to evidence-based health. Most respondents agreed that pharmacists have the necessary training to prescribe.

CONCLUSION

Over-the-counter medication counseling is a daily practice among Brazilian pharmacists. Learning needs exist for community pharmacists in relation to evidence-based practice. Thus, sources of information with good evidence could be used daily by community pharmacists, especially as regards nonprescription medication counseling.

It takes two: noninvasive brain stimulation combined with neurorehabilitation

The goal of postacute neurorehabilitation is to maximize patient function, ideally by using surviving brain and central nervous system tissue when possible. However, the structures incorporated into neurorehabilitative approaches often differ from this target, which may explain why the efficacy of conventional clinical treatments targeting neurologic impairment varies widely. Noninvasive brain stimulation (eg, transcranial magnetic stimulation [TMS], transcranial direct current stimulation [tDCS]) offers the possibility of directly targeting brain structures to facilitate or inhibit their activity to steer neural plasticity in recovery and measure neuronal output and interactions for evaluating progress. The latest advances as stereotactic navigation and electric field modeling are enabling more precise targeting of patient's residual structures in diagnosis and therapy. Given its promise, this supplement illustrates the wide-ranging significance of TMS and tDCS in neurorehabilitation, including in stroke, pediatrics, traumatic brain injury, focal hand dystonia, neuropathic pain, and spinal cord injury. TMS and tDCS are still not widely used and remain poorly understood in neurorehabilitation. Therefore, the present supplement includes articles that highlight ready clinical application of these technologies, including their comparative diagnostic capabilities relative to neuroimaging, their therapeutic benefit, their optimal delivery, the stratification of likely responders, and the variable benefits associated with their clinical use because of interactions between pathophysiology and the innate reorganization of the patient's brain. Overall, the supplement concludes that whether provided in isolation or in combination, noninvasive brain stimulation and neurorehabilitation are synergistic in the potential to transform clinical practice.