Free
Research Article  |   July 2011
Modified Constraint-Induced Movement Therapy for Elderly Clients With Subacute Stroke
Author Affiliations
  • Martha McCall, MScOT, is Occupational Therapist, Kunin–Lunenfeld Applied Research Unit, Baycrest, Toronto, Ontario, and was Student, Graduate Department of Rehabilitation Sciences, University of Toronto, Ontario, at the time of the study
  • Sara McEwen, PT, PhD, is Scientist, St. John’s Rehab Hospital, Toronto, Ontario, and Assistant Professor, Department of Physical Therapy, University of Toronto, Ontario
  • Angela Colantonio, PhD, OT Reg (ON), is Professor, Graduate Department of Rehabilitation Sciences and Department of Occupational Science and Occupational Therapy, University of Toronto, Ontario, and Senior Research Scientist, Toronto Rehabilitation Institute, Toronto, Ontario
  • David Streiner, PhD, CPsych, is Professor, Department of Psychiatry, University of Toronto, Ontario, and Professor Emeritus, Department of Clinical Epidemiology and Biostatistics and Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario
  • Deirdre R. Dawson, PhD, OT Reg (ON), is Senior Scientist, Rotman Resarch Institute, Baycrest, Toronto, Ontario, and Associate Professor, Graduate Department of Rehabilitation Sciences and Department of Occupational Science and Occupational Therapy, University of Toronto, 3560 Bathurst Street, Toronto, ON M6A 2E1, Canada ddawson@klaru-baycrest.on.ca
Article Information
Geriatrics/Productive Aging / Neurologic Conditions / Stroke / Rehabilitation, Disability, and Participation
Research Article   |   July 2011
Modified Constraint-Induced Movement Therapy for Elderly Clients With Subacute Stroke
American Journal of Occupational Therapy, July/August 2011, Vol. 65, 409-418. doi:10.5014/ajot.2011.002063
American Journal of Occupational Therapy, July/August 2011, Vol. 65, 409-418. doi:10.5014/ajot.2011.002063
Abstract

A growing body of research, including evidence from numerous randomized controlled trials, suggests that constraint-induced movement therapy (CIMT) reduces impairment. The mean age of participants in most studies has been <65 yr, even though most stroke survivors are older than that. We investigated the efficacy of a modified CIMT protocol on participation, activity, and impairment in a population of older adults experiencing subacute stroke. Using an interrupted time series design, 4 older adults (mean age = 82) were assessed before and after intervention. Although none of the participants adhered to the 6-hr per day self-practice aspect of the CIMT protocol, considerable improvements were noted in participation, as measured using the Canadian Occupational Performance Measure. Some improvements were also noted at the level of impairment and activity. This work accords with previous literature on CIMT and has important implications for the evolution of stroke rehabilitation in elderly people.

Stroke resulting in hemiplegia can have a devastating effect on a person’s capacity to perform meaningful daily activities (Mayo, Wood-Dauphinee, Cote, Durcan, & Carlton, 2002). In particular, limitations in upper-extremity movement are a significant concern to stroke survivors; conversely, improvements in upper-extremity movement are strongly related to increased daily function (Mayo et al., 2002; Wade & Hewer, 1987). Unfortunately, upper-extremity recovery after a stroke is challenging. As many as 85% of people who have a stroke present with an initial deficit in the upper extremity, and as many as 75% of that group continue to have problems 3–6 mo later (Feys et al., 1998; Parker, Wade, & Langton Hewer, 1986; Wade, Langton Hewer, Wood, Skilbeck, & Ismail, 1983).
Recently, a series of studies has demonstrated that constraint-induced movement therapy (CIMT) can reduce arm impairment and activity limitations in people living with the effects of stroke (Hakkennes & Keating, 2005). In addition, a recent systematic review examined a wide range of interventions for motor recovery and recommended offering CIMT to specific groups of stroke survivors (Langhorne, Coupar, & Pollock, 2009). Three other reviews concluded that CIMT is a promising approach for improving upper-extremity motor recovery in people living with the effects of stroke (Blanton, Wilsey, & Wolf, 2008; Bonaiuti, Rebasti, & Sioli, 2007; Langhorne et al., 2009). CIMT has had some degree of successful outcome in acute, subacute, and chronic populations of adults with stroke (Bonaiuti et al., 2007).
CIMT involves restraining the unaffected upper extremity and encouraging active use of the hemiplegic upper extremity to increase its functional use (Taub et al., 1993). It has three standard components: (1) restraint of the unaffected limb, (2) intensive practice using the affected limb (i.e., massed practice), and (3) reinforcement of successive attempts using the affected limb (i.e., shaping;Siegert, Lord, & Porter, 2004). CIMT has been credited with hastening the cortical reorganization process in nonhuman primates and in humans (Johansson, 2000; Liepert et al., 1998, 2000).
In the United States, approximately 70% of strokes occur in people who are ≥65 yr old (National Institutes of Health, 1999). In older adults, the effects of stroke are exacerbated: Increased age has been shown to be an independent predictor of worse functional mobility scores (Bagg, Pombo, & Hopman, 2002). However, the efficacy of CIMT in an exclusively elderly population has not yet been studied. A review of 19 relevant CIMT studies found that the mean ages of study participants ranged from 53 to 66 yr (McCall, 2006). Factors such as reductions in brain plasticity with aging (Hatanpaa, Isaacs, Shirao, Brady, & Stanley, 1999) and the rigorous nature of the CIMT protocol suggest that CIMT may be more challenging for an elderly population.
Conversely, previous research has also demonstrated that elderly people with stroke have the potential to make functional improvements with rehabilitation interventions (Bagg et al., 2002). Because of these discrepancies and relevance to the growing population of older adults most at risk for stroke, we studied an elderly population directly instead of generalizing findings from younger participants.
Method
Design
This study used an interrupted time series (ITS) design to determine whether CIMT had an effect greater than that of natural recovery on the participation, activity, and impairment of the hemiplegic arm and hand in elderly people after a stroke. ITS designs are characterized by the collection of multiple observations over time that are “interrupted” by an intervention or treatment (Cook & Campbell, 1979). An ITS design enables the researcher to quantify a stable baseline level of function or a growth trend before treatment and then project that trend into the future. The effect of treatment is manifested as the difference between the actual and projected outcomes (Johnston, Ottenbacher, & Reichardt, 1995). This study followed the Effective Practice and Organization of Care Cochrane definition of an ITS design, which requires that there be at least three time points before and after the intervention, that the intervention occur at a clearly defined point in time, and that the study use objective performance or outcome measures (Ramsay, Matowe, Grilli, Grimshaw, & Thomas, 2003).
Participants
Participants were recruited from inpatient and outpatient rehabilitation units at two Toronto-based rehabilitation hospitals. They were eligible to participate if they were ≥65 yr old, had functional written and spoken English, had ischemic or hemorrhagic stroke confirmed by computed tomography or magnetic resonance imaging, and were able to complete at least one of the three upper-extremity tasks at Stage 3 (with 7 being normal movement) on the Chedoke–McMaster Stroke Assessment Impairment Inventory (CMSA–II; Gowland et al., 1995). In addition, they needed to be willing and able to participate in 2 hr of daily therapy (Monday to Friday) for 2 wk and to wear a mitt on the unaffected hand for 6 hr per day. Participants were excluded if they exhibited rapidly improving motor function as identified by the unit physician or practicing clinicians; hemispatial neglect as determined by >10 errors on the left side of the Bells Assessment (Gauthier, Dehaut, & Joanette, 1969); successful completion of Stage 7 on the CMSA–II, upper-extremity injury; conditions that significantly limited use of the affected arm before the stroke, such as osteoarthritis, rheumatoid arthritis, amputation, or previous stroke; or participation in other treatment intervention studies.
Measures
Evaluation at the participation level used real-life activities that were relevant to the participant and his or her daily life, elicited using the Canadian Occupational Performance Measure (COPM; Law et al., 1998; McColl, Paterson, Davies, Doubt, & Law, 2000). The COPM’s test–retest reliability in an adult rehabilitation setting is .80 for performance and .89 for satisfaction (Bosch, 1995; Cup, Scholte op Reimer, Thijssen, & Van Kuyk-Minis, 2003), and it is highly responsive to changes in client outcomes over time (Carpenter, Baker, & Tyldesley, 2001; Chen, Rodger, & Polatajko, 2002).
To measure activity limitations, the self-report version of the FIM™ (FIM–SR; Granger, Hamilton, Linacre, Heinemann, & Wright, 1993; Keith, Granger, Hamilton, & Sherwin, 1987) and the Chedoke Arm and Hand Activity Inventory (CAHAI; Barreca, Stratford, Lambert, Masters, & Streiner, 2005) were used. The internal consistency of the FIM–SR has been reported as .94–.96 in neurological populations (Jensen, Abresch, & Carter, 2005; Masedo, Hanley, Jensen, Ehde, & Cardenas, 2005), and a test–retest reliability of .89 has been reported in patients with spinal cord injury (Masedo et al., 2005). The test–retest reliability of the CAHAI is .98 (Barreca et al., 2005). The CAHAI detects clinically important change in the affected upper extremity’s progression from stabilizer to manipulator when performing tasks of daily living (Barreca et al., 2004; Barreca, Stratford, Dobell, & O’Flaherty, 2001).
To measure impairment, we used the Action Research Arm Test (ARAT; Lyle, 1981). The ARAT is a 19-item assessment with four subscales: Grasp, Grip, Pinch, and Gross Movement. Test–retest reliability is .98–.99 for the subscales (DeWeerdt, 1985; Lyle, 1981). Participants were asked to keep a daily activity log for two purposes: (1) to record their functional use of the impaired upper extremity outside of treatment and (2) to assess adherence to constraint device (mitt) wear.
Procedures
The study was approved by research ethics boards at two Toronto hospitals; informed, written consent was obtained from all participants. Participants were assessed 4 or 5 times before the intervention over approximately 3 wk. After a 2-wk modified CIMT program, they were reassessed another 4 or 5 times, again over approximately 3 wk. The assessments and treatment were delivered at a place convenient to participants, either in their home or at one of the hospitals.
Intervention
In this study, we used a modified CIMT protocol that was based on suggestions made by Dromerick, Edwards, and Hahn (2000) . Modifications were reductions in the duration of mitt wear and massed practice compared with the traditional protocol (Taub, Crago, & Uswatte, 1998). Massed sessions were 2 hr, 5 days per wk for 2 wk. During the treatments, the participant wore the padded mitt on his or her unaffected side and focused on activities that required use of his or her affected side. Participants were also instructed to wear the mitt outside of the treatment sessions for an additional 4 hr per day, resulting in a total of 6 hr/day of mitt wear.
The training consisted primarily of shaping. The treatment protocol was individually customized; specific task selection depended on the participant’s functional goals identified on the COPM. Each participant identified three to five functional goals. For example, Participant 1 had as one of her goals, “To hold a glass of water in my left hand and drink from it.” Each treatment session consisted of three main components: (1) motor tasks related to the participant’s functional goals (e.g., grasping and releasing plastic cones); (2) goal-specific functional tasks (e.g., picking up a glass and drinking from it), and (3) other tasks of daily living (e.g., using a telephone). Techniques focused on motivating the participants to improve their performance and providing them with feedback. Examples of the techniques include the occupational therapist’s recording the time it took to complete a task, the number of repetitions completed within a certain time frame, the percentage of assistance required to complete a task, and the participant’s perceived exertion in completing a task. If the goal-specific functional tasks exceeded the participant’s motor ability, a task analysis was performed, and only components of the goal were addressed (e.g., if the participant’s goal was to lift a glass of water and drink from it, he or she might work on grasp and release before attempting to lift the glass). Over the 2 wk of treatment, components of the goal were addressed, and each treatment was shaped toward performing the final goal by the end of the 2 wk.
Throughout all treatment sessions, the therapist redirected participants’ attention and effort to the use of the affected upper extremity. Each task was repeated approximately 6–10 times with the affected extremity, even if the less affected extremity would normally be used for that function. This approach was also true for tasks that were bilateral in nature. Instead of removing the mitt and performing the tasks with both upper extremities, the participants performed the task in a modified fashion, using the more affected upper extremity or enlisting the assistance of the researcher to serve as a “second” upper extremity (Morris & Taub, 2001). This approach assisted in achieving the necessary massed practice.
Data Analysis
Data analysis included descriptive analysis of mean differences and trend line analysis to test whether this modified CIMT had a larger positive effect on impairment, activity, and participation than natural recovery. For each participant, the individual preintervention data points were used to determine a mean preintervention score on each measure; the same procedure was followed to obtain mean postintervention scores. Preintervention scores were also used to create trend lines for each participant. Trend lines were created using the Excel 2003 scatterplot function, and the linear regression was calculated to predict the postintervention results if no change was expected. Ninety-five percent confidence intervals (CIs) were calculated for each data point. The predicted trend lines were then compared with the actual postintervention results in terms of slope and in terms of the overlap in 95% CIs for each data point. A significant change was considered to have occurred if the CIs did not overlap (Borg & Gall, 1989).
Results
Participants
Of the 8 potential participants who met the inclusion criteria, 5 agreed to participate and 4 completed the treatment. Two of the 3 who did not agree to participate did not have motor goals, and the daughter of the third did not feel her parent would comply with the protocol. The participant who dropped out of the study reported that the treatment protocol was too rigorous. The characteristics of the remaining participants (2 men, 2 women) are shown in Table 1. The participants had a mean age of 82 yr (range = 71–91), and preintervention CMSA–II motor recovery ranged from Stage 3 to Stage 6 for the arm (mean [M] = 4.8) and from Stage 2 to Stage 6 for the hand (M = 3.8).
Table 1.
Participant Characteristics
Participant Characteristics×
CharacteristicParticipant 1Participant 2Participant 3Participant 4
Demographics
 Age, yr91868171
 GenderFemaleMaleFemaleMale
 Hand dominanceRightRightRightRight
 EducationHigh schoolHigh schoolHigh schoolUniversity
 Marital statusWidowedMarriedMarriedMarried
 Living environment
  Before strokeApartmentApartmentHouseHouse
  After strokeNursing homeApartmentHouseApartment
 ComorbiditiesHypertension, osteoporosis, cataractsHypertension, hyperlipidemiaHypertension, CABG, Type 2 diabetesHypertension, hypercholesterolemia, TIA
Stroke-related variables
 Type of strokeIschemicIschemicIschemicIschemic
 Location of strokeR MCAL MCAR MCAL MCA
 Number of strokes1213
 Days of inpatient rehab4684565
 Days from stroke onset to start of study43605981
Impairment measure: Chedoke Score arm/hand5/46/65/33/2
Activity measure: Total FIM–SR score before study intervention95123114112
Table Footer NoteNote. CABG = coronary artery bypass graft; FIM–SR = Self-Report Functional Independence Measure; L = left; MCA = middle cerebral artery; R = right; TIA = transient ischemic attack.
Note. CABG = coronary artery bypass graft; FIM–SR = Self-Report Functional Independence Measure; L = left; MCA = middle cerebral artery; R = right; TIA = transient ischemic attack.×
Table 1.
Participant Characteristics
Participant Characteristics×
CharacteristicParticipant 1Participant 2Participant 3Participant 4
Demographics
 Age, yr91868171
 GenderFemaleMaleFemaleMale
 Hand dominanceRightRightRightRight
 EducationHigh schoolHigh schoolHigh schoolUniversity
 Marital statusWidowedMarriedMarriedMarried
 Living environment
  Before strokeApartmentApartmentHouseHouse
  After strokeNursing homeApartmentHouseApartment
 ComorbiditiesHypertension, osteoporosis, cataractsHypertension, hyperlipidemiaHypertension, CABG, Type 2 diabetesHypertension, hypercholesterolemia, TIA
Stroke-related variables
 Type of strokeIschemicIschemicIschemicIschemic
 Location of strokeR MCAL MCAR MCAL MCA
 Number of strokes1213
 Days of inpatient rehab4684565
 Days from stroke onset to start of study43605981
Impairment measure: Chedoke Score arm/hand5/46/65/33/2
Activity measure: Total FIM–SR score before study intervention95123114112
Table Footer NoteNote. CABG = coronary artery bypass graft; FIM–SR = Self-Report Functional Independence Measure; L = left; MCA = middle cerebral artery; R = right; TIA = transient ischemic attack.
Note. CABG = coronary artery bypass graft; FIM–SR = Self-Report Functional Independence Measure; L = left; MCA = middle cerebral artery; R = right; TIA = transient ischemic attack.×
×
Mean Difference Analysis
The before, after, and mean difference scores for all measures are presented in Table 2. Positive change scores were found for all participants on all participation, activity, and impairment measures with two exceptions. Participant 3 showed a small negative change on the FIM–SR, and Participant 2 showed a small negative change on the ARAT pinch. Of note is that 3 of the 4 participants (1, 3, 4) had mean difference scores on the CAHAI that were much greater than the change score of 6.3 deemed to indicate clinical significance by Barreca and colleagues (2005). The remaining participant approached this level (mean difference = 5.7).
Table 2.
Mean Pre- and Postintervention Scores and Mean Difference
Mean Pre- and Postintervention Scores and Mean Difference×
MeasurePreintervention MeanPostintervention MeanMean Difference
Participation
 COPM performance (score range: 1 low–10 high)
  Participant 13.554.300.75
  Participant 24.175.751.58
  Participant 33.615.531.91
  Participant 42.003.701.70
 COPM Satisfaction (score range: 1 low–10 high)
  Participant 14.206.151.96
  Participant 24.174.300.17
  Participant 33.845.151.31
  Participant 42.253.801.55
Activity
 FIM–SR (score range: 5 low–35 high)
  Participant 122.8028.205.40
  Participant 232.5033.501.00
  Participant 329.0028.75−0.25
  Participant 426.0027.251.25
 CAHAI (score range: 13 low–91 high)
  Participant 139.8052.6012.80
  Participant 266.0071.755.75
  Participant 324.2538.5014.25
  Participant 417.7529.2511.50
Impairment
 ARAT Grasp (score range: 0 low – 18 high)
  Participant 113.2016.803.60
  Participant 217.0018.001.00
  Participant 39.6012.753.15
  Participant 43.255.752.50
 ARAT Grip (score range: 0 low–12 high)
  Participant 17.809.802.00
  Participant 211.2512.000.75
  Participant 37.008.251.25
  Participant 44.255.501.25
  ARAT Pinch (score range: 0 low–18 high)
  Participant 11.606.605.00
  Participant 210.009.75−0.25
  Participant 31.002.251.25
  Participant 40.250.750.50
 ARAT Gross Motor (score range: 0 low–9 high)
  Participant 18.809.000.20
  Participant 29.009.000.00
  Participant 37.408.250.85
  Participant 44.756.251.50
Table Footer NoteNote. ARAT = Action Research Arm Test; CAHAI = Chedoke Arm and Hand Activity Inventory; COPM = Canadian Occupational Performance Measure; FIM–SR = Self-Report Functional Independence Measure.
Note. ARAT = Action Research Arm Test; CAHAI = Chedoke Arm and Hand Activity Inventory; COPM = Canadian Occupational Performance Measure; FIM–SR = Self-Report Functional Independence Measure.×
Table 2.
Mean Pre- and Postintervention Scores and Mean Difference
Mean Pre- and Postintervention Scores and Mean Difference×
MeasurePreintervention MeanPostintervention MeanMean Difference
Participation
 COPM performance (score range: 1 low–10 high)
  Participant 13.554.300.75
  Participant 24.175.751.58
  Participant 33.615.531.91
  Participant 42.003.701.70
 COPM Satisfaction (score range: 1 low–10 high)
  Participant 14.206.151.96
  Participant 24.174.300.17
  Participant 33.845.151.31
  Participant 42.253.801.55
Activity
 FIM–SR (score range: 5 low–35 high)
  Participant 122.8028.205.40
  Participant 232.5033.501.00
  Participant 329.0028.75−0.25
  Participant 426.0027.251.25
 CAHAI (score range: 13 low–91 high)
  Participant 139.8052.6012.80
  Participant 266.0071.755.75
  Participant 324.2538.5014.25
  Participant 417.7529.2511.50
Impairment
 ARAT Grasp (score range: 0 low – 18 high)
  Participant 113.2016.803.60
  Participant 217.0018.001.00
  Participant 39.6012.753.15
  Participant 43.255.752.50
 ARAT Grip (score range: 0 low–12 high)
  Participant 17.809.802.00
  Participant 211.2512.000.75
  Participant 37.008.251.25
  Participant 44.255.501.25
  ARAT Pinch (score range: 0 low–18 high)
  Participant 11.606.605.00
  Participant 210.009.75−0.25
  Participant 31.002.251.25
  Participant 40.250.750.50
 ARAT Gross Motor (score range: 0 low–9 high)
  Participant 18.809.000.20
  Participant 29.009.000.00
  Participant 37.408.250.85
  Participant 44.756.251.50
Table Footer NoteNote. ARAT = Action Research Arm Test; CAHAI = Chedoke Arm and Hand Activity Inventory; COPM = Canadian Occupational Performance Measure; FIM–SR = Self-Report Functional Independence Measure.
Note. ARAT = Action Research Arm Test; CAHAI = Chedoke Arm and Hand Activity Inventory; COPM = Canadian Occupational Performance Measure; FIM–SR = Self-Report Functional Independence Measure.×
×
Trend Line Analysis
Figures 1 and 2 illustrate the trend line analysis for COPM performance and satisfaction with performance scores. For all 4 participants, the postintervention trend lines for the performance component of the COPM fell above the predicted trend lines. For 3 of the participants (1, 2, 4), there was no overlap in CIs between the predicted and postintervention COPM performance trend lines, indicating improvements associated with treatment rather than natural recovery.
Figure 1.
Trend analysis for the performance scores on the Canadian Occupational Performance Measure (COPM) for all participants. For 3 of the 4 participants (1, 2, 4), there was no overlap in confidence intervals (CIs) between the predicted and postintervention COPM performance trend lines, indicating improvements associated with treatment rather than natural recovery.
Figure 1.
Trend analysis for the performance scores on the Canadian Occupational Performance Measure (COPM) for all participants. For 3 of the 4 participants (1, 2, 4), there was no overlap in confidence intervals (CIs) between the predicted and postintervention COPM performance trend lines, indicating improvements associated with treatment rather than natural recovery.
×
Figure 2.
Trend analysis for the satisfaction scores on the Canadian Occupational Performance Measure (COPM) for all participants. For 3 of the 4 participants (1, 3, 4), the postintervention trend lines for the satisfaction component of the COPM fell above the predicted trend line. Participants 1 and 4 had no overlap in the confidence intervals (CIs) between the predicted and postintervention trend lines.
Figure 2.
Trend analysis for the satisfaction scores on the Canadian Occupational Performance Measure (COPM) for all participants. For 3 of the 4 participants (1, 3, 4), the postintervention trend lines for the satisfaction component of the COPM fell above the predicted trend line. Participants 1 and 4 had no overlap in the confidence intervals (CIs) between the predicted and postintervention trend lines.
×
In the COPM satisfaction with performance component (Figure 2), the postintervention trend lines for 3 of the participants (1, 3, 4) fell above the predicted trend line. Participants 1 and 4 had no overlap in the CIs between the predicted and postintervention trend lines.
In the interest of space, we do not present trend line analysis figures for the FIM–SR, CAHAI, and ARAT. In the FIM–SR trend line analysis, 3 of the 4 participants (1, 2, 3) had postintervention trend lines above the predicted trend lines. Of those, only Participant 1 had no overlap in CIs between the predicted and postintervention trend lines.
On the CAHAI, all participants had postintervention trend lines fall above the predicted trend lines. Although all the participants had overlapping CIs, 100% of the postintervention data points exceeded the highest preintervention data point. Also suggestive of improvement is that for Participant 3, the slope of the postintervention trend line was substantially steeper than the slope of the preintervention trend line.
The data also suggest improvement in the grasp subtest of the ARAT, because for 3 of 4 participants (2, 3, 4) the postintervention trend lines are higher than the predicted trend lines. However, the CIs for all 4 participants overlapped, and none of the postintervention points were higher than the preintervention points. For the grip data, only Participant 2 had a postintervention trend line that was higher than the predicted trend line. Only Participant 1 had no overlap in CIs for pinch. On the gross motor subtest of the ARAT, only Participant 4 had a postintervention trend line that fell above the predicted trend line, because there was a ceiling effect for the other participants. The CIs of this participant did not overlap.
Daily Activity Log
Only 1 of 4 participants completed a daily activity log to record the types of activities he performed with the affected arm outside of the treatment time. Types of activities included opening and closing doors, turning lights on and off, turning faucets on and off, peeling a banana, and eating papaya and sausage with a fork. He did not wear the mitt during this time, nor did he record the number of hours he used the affected arm each day. The remaining participants did not wear the mitt outside of the treatment period, nor did they complete an activity log. They reported that it was too difficult to manage around the home when wearing the mitt or that they were frustrated wearing the mitt to complete tasks.
Discussion
The primary purpose of this study was to evaluate whether modified CIMT had a positive effect on impairment, activity, and participation compared with natural recovery in elderly people in the subacute phase after a stroke. Our data showed a positive effect at the participation and activity levels. The benefits of modified CIMT were much less evident at the impairment level.
Using Modified CIMT in an Elderly Population
The mean age of our study participants was 82, much higher than the mean ages in previous CIMT studies. Of the 5 initial participants, only 1 dropped out, suggesting that older people may be able to tolerate an intense treatment such as CIMT. Participants all tolerated 2 hr of intense daily therapy wearing the restraint mitt but, in general, did not wear the restraint outside of the treatment sessions. Only 1 participant reported diligently using his affected arm outside of the treatment session, but he also did not wear the mitt, and his gains were not greater than those of the other participants. Poor mitt-wearing adherence in this study suggests that a modified CIMT protocol with less restraint time may be more appropriate for older adults such as those in this study (i.e., age ≥70).
The poor adherence resulted in a study protocol of 2 hr of mitt wear versus the original study protocol of 6 hr of mitt wear. Nevertheless, substantial improvements were noted, consistent with the other subacute studies using modified protocols, such as those described by Dromerick et al. (2000). A direct comparison cannot be made between the studies described in Dromerick et al. and our study, however, because mitt adherence was much higher in those studies (5–6 hr of mitt wear time). One possible explanation for why we were still able to see a strong effect is that the high-intensity program of massed practice may be more important than motor restriction of the less affected arm, as suggested by Liepert and colleagues (1998) and Taub and colleagues (1998).
Participation, Activity, and Impairment
CIMT modified to 2 hr per day of mitt wear and task-specific practice using the affected upper extremity had a positive effect on participation. This finding supports and extends the findings of the three other studies that have investigated participation as an outcome (Dettmers et al., 2005; Gillot, Holder-Walls, Hurtz, & Varley, 2003; Roberts,Vegher, Gilewski, Bender, & Riggs, 2005).
This study also demonstrated an improvement at the level of activity. Our findings are consistent with those of Dromerick et al. (2000) . In their randomized controlled study, mean difference scores on the FIM–SR were higher for the CIMT group than for the control group; the only significant difference occurred on the upper-extremity dressing item.
The effects of modified CIMT on impairment as measured by the ARAT were less evident, with the exception of the results on the Grasp subtest. On the Grasp subtest, all 4 participants had higher mean scores postintervention than preintervention, 3 of the 4 participants had postintervention trend lines above the predicted trend lines, and 100% of their postintervention data points exceeded the highest preintervention data point, suggesting that modified CIMT had a beneficial effect. On the other three subtests, the results were variable, making it difficult to draw conclusions.
The ARAT is one of three primary measures used across CIMT studies for impairment. Dromerick and colleagues (2000) analyzed the ARAT by subtest and found that all mean posttreatment ARAT subtest scores were higher for patients in the CIMT group than in the control group; however, only the Pinch subtest scores achieved statistical significance. It is difficult to explain why Pinch was the only significant change when it was the least sensitive of the four subtests in our study; with the exception of age, the two studies’ participants appeared to be well matched for motor abilities, cognitive status, and CIMT protocol. Perhaps this difference is related to the type of intervention (i.e., a larger focus of the treatment intervention in the study by Dromerick et al., 2000, was on pinch activities). Other researchers, using total ARAT score, have demonstrated improvements (Page, Sisto, Levine, Johnston, & Hughes, 2001; van der Lee et al., 1999).
Limitations
Several considerations limit the conclusions that can be drawn from this work. Only 4 participants were evaluated, and additional study with a larger sample is required. Nonblinded assessment of the outcome measures may have been a source of bias. We attempted to control for this limitation by using standardized measures, by retesting participants without looking at previous scores, and by validating test scores against videotapes.
In some cases, participants’ behavior systematically improved during the baseline period and continued to improve during the treatment phase. This improvement made it difficult to separate treatment effects from naturally occurring recovery or placebo effect. The trend line analysis is reported to be robust in discriminating between the effects of time and intervention (Borg & Gall, 1989), and the intervention is the most likely explanation for improvements in these participants.
Conclusions
This study demonstrates that 4 elderly adults in the subacute phase after a stroke were able to tolerate 2 hr of restraint wear on the unaffected upper extremity and intensive task-specific training for the affected upper extremity. Positive effects were reported on the performance of self-selected goals and satisfaction with that performance, results suggesting a positive effect on participation. Benefits were also seen in one activity measure and one subtest of our impairment measure. Continued study in a larger sample is necessary to determine whether elderly adults with stroke maintain the gains noted immediately after a CIMT program and whether improvements in participation, activity, and impairment will have a meaningful impact on quality of life after stroke. In addition, future research is required to examine the relative importance of restraint wear and massed task-specific practice for skill acquisition in the elderly stroke population.
Acknowledgments
We thank the participants in the study for their time and participation and Larry Leach and Cynthia McCall for their support and advice. Martha McCall received financial support for this study from the Hy and Bertha Shore and Harry and Sara Gorman families, the Ontario Ministry of Health and Long Term Care, the Toronto Rehabilitation Institute Foundation, and the University of Toronto while she was doing this research. Sara McEwen received financial support from the Heart and Stroke Foundation of Ontario, Centre for Stroke Recovery while she was assisting with manuscript preparation.
References
Bagg, S., Pombo, A. P., & Hopman, W. (2002). Effect of age on functional outcomes after stroke rehabilitation. Stroke, 33, 179–185. doi: 10.1161/hs0102.101224 [Article] [PubMed]
Bagg, S., Pombo, A. P., & Hopman, W. (2002). Effect of age on functional outcomes after stroke rehabilitation. Stroke, 33, 179–185. doi: 10.1161/hs0102.101224 [Article] [PubMed]×
Barreca, S. R., Gowland, C., Stratford, P. W., Huijbrets, M., Griffiths, J., Torresin, W., et al. (2004). Development of the Chedoke Arm and Hand Activity Inventory: Theoretical constructs, item generation and selection. Topics in Stroke Rehabilitation, 11(4), 31–42. [Article] [PubMed]
Barreca, S. R., Gowland, C., Stratford, P. W., Huijbrets, M., Griffiths, J., Torresin, W., et al. (2004). Development of the Chedoke Arm and Hand Activity Inventory: Theoretical constructs, item generation and selection. Topics in Stroke Rehabilitation, 11(4), 31–42. [Article] [PubMed]×
Barreca, S., Stratford, P., Dobell, H., & O’Flaherty, J. (2001, April). Measuring functional recovery in the hemiplegic arm and hand. Synapse—Neuroscience Division Newsletter, 21(2), 3–4.
Barreca, S., Stratford, P., Dobell, H., & O’Flaherty, J. (2001, April). Measuring functional recovery in the hemiplegic arm and hand. Synapse—Neuroscience Division Newsletter, 21(2), 3–4.×
Barreca, S. R., Stratford, P. W., Lambert, C. L., Masters, L. M., & Streiner, D. L. (2005). Test–retest reliability, validity, and sensitivity of the Chedoke Arm and Hand Activity Inventory: A new measure of upper-limb function for survivors of stroke. Archives of Physical Medicine and Rehabilitation, 86, 1616–1622. doi: 10.1016/j.apmr.2005.03.017 [Article] [PubMed]
Barreca, S. R., Stratford, P. W., Lambert, C. L., Masters, L. M., & Streiner, D. L. (2005). Test–retest reliability, validity, and sensitivity of the Chedoke Arm and Hand Activity Inventory: A new measure of upper-limb function for survivors of stroke. Archives of Physical Medicine and Rehabilitation, 86, 1616–1622. doi: 10.1016/j.apmr.2005.03.017 [Article] [PubMed]×
Blanton, S., Wilsey, H., & Wolf, S. L. (2008). Constraint-induced movement therapy in stroke rehabilitation: Perspectives on future clinical applications. Neuro Rehabilitation, 23, 15–28. [PubMed]
Blanton, S., Wilsey, H., & Wolf, S. L. (2008). Constraint-induced movement therapy in stroke rehabilitation: Perspectives on future clinical applications. Neuro Rehabilitation, 23, 15–28. [PubMed]×
Bonaiuti, D., Rebasti, L., & Sioli, P. (2007). The constraint induced movement therapy: A systematic review of randomized controlled trials on the adult stroke patients. Europa Medicophysica, 43, 139–146. [PubMed]
Bonaiuti, D., Rebasti, L., & Sioli, P. (2007). The constraint induced movement therapy: A systematic review of randomized controlled trials on the adult stroke patients. Europa Medicophysica, 43, 139–146. [PubMed]×
Borg, W. R., & Gall, M. D. (1989). Educational research: An introduction (5th ed.). New York: Longman.
Borg, W. R., & Gall, M. D. (1989). Educational research: An introduction (5th ed.). New York: Longman.×
Bosch, J. (1995). The reliability and validity of the Canadian Occupational Performance Measure. Unpublished master’s thesis, McMaster University, Hamilton, Ontario, Canada.
Bosch, J. (1995). The reliability and validity of the Canadian Occupational Performance Measure. Unpublished master’s thesis, McMaster University, Hamilton, Ontario, Canada.×
Carpenter, L., Baker, G. A., & Tyldesley, B. (2001). The use of the Canadian Occupational Performance Measure as an outcome of a pain management program. Canadian Journal of Occupational Therapy, 68, 16–22. [Article]
Carpenter, L., Baker, G. A., & Tyldesley, B. (2001). The use of the Canadian Occupational Performance Measure as an outcome of a pain management program. Canadian Journal of Occupational Therapy, 68, 16–22. [Article] ×
Chen, Y. H., Rodger, S., & Polatajko, H. (2002). Experiences with the COPM and client-centred practice in adult neurorehabilitation in Taiwan. Occupational Therapy International, 9, 167–184. doi: 10.1002/oti.163 [Article] [PubMed]
Chen, Y. H., Rodger, S., & Polatajko, H. (2002). Experiences with the COPM and client-centred practice in adult neurorehabilitation in Taiwan. Occupational Therapy International, 9, 167–184. doi: 10.1002/oti.163 [Article] [PubMed]×
Cook, T. D., & Campbell, D. T. (1979). Quasi-experimentation: Design and analysis issues for field settings. Chicago: Rand McNally.
Cook, T. D., & Campbell, D. T. (1979). Quasi-experimentation: Design and analysis issues for field settings. Chicago: Rand McNally.×
Cup, E. H. C., Scholte op Reimer, W. J. M., Thijssen, M. C. E., & van Kuyk-Minis, M. A. H. (2003). Reliability and validity of the Canadian Occupational Performance Measure in stroke patients. Clinical Rehabilitation, 17, 402–409. doi: 10.1191/0269215503cr635oa [Article] [PubMed]
Cup, E. H. C., Scholte op Reimer, W. J. M., Thijssen, M. C. E., & van Kuyk-Minis, M. A. H. (2003). Reliability and validity of the Canadian Occupational Performance Measure in stroke patients. Clinical Rehabilitation, 17, 402–409. doi: 10.1191/0269215503cr635oa [Article] [PubMed]×
Dettmers, C., Teske, U., Hamzei, F., Uswatte, G., Taub, E., & Weiller, C. (2005). Distributed form of constraint induced movement therapy improves functional outcome and quality of life after stroke. Archives of Physical Medicine and Rehabilitation, 86, 204–209. doi: 10.1016/j.apmr.2004.05.007 [Article] [PubMed]
Dettmers, C., Teske, U., Hamzei, F., Uswatte, G., Taub, E., & Weiller, C. (2005). Distributed form of constraint induced movement therapy improves functional outcome and quality of life after stroke. Archives of Physical Medicine and Rehabilitation, 86, 204–209. doi: 10.1016/j.apmr.2004.05.007 [Article] [PubMed]×
De Weerdt, W. J. G. (1985). Measuring recovery of the arm–hand function in stroke patients: A comparison of the Brunnstrom Fugl-Meyer test and the Action Research Arm Test. Physiotherapy Canada, 37, 65–67. doi: 10.3138/ptc.37.2.065 [Article]
De Weerdt, W. J. G. (1985). Measuring recovery of the arm–hand function in stroke patients: A comparison of the Brunnstrom Fugl-Meyer test and the Action Research Arm Test. Physiotherapy Canada, 37, 65–67. doi: 10.3138/ptc.37.2.065 [Article] ×
Dromerick, A. W., Edwards, D. F., & Hahn, M. (2000). Does the application of constraint-induced movement therapy during acute rehabilitation reduce arm impairment after ischemic stroke?. Stroke, 31, 2984–2988. [Article] [PubMed]
Dromerick, A. W., Edwards, D. F., & Hahn, M. (2000). Does the application of constraint-induced movement therapy during acute rehabilitation reduce arm impairment after ischemic stroke?. Stroke, 31, 2984–2988. [Article] [PubMed]×
Feys, H. M., De Weerdt, W. J., Selz, B. E., Cox Steck, G. A., Spinchinger, R., & Vereeck, L. E. (1998). Effect of a therapeutic intervention for the hemiplegic upper limb in the acute rehabilitation phase after stroke: A single-blind, randomized, controlled multicenter trial. Stroke, 29, 785–792. [Article] [PubMed]
Feys, H. M., De Weerdt, W. J., Selz, B. E., Cox Steck, G. A., Spinchinger, R., & Vereeck, L. E. (1998). Effect of a therapeutic intervention for the hemiplegic upper limb in the acute rehabilitation phase after stroke: A single-blind, randomized, controlled multicenter trial. Stroke, 29, 785–792. [Article] [PubMed]×
Gauthier, L., Dehaut, F., & Joanette, Y. (1969). The Bell’s Test: A quantitative and qualitative test for visual neglect. International Journal of Clinical Neuropsychology, 11, 49–54.
Gauthier, L., Dehaut, F., & Joanette, Y. (1969). The Bell’s Test: A quantitative and qualitative test for visual neglect. International Journal of Clinical Neuropsychology, 11, 49–54.×
Gillot, A. J., Holder-Walls, A., Hurtz, J. R., & Varley, N. C. (2003). Perceptions and experiences of two survivors of stroke who participated in constraint-induced movement therapy home programs. American Journal of Occupational Therapy, 57, 168–176. doi: 10.5014/ajot.57.2.168 [Article] [PubMed]
Gillot, A. J., Holder-Walls, A., Hurtz, J. R., & Varley, N. C. (2003). Perceptions and experiences of two survivors of stroke who participated in constraint-induced movement therapy home programs. American Journal of Occupational Therapy, 57, 168–176. doi: 10.5014/ajot.57.2.168 [Article] [PubMed]×
Gowland, C., VanHullenaar, S., Torresin, W., Moreland, J., Vanspall, B., Barreca, S., et al. (1995). Chedoke–McMaster Stroke Assessment: Development, validation, and administration manual. Hamilton, Ontario: School of Rehabilitation Science, McMaster University.
Gowland, C., VanHullenaar, S., Torresin, W., Moreland, J., Vanspall, B., Barreca, S., et al. (1995). Chedoke–McMaster Stroke Assessment: Development, validation, and administration manual. Hamilton, Ontario: School of Rehabilitation Science, McMaster University.×
Hakkennes, S., & Keating, J. L. (2005). Constraint-induced movement therapy following stroke: A systematic review of randomized controlled trials. Australian Journal of Physiotherapy, 51, 221–231. [Article] [PubMed]
Hakkennes, S., & Keating, J. L. (2005). Constraint-induced movement therapy following stroke: A systematic review of randomized controlled trials. Australian Journal of Physiotherapy, 51, 221–231. [Article] [PubMed]×
Hatanpaa, K., Isaacs, K. R., Shirao, T., Brady, D. R., & Stanley, I. R. (1999). Loss of proteins regulating synaptic plasticity in normal aging of the human brain and in Alzheimer disease. Journal of Neuropathology and Experimental Neurology, 58, 637–643. doi: 10.1097/00005072-199906000-00008 [Article] [PubMed]
Hatanpaa, K., Isaacs, K. R., Shirao, T., Brady, D. R., & Stanley, I. R. (1999). Loss of proteins regulating synaptic plasticity in normal aging of the human brain and in Alzheimer disease. Journal of Neuropathology and Experimental Neurology, 58, 637–643. doi: 10.1097/00005072-199906000-00008 [Article] [PubMed]×
Jensen, M. P., Abresch, R. T., & Carter, G. T. (2005). The reliability and validity of a self-report version of the FIM instrument in persons with neuromuscular disease and chronic pain. Archives of Physical Medicine and Rehabilitation, 86, 116–122. doi: 10.1016/j.apmr.2004.01.040 [Article] [PubMed]
Jensen, M. P., Abresch, R. T., & Carter, G. T. (2005). The reliability and validity of a self-report version of the FIM instrument in persons with neuromuscular disease and chronic pain. Archives of Physical Medicine and Rehabilitation, 86, 116–122. doi: 10.1016/j.apmr.2004.01.040 [Article] [PubMed]×
Johansson, B. B. (2000). Brain plasticity and stroke rehabilitation: The Willis lecture. Stroke, 31, 223–230. [Article] [PubMed]
Johansson, B. B. (2000). Brain plasticity and stroke rehabilitation: The Willis lecture. Stroke, 31, 223–230. [Article] [PubMed]×
Johnston, M. V., Ottenbacher, K. J., & Reichardt, C. S. (1995). Strong quasi-experimental designs for research on the effectiveness of rehabilitation. American Journal of Physical Medicine and Rehabilitation, 74, 383–392. doi: 10.1097/00002060-199509000-00014 [Article] [PubMed]
Johnston, M. V., Ottenbacher, K. J., & Reichardt, C. S. (1995). Strong quasi-experimental designs for research on the effectiveness of rehabilitation. American Journal of Physical Medicine and Rehabilitation, 74, 383–392. doi: 10.1097/00002060-199509000-00014 [Article] [PubMed]×
Langhorne, P., Coupar, F., & Pollock, A. (2009). Motor recovery after stroke: A systematic review. Lancet Neurology, 8, 741–754. doi: 10.1016/S1474-4422(09)70150-4 [Article] [PubMed]
Langhorne, P., Coupar, F., & Pollock, A. (2009). Motor recovery after stroke: A systematic review. Lancet Neurology, 8, 741–754. doi: 10.1016/S1474-4422(09)70150-4 [Article] [PubMed]×
Law, M., Baptiste, S., Carswell, A., McColl, M., Polatajko, H., & Pollack, N. (1998). Canadian Occupational Performance Measure (3rd ed.). Ottawa, Ontario: CAOT.
Law, M., Baptiste, S., Carswell, A., McColl, M., Polatajko, H., & Pollack, N. (1998). Canadian Occupational Performance Measure (3rd ed.). Ottawa, Ontario: CAOT.×
Liepert, J., Bauder, H., Wolfgang, H. R., Miltner, W. H. R., Taub, E., & Weiller, C. (2000). Treatment-induced cortical reorganization after stroke in humans. Stroke, 31, 1210–1216. [Article] [PubMed]
Liepert, J., Bauder, H., Wolfgang, H. R., Miltner, W. H. R., Taub, E., & Weiller, C. (2000). Treatment-induced cortical reorganization after stroke in humans. Stroke, 31, 1210–1216. [Article] [PubMed]×
Liepert, J., Miltner, W. H. R., Bauder, H., Sommer, M., Dettmers, C., Taub, E., et al. (1998). Motor cortex plasticity during constraint-induced movement therapy in stroke patients. Neuroscience Letters, 250, 5–8. doi: 10.1016/S0304-3940(98)00386-3 [Article] [PubMed]
Liepert, J., Miltner, W. H. R., Bauder, H., Sommer, M., Dettmers, C., Taub, E., et al. (1998). Motor cortex plasticity during constraint-induced movement therapy in stroke patients. Neuroscience Letters, 250, 5–8. doi: 10.1016/S0304-3940(98)00386-3 [Article] [PubMed]×
Lyle, R. C. (1981). A performance test for assessment of upper limb function in physical rehabilitation treatment and research. International Journal of Rehabilitation Research, 4, 483–492. [Article] [PubMed]
Lyle, R. C. (1981). A performance test for assessment of upper limb function in physical rehabilitation treatment and research. International Journal of Rehabilitation Research, 4, 483–492. [Article] [PubMed]×
Masedo, A. L., Hanley, M., Jensen, M. P., Ehde, D., & Cardenas, D. D. (2005). Reliability and validity of a Self-Report FIM (FIM–SR) in persons with amputations or spinal cord injury and chronic pain. American Journal of Physical Medicine and Rehabilitation, 84, 167–178. doi: 10.1097/01.PHM.0000154898.25609.4A [Article] [PubMed]
Masedo, A. L., Hanley, M., Jensen, M. P., Ehde, D., & Cardenas, D. D. (2005). Reliability and validity of a Self-Report FIM (FIM–SR) in persons with amputations or spinal cord injury and chronic pain. American Journal of Physical Medicine and Rehabilitation, 84, 167–178. doi: 10.1097/01.PHM.0000154898.25609.4A [Article] [PubMed]×
Mayo, N. E., Wood-Dauphinee, S., Cote, R., Durcan, L., & Carlton, J. (2002). Activity, participation and quality of life 6 months post stroke. Archives of Physical Medicine and Rehabilitation, 83, 1035–1042. doi: 10.1053/apmr.2002.33984 [Article] [PubMed]
Mayo, N. E., Wood-Dauphinee, S., Cote, R., Durcan, L., & Carlton, J. (2002). Activity, participation and quality of life 6 months post stroke. Archives of Physical Medicine and Rehabilitation, 83, 1035–1042. doi: 10.1053/apmr.2002.33984 [Article] [PubMed]×
McCall, M. E. (2006). A modified constraint-induced movement therapy program with the geriatric subacute stroke population. (Master's thesis). Available from Dissertations and Theses database. (AAT MR21409).
McCall, M. E. (2006). A modified constraint-induced movement therapy program with the geriatric subacute stroke population. (Master's thesis). Available from Dissertations and Theses database. (AAT MR21409).×
McColl, M. A., Paterson, M., Davies, D., Doubt, L., & Law, M. (2000). Validity and community utility of the Canadian Occupational Performance Measure. Canadian Journal of Occupational Therapy, 67, 22–30. [Article]
McColl, M. A., Paterson, M., Davies, D., Doubt, L., & Law, M. (2000). Validity and community utility of the Canadian Occupational Performance Measure. Canadian Journal of Occupational Therapy, 67, 22–30. [Article] ×
Morris, D., & Taub, E. (2001). Constraint-induced therapy approach to restoring function after neurological injury. Topics in Stroke Rehabilitation, 8, 16–30. doi: 10.1310/BLJX-M89N-PTPY-JDKW [Article] [PubMed]
Morris, D., & Taub, E. (2001). Constraint-induced therapy approach to restoring function after neurological injury. Topics in Stroke Rehabilitation, 8, 16–30. doi: 10.1310/BLJX-M89N-PTPY-JDKW [Article] [PubMed]×
National Institutes of Health, National Institute of Neurological Disorders and Stroke. (1999). Stroke: Hope through research. Retrieved March 9, 2009, from www.ninds.nih.gov/disorders/stroke/detail_stroke.htm
National Institutes of Health, National Institute of Neurological Disorders and Stroke. (1999). Stroke: Hope through research. Retrieved March 9, 2009, from www.ninds.nih.gov/disorders/stroke/detail_stroke.htm×
Page, S. J., Sisto, S., Levine, P., Johnston, M. V., & Hughes, M. (2001). Modified constraint induced therapy: A randomized feasibility and efficacy study. Journal of Rehabilitation Research and Development, 38, 583–590. [PubMed]
Page, S. J., Sisto, S., Levine, P., Johnston, M. V., & Hughes, M. (2001). Modified constraint induced therapy: A randomized feasibility and efficacy study. Journal of Rehabilitation Research and Development, 38, 583–590. [PubMed]×
Parker, V. M., Wade, D. T., & Langton Hewer, R. (1986). Loss of arm function after stroke: Measurement, frequency, and recovery. International Rehabilitation Medicine, 8, 69–83. [PubMed]
Parker, V. M., Wade, D. T., & Langton Hewer, R. (1986). Loss of arm function after stroke: Measurement, frequency, and recovery. International Rehabilitation Medicine, 8, 69–83. [PubMed]×
Ramsay, C. R., Matowe, L., Grilli, R., Grimshaw, J. M., & Thomas, R. E. (2003). Interrupted time series designs in health technology assessment: Lessons from two systematic reviews of behaviour change strategies. International Journal of Technology Assessment in Health Care, 19, 613–623. doi: 10.1017/S0266462303000576 [Article] [PubMed]
Ramsay, C. R., Matowe, L., Grilli, R., Grimshaw, J. M., & Thomas, R. E. (2003). Interrupted time series designs in health technology assessment: Lessons from two systematic reviews of behaviour change strategies. International Journal of Technology Assessment in Health Care, 19, 613–623. doi: 10.1017/S0266462303000576 [Article] [PubMed]×
Roberts, P. S., Vegher, J. A., Gilewski, M., Bender, A., & Riggs, R. V. (2005). Client-centered occupational therapy using constraint-induced therapy. Journal of Stroke and Cerebrovascular Diseases, 14, 115–121. doi: 10.1016/j.jstrokecerebrovasdis.2005.01.002 [Article] [PubMed]
Roberts, P. S., Vegher, J. A., Gilewski, M., Bender, A., & Riggs, R. V. (2005). Client-centered occupational therapy using constraint-induced therapy. Journal of Stroke and Cerebrovascular Diseases, 14, 115–121. doi: 10.1016/j.jstrokecerebrovasdis.2005.01.002 [Article] [PubMed]×
Siegert, R. J., Lord, S., & Porter, K. (2004). Constraint-induced movement therapy: Time for a little restraint. Clinical Rehabilitation, 18, 110–114. doi: 10.1191/0269215504cr711oa [Article] [PubMed]
Siegert, R. J., Lord, S., & Porter, K. (2004). Constraint-induced movement therapy: Time for a little restraint. Clinical Rehabilitation, 18, 110–114. doi: 10.1191/0269215504cr711oa [Article] [PubMed]×
Taub, E., Crago, J. E., & Uswatte, G. (1998). Constraint induced movement therapy: A new approach to treatment in physical rehabilitation. Rehabilitation Psychology, 43, 152–170. doi: 10.1037/0090-5550.43.2.152 [Article]
Taub, E., Crago, J. E., & Uswatte, G. (1998). Constraint induced movement therapy: A new approach to treatment in physical rehabilitation. Rehabilitation Psychology, 43, 152–170. doi: 10.1037/0090-5550.43.2.152 [Article] ×
Taub, E., Miller, N. E., Novack, T. A., Cook, I. E. W., Fleming, W. C., Nepomuceno, C. S., et al. (1993). Technique to improve chronic deficit after stroke. Archives of Physical Medicine and Rehabilitation, 74, 347–354. [PubMed]
Taub, E., Miller, N. E., Novack, T. A., Cook, I. E. W., Fleming, W. C., Nepomuceno, C. S., et al. (1993). Technique to improve chronic deficit after stroke. Archives of Physical Medicine and Rehabilitation, 74, 347–354. [PubMed]×
van der Lee, J. H., Wagenaar, R. C., Lankhorst, G. J., Vogelaar, T. W., Deville, W. L., & Bouter, L. M. (1999). Forced use of the upper extremity in chronic stroke patients. Stroke, 30, 2369–2375. [Article] [PubMed]
van der Lee, J. H., Wagenaar, R. C., Lankhorst, G. J., Vogelaar, T. W., Deville, W. L., & Bouter, L. M. (1999). Forced use of the upper extremity in chronic stroke patients. Stroke, 30, 2369–2375. [Article] [PubMed]×
Wade, D. T., & Hewer, R. (1987). Functional abilities after stroke: Measurement, natural history and prognosis. Journal of Neurology, Neurosurgery, and Psychiatry, 50, 177–182. doi: 10.1136/jnnp.50.2.177 [Article] [PubMed]
Wade, D. T., & Hewer, R. (1987). Functional abilities after stroke: Measurement, natural history and prognosis. Journal of Neurology, Neurosurgery, and Psychiatry, 50, 177–182. doi: 10.1136/jnnp.50.2.177 [Article] [PubMed]×
Wade, D. T., Langton Hewer, R., Wood, V. A., Skilbeck, C. E., & Ismail, H. M. (1983). The hemiplegic arm after stroke: Measurement and recovery. Journal of Neurology, Neurosurgery, and Psychiatry, 46, 521–524. doi: 10.1136/jnnp.46.6.521 [Article] [PubMed]
Wade, D. T., Langton Hewer, R., Wood, V. A., Skilbeck, C. E., & Ismail, H. M. (1983). The hemiplegic arm after stroke: Measurement and recovery. Journal of Neurology, Neurosurgery, and Psychiatry, 46, 521–524. doi: 10.1136/jnnp.46.6.521 [Article] [PubMed]×
Figure 1.
Trend analysis for the performance scores on the Canadian Occupational Performance Measure (COPM) for all participants. For 3 of the 4 participants (1, 2, 4), there was no overlap in confidence intervals (CIs) between the predicted and postintervention COPM performance trend lines, indicating improvements associated with treatment rather than natural recovery.
Figure 1.
Trend analysis for the performance scores on the Canadian Occupational Performance Measure (COPM) for all participants. For 3 of the 4 participants (1, 2, 4), there was no overlap in confidence intervals (CIs) between the predicted and postintervention COPM performance trend lines, indicating improvements associated with treatment rather than natural recovery.
×
Figure 2.
Trend analysis for the satisfaction scores on the Canadian Occupational Performance Measure (COPM) for all participants. For 3 of the 4 participants (1, 3, 4), the postintervention trend lines for the satisfaction component of the COPM fell above the predicted trend line. Participants 1 and 4 had no overlap in the confidence intervals (CIs) between the predicted and postintervention trend lines.
Figure 2.
Trend analysis for the satisfaction scores on the Canadian Occupational Performance Measure (COPM) for all participants. For 3 of the 4 participants (1, 3, 4), the postintervention trend lines for the satisfaction component of the COPM fell above the predicted trend line. Participants 1 and 4 had no overlap in the confidence intervals (CIs) between the predicted and postintervention trend lines.
×
Table 1.
Participant Characteristics
Participant Characteristics×
CharacteristicParticipant 1Participant 2Participant 3Participant 4
Demographics
 Age, yr91868171
 GenderFemaleMaleFemaleMale
 Hand dominanceRightRightRightRight
 EducationHigh schoolHigh schoolHigh schoolUniversity
 Marital statusWidowedMarriedMarriedMarried
 Living environment
  Before strokeApartmentApartmentHouseHouse
  After strokeNursing homeApartmentHouseApartment
 ComorbiditiesHypertension, osteoporosis, cataractsHypertension, hyperlipidemiaHypertension, CABG, Type 2 diabetesHypertension, hypercholesterolemia, TIA
Stroke-related variables
 Type of strokeIschemicIschemicIschemicIschemic
 Location of strokeR MCAL MCAR MCAL MCA
 Number of strokes1213
 Days of inpatient rehab4684565
 Days from stroke onset to start of study43605981
Impairment measure: Chedoke Score arm/hand5/46/65/33/2
Activity measure: Total FIM–SR score before study intervention95123114112
Table Footer NoteNote. CABG = coronary artery bypass graft; FIM–SR = Self-Report Functional Independence Measure; L = left; MCA = middle cerebral artery; R = right; TIA = transient ischemic attack.
Note. CABG = coronary artery bypass graft; FIM–SR = Self-Report Functional Independence Measure; L = left; MCA = middle cerebral artery; R = right; TIA = transient ischemic attack.×
Table 1.
Participant Characteristics
Participant Characteristics×
CharacteristicParticipant 1Participant 2Participant 3Participant 4
Demographics
 Age, yr91868171
 GenderFemaleMaleFemaleMale
 Hand dominanceRightRightRightRight
 EducationHigh schoolHigh schoolHigh schoolUniversity
 Marital statusWidowedMarriedMarriedMarried
 Living environment
  Before strokeApartmentApartmentHouseHouse
  After strokeNursing homeApartmentHouseApartment
 ComorbiditiesHypertension, osteoporosis, cataractsHypertension, hyperlipidemiaHypertension, CABG, Type 2 diabetesHypertension, hypercholesterolemia, TIA
Stroke-related variables
 Type of strokeIschemicIschemicIschemicIschemic
 Location of strokeR MCAL MCAR MCAL MCA
 Number of strokes1213
 Days of inpatient rehab4684565
 Days from stroke onset to start of study43605981
Impairment measure: Chedoke Score arm/hand5/46/65/33/2
Activity measure: Total FIM–SR score before study intervention95123114112
Table Footer NoteNote. CABG = coronary artery bypass graft; FIM–SR = Self-Report Functional Independence Measure; L = left; MCA = middle cerebral artery; R = right; TIA = transient ischemic attack.
Note. CABG = coronary artery bypass graft; FIM–SR = Self-Report Functional Independence Measure; L = left; MCA = middle cerebral artery; R = right; TIA = transient ischemic attack.×
×
Table 2.
Mean Pre- and Postintervention Scores and Mean Difference
Mean Pre- and Postintervention Scores and Mean Difference×
MeasurePreintervention MeanPostintervention MeanMean Difference
Participation
 COPM performance (score range: 1 low–10 high)
  Participant 13.554.300.75
  Participant 24.175.751.58
  Participant 33.615.531.91
  Participant 42.003.701.70
 COPM Satisfaction (score range: 1 low–10 high)
  Participant 14.206.151.96
  Participant 24.174.300.17
  Participant 33.845.151.31
  Participant 42.253.801.55
Activity
 FIM–SR (score range: 5 low–35 high)
  Participant 122.8028.205.40
  Participant 232.5033.501.00
  Participant 329.0028.75−0.25
  Participant 426.0027.251.25
 CAHAI (score range: 13 low–91 high)
  Participant 139.8052.6012.80
  Participant 266.0071.755.75
  Participant 324.2538.5014.25
  Participant 417.7529.2511.50
Impairment
 ARAT Grasp (score range: 0 low – 18 high)
  Participant 113.2016.803.60
  Participant 217.0018.001.00
  Participant 39.6012.753.15
  Participant 43.255.752.50
 ARAT Grip (score range: 0 low–12 high)
  Participant 17.809.802.00
  Participant 211.2512.000.75
  Participant 37.008.251.25
  Participant 44.255.501.25
  ARAT Pinch (score range: 0 low–18 high)
  Participant 11.606.605.00
  Participant 210.009.75−0.25
  Participant 31.002.251.25
  Participant 40.250.750.50
 ARAT Gross Motor (score range: 0 low–9 high)
  Participant 18.809.000.20
  Participant 29.009.000.00
  Participant 37.408.250.85
  Participant 44.756.251.50
Table Footer NoteNote. ARAT = Action Research Arm Test; CAHAI = Chedoke Arm and Hand Activity Inventory; COPM = Canadian Occupational Performance Measure; FIM–SR = Self-Report Functional Independence Measure.
Note. ARAT = Action Research Arm Test; CAHAI = Chedoke Arm and Hand Activity Inventory; COPM = Canadian Occupational Performance Measure; FIM–SR = Self-Report Functional Independence Measure.×
Table 2.
Mean Pre- and Postintervention Scores and Mean Difference
Mean Pre- and Postintervention Scores and Mean Difference×
MeasurePreintervention MeanPostintervention MeanMean Difference
Participation
 COPM performance (score range: 1 low–10 high)
  Participant 13.554.300.75
  Participant 24.175.751.58
  Participant 33.615.531.91
  Participant 42.003.701.70
 COPM Satisfaction (score range: 1 low–10 high)
  Participant 14.206.151.96
  Participant 24.174.300.17
  Participant 33.845.151.31
  Participant 42.253.801.55
Activity
 FIM–SR (score range: 5 low–35 high)
  Participant 122.8028.205.40
  Participant 232.5033.501.00
  Participant 329.0028.75−0.25
  Participant 426.0027.251.25
 CAHAI (score range: 13 low–91 high)
  Participant 139.8052.6012.80
  Participant 266.0071.755.75
  Participant 324.2538.5014.25
  Participant 417.7529.2511.50
Impairment
 ARAT Grasp (score range: 0 low – 18 high)
  Participant 113.2016.803.60
  Participant 217.0018.001.00
  Participant 39.6012.753.15
  Participant 43.255.752.50
 ARAT Grip (score range: 0 low–12 high)
  Participant 17.809.802.00
  Participant 211.2512.000.75
  Participant 37.008.251.25
  Participant 44.255.501.25
  ARAT Pinch (score range: 0 low–18 high)
  Participant 11.606.605.00
  Participant 210.009.75−0.25
  Participant 31.002.251.25
  Participant 40.250.750.50
 ARAT Gross Motor (score range: 0 low–9 high)
  Participant 18.809.000.20
  Participant 29.009.000.00
  Participant 37.408.250.85
  Participant 44.756.251.50
Table Footer NoteNote. ARAT = Action Research Arm Test; CAHAI = Chedoke Arm and Hand Activity Inventory; COPM = Canadian Occupational Performance Measure; FIM–SR = Self-Report Functional Independence Measure.
Note. ARAT = Action Research Arm Test; CAHAI = Chedoke Arm and Hand Activity Inventory; COPM = Canadian Occupational Performance Measure; FIM–SR = Self-Report Functional Independence Measure.×
×