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Boccuni L, Marinelli L, Trompetto C, Pascual-Leone A, Tormos Muñoz JM. Time to reconcile research findings and clinical practice on upper limb neurorehabilitation. Front Neurol 2022; 13:939748. [PMID: 35928130 PMCID: PMC9343948 DOI: 10.3389/fneur.2022.939748] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 06/27/2022] [Indexed: 11/13/2022] Open
Abstract
The problemIn the field of upper limb neurorehabilitation, the translation from research findings to clinical practice remains troublesome. Patients are not receiving treatments based on the best available evidence. There are certainly multiple reasons to account for this issue, including the power of habit over innovation, subjective beliefs over objective results. We need to take a step forward, by looking at most important results from randomized controlled trials, and then identify key active ingredients that determined the success of interventions. On the other hand, we need to recognize those specific categories of patients having the greatest benefit from each intervention, and why. The aim is to reach the ability to design a neurorehabilitation program based on motor learning principles with established clinical efficacy and tailored for specific patient's needs.Proposed solutionsThe objective of the present manuscript is to facilitate the translation of research findings to clinical practice. Starting from a literature review of selected neurorehabilitation approaches, for each intervention the following elements were highlighted: definition of active ingredients; identification of underlying motor learning principles and neural mechanisms of recovery; inferences from research findings; and recommendations for clinical practice. Furthermore, we included a dedicated chapter on the importance of a comprehensive assessment (objective impairments and patient's perspective) to design personalized and effective neurorehabilitation interventions.ConclusionsIt's time to reconcile research findings with clinical practice. Evidence from literature is consistently showing that neurological patients improve upper limb function, when core strategies based on motor learning principles are applied. To this end, practical take-home messages in the concluding section are provided, focusing on the importance of graded task practice, high number of repetitions, interventions tailored to patient's goals and expectations, solutions to increase and distribute therapy beyond the formal patient-therapist session, and how to integrate different interventions to maximize upper limb motor outcomes. We hope that this manuscript will serve as starting point to fill the gap between theory and practice in upper limb neurorehabilitation, and as a practical tool to leverage the positive impact of clinicians on patients' recovery.
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Affiliation(s)
- Leonardo Boccuni
- Institut Guttmann, Institut Universitari de Neurorehabilitació adscrit a la UAB, Badalona, Spain
- Universitat Autònoma de Barcelona, Bellaterra, Spain
- Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Badalona, Spain
- *Correspondence: Leonardo Boccuni
| | - Lucio Marinelli
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
- IRCCS Ospedale Policlinico San Martino, Department of Neuroscience, Division of Clinical Neurophysiology, Genova, Italy
| | - Carlo Trompetto
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
- IRCCS Ospedale Policlinico San Martino, Department of Neuroscience, Division of Neurorehabilitation, Genova, Italy
| | - Alvaro Pascual-Leone
- Institut Guttmann, Institut Universitari de Neurorehabilitació adscrit a la UAB, Badalona, Spain
- Hinda and Arthur Marcus Institute for Aging Research and Deanna and Sidney Wolk Center for Memory Health, Hebrew SeniorLife, Boston, MA, United States
- Department of Neurology and Harvard Medical School, Boston, MA, United States
| | - José María Tormos Muñoz
- Institut Guttmann, Institut Universitari de Neurorehabilitació adscrit a la UAB, Badalona, Spain
- Universitat Autònoma de Barcelona, Bellaterra, Spain
- Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Badalona, Spain
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Friesen CL, Bardouille T, Neyedli HF, Boe SG. Combined Action Observation and Motor Imagery Neurofeedback for Modulation of Brain Activity. Front Hum Neurosci 2017; 10:692. [PMID: 28119594 PMCID: PMC5223402 DOI: 10.3389/fnhum.2016.00692] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Accepted: 12/26/2016] [Indexed: 12/27/2022] Open
Abstract
Motor imagery (MI) and action observation have proven to be efficacious adjuncts to traditional physiotherapy for enhancing motor recovery following stroke. Recently, researchers have used a combined approach called imagined imitation (II), where an individual watches a motor task being performed, while simultaneously imagining they are performing the movement. While neurofeedback (NFB) has been used extensively with MI to improve patients' ability to modulate sensorimotor activity and enhance motor recovery, the effectiveness of using NFB with II to modulate brain activity is unknown. This project tested the ability of participants to modulate sensorimotor activity during electroencephalography-based II-NFB of a complex, multi-part unilateral handshake, and whether this ability transferred to a subsequent bout of MI. Moreover, given the goal of translating findings from NFB research into practical applications, such as rehabilitation, the II-NFB system was designed with several user interface and user experience features, in an attempt to both drive user engagement and match the level of challenge to the abilities of the subjects. In particular, at easy difficulty levels the II-NFB system incentivized contralateral sensorimotor up-regulation (via event related desynchronization of the mu rhythm), while at higher difficulty levels the II-NFB system incentivized sensorimotor lateralization (i.e., both contralateral up-regulation and ipsilateral down-regulation). Thirty-two subjects, receiving real or sham NFB attended four sessions where they engaged in II-NFB training and subsequent MI. Results showed the NFB group demonstrated more bilateral sensorimotor activity during sessions 2–4 during II-NFB and subsequent MI, indicating mixed success for the implementation of this particular II-NFB system. Here we discuss our findings in the context of the design features included in the II-NFB system, highlighting limitations that should be considered in future designs.
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Affiliation(s)
- Christopher L Friesen
- Laboratory for Brain Recovery and Function, Dalhousie UniversityHalifax, NS, Canada; Department of Psychology and Neuroscience, Dalhousie UniversityHalifax, NS, Canada
| | - Timothy Bardouille
- Department of Psychology and Neuroscience, Dalhousie UniversityHalifax, NS, Canada; Biomedical Translational Imaging Centre, IWK Health CentreHalifax, NS, Canada; School of Physiotherapy, Dalhousie UniversityHalifax, NS, Canada
| | - Heather F Neyedli
- Department of Psychology and Neuroscience, Dalhousie UniversityHalifax, NS, Canada; School of Health and Human Performance, Dalhousie UniversityHalifax, NS, Canada
| | - Shaun G Boe
- Laboratory for Brain Recovery and Function, Dalhousie UniversityHalifax, NS, Canada; Department of Psychology and Neuroscience, Dalhousie UniversityHalifax, NS, Canada; School of Physiotherapy, Dalhousie UniversityHalifax, NS, Canada; School of Health and Human Performance, Dalhousie UniversityHalifax, NS, Canada
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Willigenburg NW, McNally MP, Hewett TE, Page SJ. Portable Myoelectric Brace Use Increases Upper Extremity Recovery and Participation But Does Not Impact Kinematics in Chronic, Poststroke Hemiparesis. J Mot Behav 2016; 49:46-54. [PMID: 27749154 DOI: 10.1080/00222895.2016.1152220] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The authors examined the efficacy of an 8-week regimen combining repetitive task-specific practice (RTP) with a myoelectric brace (RTP+Myomo) on paretic upper extremity (UE; use in valued activities, perceived recovery, and reaching kinematics) in 12 subjects (4 men; M age = 53.5 years; mean time poststroke = 61.7 months). Seven subjects were administered RTP+Myomo therapy, and 5 were administered RTP only. Both groups participated in individualized, 45-min therapy sessions occurring 3 days/week over an 8-week period. The arm, hand ability, activities of daily living, and perceptions of recovery subscales of the Stroke Impact Scale (SIS), as well as UE reaching kinematics, assessed before and after the intervention. Subjects in the RTP+Myomo group showed greater improvements on all SIS subscales, with the recovery scale reaching statistical significance (p = .03). Subjects in the RTP-only group showed a greater increase in hand velocity in the reach up task (p = .02), but no changes were observed in the range of shoulder flexion or elbow extension during reaching. None of the changes in kinematic outcome measures significantly correlated with any of the changes in SIS subscales. RTP integrating myoelectric bracing may be more beneficial than RTP only in improving self-reported function and perceptions of overall recovery. The authors observed no changes in the range of elbow extension, and no relationship between self-reported improvements and changes in reaching kinematics.
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Affiliation(s)
- Nienke W Willigenburg
- a Sports Health and Performance Institute, OSU Sports Medicine , The Ohio State University , Columbus , Ohio.,b Joint Research, Department of Orthopaedic Surgery , OLVG , Amsterdam , the Netherlands
| | - Michael P McNally
- c Department of Orthopaedics , Sports Health and Performance Institute, OSU Sports Medicine, The Ohio State University , Columbus , Ohio
| | - Timothy E Hewett
- d Departments of Physiology & Cell Biology, Family Medicine, Biomedical Engineering, and Orthopaedics , Sports Health and Performance Institute, OSU Sports Medicine, The Ohio State University , Columbus , Ohio.,e Department of Orthopedics , Mayo Clinic, Rochester , Minnesota , USA
| | - Stephen J Page
- f Better Rehabilitation and Assessment for Improved Neurorecovery Laboratory , Division of Occupational Therapy, School of Health and Rehabilitation Sciences, The Ohio State University Medical Center , Columbus , Ohio , USA
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Abstract
PURPOSE OF REVIEW Prescribing the most appropriate dose of motor therapy for individual patients is a challenge because minimal data are available and a large number of factors are unknown. This review explores the concept of dose and reviews the most recent findings in the field of neurorehabilitation, with a focus on relearning motor skills after stroke. RECENT FINDINGS Appropriate dosing involves the prescription of a specific amount of an active ingredient, at a specific frequency and duration. Dosing parameters, particularly amount, are not well defined or quantified in most studies. Compiling data across studies indicates a positive, moderate dose-response relationship, indicating that more movement practice results in better outcomes. This relationship is confounded by time after stroke, however, wherein longer durations of scheduled therapy may not be beneficial in the first few hours, days, and/or weeks. SUMMARY These findings suggest that substantially more movement practice may be necessary to achieve better outcomes for people living with the disabling consequences of stroke. Preclinical investigations are needed to elucidate many of the unknowns and allow for a more biologically driven rehabilitation prescription process. Likewise, clinical investigations are needed to determine the dose-response relationships and examine the potential dose-timing interaction in humans.
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Peters HT, Richards L, Basobas BA, Faieta JM, Page SJ. Changing Their Minds: Enhancing Poststroke Occupational Performance Using Transcranial Direct Current Stimulation. J Mot Behav 2016; 49:8-19. [DOI: 10.1080/00222895.2016.1191417] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Heather T. Peters
- Division of Occupational Therapy, The Ohio State University, Columbus, Ohio, USA
- B.R.A.I.N. Laboratory (Better Rehabilitation and Assessment for Improved Neuro-recovery), Ohio State University, Columbus, Ohio, USA
| | - Lorie Richards
- Occupational Therapy, University of Utah, Salt Lake City, Utah, USA
| | - Brittani A. Basobas
- Division of Occupational Therapy, The Ohio State University, Columbus, Ohio, USA
- B.R.A.I.N. Laboratory (Better Rehabilitation and Assessment for Improved Neuro-recovery), Ohio State University, Columbus, Ohio, USA
| | - Julie M. Faieta
- Division of Occupational Therapy, The Ohio State University, Columbus, Ohio, USA
- B.R.A.I.N. Laboratory (Better Rehabilitation and Assessment for Improved Neuro-recovery), Ohio State University, Columbus, Ohio, USA
| | - Stephen J. Page
- Division of Occupational Therapy, The Ohio State University, Columbus, Ohio, USA
- B.R.A.I.N. Laboratory (Better Rehabilitation and Assessment for Improved Neuro-recovery), Ohio State University, Columbus, Ohio, USA
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Peters HT, Edwards DJ, Wortman-Jutt S, Page SJ. Moving Forward by Stimulating the Brain: Transcranial Direct Current Stimulation in Post-Stroke Hemiparesis. Front Hum Neurosci 2016; 10:394. [PMID: 27555811 PMCID: PMC4977294 DOI: 10.3389/fnhum.2016.00394] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 07/22/2016] [Indexed: 12/13/2022] Open
Abstract
Stroke remains a leading cause of disability worldwide, with a majority of survivors experiencing long term decrements in motor function that severely undermine quality of life. While many treatment approaches and adjunctive strategies exist to remediate motor impairment, many are only efficacious or feasible for survivors with active hand and wrist function, a population who constitute only a minority of stroke survivors. Transcranial direct current stimulation (tDCS), a type of non-invasive brain stimulation, has been increasingly utilized to increase motor function following stroke as it is able to be used with stroke survivors of varying impairment levels, is portable, is relatively inexpensive and has few side effects and contraindications. Accordingly, in recent years the number of studies investigating its efficacy when utilized as an adjunct to motor rehabilitation regimens has drastically increased. While many of these trials have reported positive and promising efficacy, methodologies vary greatly between studies, including differences in stimulation parameters, outcome measures and the nature of physical practice. As such, an urgent need remains, centering on the need to investigate these methodological differences and synthesize the most current evidence surrounding the application of tDCS for post-stroke motor rehabilitation. Accordingly, the purpose of this paper is to provide a detailed overview of the most recent tDCS literature (published 2014-2015), while highlighting these variations in methodological approach, as well to elucidate the mechanisms associated with tDCS and post-stroke motor re-learning and neuroplasticity.
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Affiliation(s)
- Heather T. Peters
- Division of Occupational Therapy, The Ohio State UniversityColumbus, OH, USA
- Better Rehabilitation and Assessment for Improved Neuro-recovery (B.R.A.I.N.) Laboratory, Ohio State UniversityColumbus, OH, USA
| | - Dylan J. Edwards
- Laboratory for Non-Invasive Brain Stimulation and Human Motor Control, The Burke Medical Research InstituteWhite Plains, NY, USA
- Department of Neurology, Weill Cornell Medical CollegeWhite Plains, NY, USA
| | | | - Stephen J. Page
- Division of Occupational Therapy, The Ohio State UniversityColumbus, OH, USA
- Better Rehabilitation and Assessment for Improved Neuro-recovery (B.R.A.I.N.) Laboratory, Ohio State UniversityColumbus, OH, USA
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Greenwood R, Caine D, Hammerbeck U, Leff A, Playford D, Stevenson V, Ward N. Restorative Neurology, Rehabilitation and Brain Injury. Neurology 2016. [DOI: 10.1002/9781118486160.ch18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
| | - Diana Caine
- National Hospital for Neurology & Neurosurgery
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Retention of the spacing effect with mental practice in hemiparetic stroke. Exp Brain Res 2016; 234:2841-7. [PMID: 27271870 DOI: 10.1007/s00221-016-4686-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 05/25/2016] [Indexed: 10/21/2022]
Abstract
Mental practice (MP) is a promising adjuvant to physical practice that involves many of the same mechanisms and takes on many of the same properties as physical practice. This study compared efficacy of a "massed" MP regimen versus a "distributed" MP regimen on upper extremity (UE) motor impairment and functional limitation. Twenty-seven chronic stroke survivors were administered the UE section of the Fugl-Meyer (FM) and Action Research Arm Test (ARAT), followed by standardized physical practice and MP regimens. One group was administered "massed" MP (60 min of MP during a single daily session) and a second group administered distributed MP (20 min of MP occurring three times/day). After intervention, changes in FM and ARAT scores of subjects in the distributed condition were significantly higher than those of subjects in the massed condition (FM 3.65, 95 % CI 0.82-6.49, p value = 0.01; ARAT 3.95, 95 % CI 1.24-6.67, p value = 0.006). Likewise, at POST 3, subjects in the distributed group showed significantly higher change in ARAT scores (ARAT 4.90, 95 % CI 0.57-9.22, p value = 0.03); the change in FM scores at POST 3 was 3.18 points higher among subjects in the distributed condition, but only approached significance (95 % CI -1.27 to 7.63, p value = 0.15). Results suggest that a distributed MP schedule is more efficacious in bringing about paretic UE changes than a massed practice schedule, especially in terms of reducing UE functional limitation.
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Matching Task Difficulty to Patient Ability During Task Practice Improves Upper Extremity Motor Skill After Stroke: A Proof-of-Concept Study. Arch Phys Med Rehabil 2016; 97:1863-1871. [PMID: 27117385 DOI: 10.1016/j.apmr.2016.03.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 02/11/2016] [Accepted: 03/22/2016] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To test the feasibility of the Fugl-Meyer Assessment of the Upper Extremity "keyform," derived from Rasch analysis, as a method for systematically planning and progressing rehabilitation. DESIGN Feasibility study, single group design. SETTING University rehabilitation research laboratory. PARTICIPANTS Participants (N=10; mean age, 59.70±9.96y; 24.1±30.54mo poststroke) with ischemic or hemorrhagic stroke >3 months prior, voluntarily shoulder flexion ≥30°, and simultaneous elbow extension ≥20°. INTERVENTIONS The keyform method defined initial rehabilitation targets (goals) and progressed the rehabilitation program after every third session. Targets were repetitively practiced within the context of client-selected functional tasks not in isolation. MAIN OUTCOME MEASURES Feasibility was defined by subject's pain or fatigue, upper extremity motor function (Wolf Motor Function Test), and movement patterns (kinematics). Assessments were administered pre- and posttreatment and compared using paired t tests. Task-difficulty and patient-ability measures were calculated using Rasch analysis and compared using paired t tests (P<.05). RESULTS Ten participants completed 9 sessions, 200 movement repetitions per session in <2 hours without pain or fatigue. Participants gained upper extremity motor function (Wolf Motor Function Test: pretreatment, 22.23±24.26s; posttreatment, 15.46±22.12s; P=.01), improved shoulder-elbow coordination (index of curvature: pretreatment, 1.30±0.15; posttreatment, 1.21±0.11; P=.01), and exhibited reduced trunk compensatory movement (trunk displacement: pretreatment, 133.97±74.15mm; posttreatment, 108.08±64.73mm; P=.02). Task-difficulty and patient-ability measures were not statistically different throughout the program (person-ability measures of 1.01±0.05, 1.64±0.45, and 2.22±0.65 logits and item-difficulty measures of 0.93±0.37, 1.70±0.20, and 2.06±0.24 logits at the 3 testing time points, respectively; P>.05). CONCLUSIONS The Fugl-Meyer Assessment of the Upper Extremity keyform is a feasible method to ensure that the difficulty of tasks practiced were well matched to initial and evolving levels of upper extremity motor ability.
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Page SJ, Levine P, Hill V. Mental practice--triggered electrical stimulation in chronic, moderate, upper-extremity hemiparesis after stroke. Am J Occup Ther 2015; 69:6901290050p1-8. [PMID: 25553754 PMCID: PMC4322927 DOI: 10.5014/ajot.2015.014902] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To determine the feasibility and impact of home-based, mental practice-triggered electrical stimulation among stroke survivors exhibiting moderate upper-extremity (UE) impairment. METHOD Five participants with moderate, stable UE hemiparesis were administered the Fugl-Meyer Assessment, the Box and Block Test, and the Activities of Daily Living, Hand Function, and overall recovery domains of the Stroke Impact Scale (Version 3). They were then administered an 8-wk regimen consisting of 1 hr of mental practice-triggered electrical stimulation every weekday in their home. At the end of every 2 wk, participants attended supervised stimulation to progress therapeutic exercises and stimulation levels and monitor compliance. RESULTS Six instances of device noncompliance were reported. Participants exhibited reduced UE motor impairment and increased UE dexterity and participation in valued activities. CONCLUSION The regimen appears feasible and had a substantial impact on UE impairment, dexterity, and participation in valued activities as well as perceptions of recovery.
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Affiliation(s)
- Stephen J Page
- Stephen J. Page, PhD, MS, OTR/L, FAHA, FACRM, is Director, Better Rehabilitation and Assessment for Improved Neuro-recovery (B.R.A.I.N.) Laboratory, and Associate Professor, Division of Occupational Therapy, School of Health and Rehabilitation Sciences, The Ohio State University, Columbus;
| | - Peter Levine
- Peter Levine, PTA, is Director, Synaps Together, LLC, Cincinnati, OH
| | - Valerie Hill
- Valerie Hill, PhD, OTR/L, is Postdoctoral Fellow, University of Southern California, Los Angeles
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Fleet A, Che M, Mackay-Lyons M, Mackenzie D, Page S, Eskes G, McDonald A, Boyce J, Boe S. Examining the use of constraint-induced movement therapy in canadian neurological occupational and physical therapy. Physiother Can 2014; 66:60-71. [PMID: 24719511 DOI: 10.3138/ptc.2012-61] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To investigate the use of constraint-induced movement therapy (CIMT) in Canadian neurological occupational and physical therapy. METHOD An online survey was completed by occupational and physical therapists practising in Canadian adult neurological rehabilitation. We measured participants' practices, perceptions, and opinions in relation to their use of CIMT in clinical practice. RESULTS A total of 338 surveys were returned for a 13% response rate; 92% of respondents knew of CIMT, and 43% reported using it. The majority (88%) of respondents using CIMT employed a non-traditional protocol. Self-rating of level of CIMT knowledge was found to be a significant predictor of CIMT use (p≤0.001). Commonly identified barriers to use included "patients having cognitive challenges that prohibit use of this treatment" and "lack of knowledge regarding treatment." CONCLUSIONS Although the majority of respondents knew about CIMT, less than half reported using it. Barriers to CIMT use include lack of knowledge about the treatment and institutional resources to support its use. Identifying and addressing barriers to CIMT use-for example, by using continuing professional education to remediate knowledge gaps or developing new protocols that require fewer institutional resources-can help improve the feasibility of CIMT, and thus promote its clinical application.
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Affiliation(s)
- Alana Fleet
- Laboratory for Brain Recovery and Function ; School of Physiotherapy
| | - Marion Che
- Laboratory for Brain Recovery and Function ; Department of Medicine, Division of Physical Medicine and Rehabilitation
| | - Marilyn Mackay-Lyons
- School of Physiotherapy ; Department of Medicine, Division of Physical Medicine and Rehabilitation
| | - Diane Mackenzie
- Department of Medicine, Division of Physical Medicine and Rehabilitation ; School of Occupational Therapy
| | - Stephen Page
- Division of Occupational Therapy, The Ohio State University Medical Centre, Columbus Ohio, USA
| | - Gail Eskes
- Department of Psychiatry ; Department of Psychology and Neuroscience
| | | | - Joy Boyce
- Acquired Brain Injury Service, Capital Health, Halifax, N.S
| | - Shaun Boe
- Laboratory for Brain Recovery and Function ; School of Physiotherapy ; Department of Medicine, Division of Physical Medicine and Rehabilitation ; Department of Psychology and Neuroscience ; School of Health and Human Performance, Dalhousie University, Halifax, N.S. ; Heart and Stroke Foundation Centre for Stroke Recovery, Sunnybrook Health Sciences Centre, Toronto
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