Use of Occupations and Activities in a Modified Constraint-Induced Movement Therapy Program: A Musician’s Triumphs Over Chronic Hemiparesis From Stroke

Donald Earley; Ellen Herlache; Dana R. Skelton

doi:10.5014/ajot.2010.08073

Abstract

OBJECTIVE. This case report addresses the use of therapeutic occupations and activities within a modified constraint-induced movement therapy (mCIMT) approach for a 52-yr-old female violinist 4 yr after ischemic stroke.

METHOD. Analysis of occupational performance was completed before and after intervention using a modified version of the Fugl-Meyer Sensorimotor Evaluation, the Motor Functioning Assessment, the Arm Improvement and Movement Checklist, and information obtained from a client journal maintained throughout treatment. The mCIMT protocol included use of constraint of the affected arm, with emphasis placed on participation in meaningful occupations and activities.

RESULTS. Improved function in the affected extremity was noted at the conclusion of mCIMT. After completion of therapy, the client reported a return to playing violin.

DISCUSSION. The findings from this case report suggest that use of meaningful occupations and activities integrated into a mCIMT protocol may be effective in addressing skills deficits for clients with upper-extremity chronic hemiparesis.

In recent years, the literature has described numerous approaches to addressing residual sensorimotor effects of cerebral vascular accidents (CVAs; Liepert, Bauder, Miltner, Taub, & Weiller, 2000; Schultz-Krohn, Royeen, McCormack, Pope-Davis, & Joudan, 2006; Taub, Uswatte, & Morris, 2003; Wolf et al., 2006). Many traditional therapeutic approaches have been used to treat those with hemiparesis, including proprioceptive neuromuscular facilitation, movement therapy, neurophysiological–sensorimotor treatment, and neurodevelopmental interventions (Schultz-Krohn et al., 2006). However, contemporary interdisciplinary studies have suggested that modified constraint-induced movement therapy (mCIMT) is a highly effective rehabilitation approach for use with people with chronic impairment and disability of the upper extremity (Gillot, Holder-Walls, Kurtz, & Varley, 2003; Kunkel et al., 1999; Page, Sisto, Johnston, & Levine, 2002; Page, Sisto, Levine, Johnston, & Hughes, 2001; Pierce et al., 2003; Porter & Lord, 2004; Van der Lee et al., 1999; Wolf et al., 2006).

This case report demonstrates how therapeutic occupations and activities were used within a mCIMT approach to address upper-extremity motor control impairments in a 52-yr-old female violinist 4 yr after ischemic stroke. Through participation in meaningful occupations and activities within a mCIMT approach, the client was able to return to a valued occupational role in her community, that of a talented violinist in several community symphony orchestras.

The term case report refers to a retrospective approach that describes how one case was managed and the outcomes of that case. Case reports, as a methodology, reflect actual client situations and provide a context for learning about occupational therapy case issues (Creswell, 1998; McEwen, 1996). This case report will provide occupational therapists with information about the use of occupations and activities within a mCIMT approach to provide meaningful interventions to clients experiencing chronic residual sensorimotor impairment from CVA.

Learned Disuse

Ischemic stroke is a deficiency of blood to the brain caused by an occlusion of an artery from a thrombus or embolism. Ischemic stroke can result in contralateral motor and sensory impairment involving the upper extremity and the face, trunk, and lower extremity (Bierman & Atchison, 2000). As the course of the disability becomes more chronic, a learned disuse phenomenon may occur. When attempts to use the affected upper extremity during the performance of daily occupations produce negative results, people tend to use the affected arm less and, consequently, adapt and habituate to using their unaffected upper extremity for most daily tasks. This downward spiral of disuse contributes to greater disability of the affected arm and hand (Wolf et al., 2006).

mCIMT

A typical mCIMT program involves 3 hr/day of therapy, 5 days/wk, for 4 wk. This form of movement therapy supports the use of traditional neurodevelopmental and motor control therapies in which constraint of the nonaffected upper extremity, combined with forced repetitive use of the affected upper extremity, work to improve function. The constraint is also worn on the unaffected hand, arm, or both during the top 5–6 arm-use hours at home every day during the treatment period (Page, 2004; Page et al., 2001; Pierce et al., 2003). For the purpose of this study, the top 5–6 arm-use hours included times in which forced use of the client’s affected upper extremity occurred with the client engaged in occupation-based activities outside of therapy. Research has shown that mCIMT is effective in addressing chronic residual upper-extremity motor control effects resulting from CVA (Bonaiuti, Rebasti, & Sioli, 2007; Hakkennes & Keating, 2005; Kunkel et al., 1999; Miltner, Bauder, Sommer, Dettmers, & Taub, 1999; Page, Sisto, Levine, & McGrath, 2004; Taub, Miller, & Novack, 1993; Van Peppen et al., 2004; Wolf, Lecraw, Barton, & Jann, 1989).

Occupation-Embedded Interventions

Relative to the neurologically impaired upper extremity, only a few studies have addressed occupation-embedded interventions as an effective tool within the rehabilitation process (Nelson, 1996; Trombly & Cole, 1979; Trombly & Ma, 2000; Trombly & Quintana, 1983; Trombly & Wu, 1999; Wu, Trombly, Lin, & Tickle-Degnen, 1998). Moreover, no studies have addressed use of mCIMT (e.g., see Rao, 2004) to assist clients in returning to participation in meaningful occupational roles in their communities. Although the importance of integrating therapeutic occupations and activities into practice with clients has been noted in key documents, including the Occupational Therapy Practice Framework: Domain and Process, 2nd Edition (American Occupational Therapy Association [AOTA], 2008), we were unable to locate any studies or case reports examining the explicit use of occupations and activities, as described in the Framework, in mCIMT interventions. This case report will supplement the literature in this area by illustrating how therapeutic occupations, as described in the Framework, can be integrated into a traditional mCIMT approach.

Occupational Therapy Processes

The Occupational Therapy Practice Framework identifies two types of occupational therapy intervention: (1) therapeutic use of self and (2) therapeutic use of occupations and activities. Therapeutic use of occupations and activities includes preparatory methods, purposeful activities, and occupation-based activities. In the context of mCIMT interventions, preparatory methods such as stretching, progressive resistive exercises, and weight bearing can be used to prepare clients (and the affected arm) for participation in purposeful activity. Purposeful activities can be designed to engage clients in goal-directed occupations. Some of these tasks can include the use of occupation simulation and motor learning strategies to include part–whole practice (Magill, 1989). Occupation-based activities can be used to engage clients in actual occupations that are part of their own context and match established client-centered goals (AOTA, 2008). Occupation-based activities could include tasks such as participating in meal preparation (Table 1).

Table 1.

Occupational Therapy Intervention

Therapeutic Use of Occupations and Activities	Definition	Examples of Intervention
Occupation-based activity	Allows the client to engage in actual occupations that are part of their own context and that match their goals (AOTA, 2008)	Home program; constraint worn during daily activities for 5-6 hr Craft activity; making scrapbook of meaningful violin experiences. Promoted self-expression, client-centeredness, and in-hand manipulation for affected extremity.
Purposeful activity	Allows the client to engage in goal-directed behavior or activities within a therapeutically designed context that lead to an occupation or occupations (AOTA, 2008)	Use of the Baltimore Therapeutic Equipment; simulation of violin playing by implementing the primary movements needed to play the violin Simulated playing the violin, which related to a dominant role in her life Opening jars; incorporated ulnar–radial deviation needed in violin playing, strengthening of intrinsic–extrinsic musculature, and also related to leisure activity of cooking which client enjoyed doing for comrades in orchestra.
Preparatory methods	Prepares the client for occupational performance Used in preparation for purposeful and occupation-based activities (AOTA, 2008).	Therapeutic stretching in all anatomical planes of motion Progressive resistive exercises Weight bearing and joint compression to affected extremity.

Note. AOTA = American Occupational Therapy Association.

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Table 1.

Occupational Therapy Intervention

Therapeutic Use of Occupations and Activities	Definition	Examples of Intervention
Occupation-based activity	Allows the client to engage in actual occupations that are part of their own context and that match their goals (AOTA, 2008)	Home program; constraint worn during daily activities for 5-6 hr Craft activity; making scrapbook of meaningful violin experiences. Promoted self-expression, client-centeredness, and in-hand manipulation for affected extremity.
Purposeful activity	Allows the client to engage in goal-directed behavior or activities within a therapeutically designed context that lead to an occupation or occupations (AOTA, 2008)	Use of the Baltimore Therapeutic Equipment; simulation of violin playing by implementing the primary movements needed to play the violin Simulated playing the violin, which related to a dominant role in her life Opening jars; incorporated ulnar–radial deviation needed in violin playing, strengthening of intrinsic–extrinsic musculature, and also related to leisure activity of cooking which client enjoyed doing for comrades in orchestra.
Preparatory methods	Prepares the client for occupational performance Used in preparation for purposeful and occupation-based activities (AOTA, 2008).	Therapeutic stretching in all anatomical planes of motion Progressive resistive exercises Weight bearing and joint compression to affected extremity.

Note. AOTA = American Occupational Therapy Association.

mCIMT is used to address how well and how often a person uses the impaired upper extremity. Similar to preparatory methods and purposeful activity, traditional mCIMT behavioral training principles of shaping and adaptive task practice are used as intervention strategies in mCIMT approaches to help clients with lower levels of motor control overcome learned disuse (Panyan, 1980; Taub, Crago, & Burgio, 1994; Wolf et al., 2006). These repetitive part–whole practice methods are used to enhance upper-extremity performance skills by helping clients to make improvements in small increments.

Like occupation-based interventions, functional task practice and standard task practice are used with clients who demonstrate higher levels of motor functioning and little to no learned disuse of their impaired upper extremities (Wolf et al., 2006). The ultimate goal of mCIMT, as with other occupation-based interventions, is to enhance clients’ abilities to participate in valued occupations.

Method

This case report involved use of quantitative and qualitative methodologies. The client was evaluated using a comprehensive assessment battery at the time of intake and at discharge. Evaluation tools assessed quality and quantity of movement, gross and fine motor control, and gross strength of the affected upper extremity. Qualitative data were collected from a daily participant journal and used to gain insight into the client’s thoughts and feelings regarding her participation in the mCIMT intervention. The study was approved by the university’s ethics review board, and the client provided informed consent to participate in the study.

Description of the Participant

At the time of the study, E. W. was a 52-yr-old White woman who had had an ischemic CVA 4 yr prior that predominantly affected the right side of her body. Before her CVA, E. W. was independent in all activities of daily living (ADLs) and instrumental activities of daily living (IADLs) and was a talented violinist. The CVA left her with symptoms including an impaired sense of equilibrium and balance. She also had decreased motor control on the right side, which significantly affected the quality of her violin playing. The only occupational therapy services that E. W. received before her participation in the mCIMT program was in the acute care setting of the hospital immediately after her stroke. Four years after her CVA, E. W. obtained physician’s consent for participation in the Arm Improvement and Movement mCIMT Program conducted in the spring 2007 at a university in the midwestern United States. This program was part of a research study investigating mCIMT.

mCIMT Program Inclusion Criteria

To participate in the mCIMT program, E. W. had to meet specific baseline criteria. All program participants had to be ≥6 mo poststroke and have scores of ≥24/30 on the Mini-Mental State Examination (MMSE; Folstein, Folstein, & McHugh, 1975; Wolf et al., 2006). Participants also had to be able to understand and follow written, verbal, and demonstrative direction and instruction. Hemiplegic shoulder pain, rotator cuff pain, bursitis, and tendonitis were exclusionary criteria; however, shoulder discomfort from osteoarthritis was not.

To take part in the program, participants had to be ambulatory without the use of assistive devices and have activity tolerance sufficient for full participation in all therapy activities. Clients also had to be able to actively complete the following actions with their affected upper extremity: (1) 45°–90° shoulder flexion and abduction; (2) 45° external rotation at the shoulder; (3) nominal elbow extension; (4) 45° forearm supination and pronation; (5) ≥5° wrist extension; (6) 5° digital extension, specifically thumb, index, and middle fingers; and (7) grasp and release a washcloth 3 times within 1 min (Wolf, Blanton, Baer, Breshears, & Butler, 2002).

Emotional support from family members or significant others plays an important role in helping clients stay motivated throughout the challenging mCIMT protocol. The degree and quality of this support was evaluated through the use of “readiness counseling” (Earley, 2007), which involved an initial occupational profile interview of the client and family. However, all participants also had to verbalize intrinsic motivation to participate fully in the mCIMT program, with no coercion from outside people such as physicians or family. If a client showed any reservations relative to participation in the mCIMT program, he or she was excluded.

Analysis of Occupational Performance

At the time of E. W.’s initial occupational therapy evaluation in May 2007, she voiced concerns regarding a slight limp in her gait, impaired balance and equilibrium, decreased strength in her affected right upper extremity, and decreased use of her affected arm when engaging in bilateral upper-extremity tasks. She also reported difficulty performing several basic ADLs, particularly dressing, grooming, feeding, and toileting.

E. W.’s chief concern, however, was the enduring effects of her CVA on her ability to play the violin. E. W. stated that her abilities to perform the primary movements needed to play the violin (particularly radial and ulnar deviation) were significantly affected by her CVA. She expressed that holding the violin and precise finger placement were essential to the quality of sound produced by the violin.

E. W. noted that after her CVA, her ability to play the violin dwindled considerably. Before, she had played in several community orchestras. After, however, she ceased playing in the orchestras, which affected her self-concept to the extent that “concerts were no longer an enjoyable experience. I was so depressed after the stroke about how my playing sounded. I could still perform in the orchestra, but was not fully satisfied.” At the conclusion of the initial evaluation, E. W. stated that her goal for therapy was to “have more control with my hand so I can play my violin better.” Being in the orchestra was a major life occupation for E. W. In accordance with the Framework, she achieved a sense of competence through her accomplishments in violin playing and reported a sense of satisfaction and fulfillment through skilled participation in this valued occupation.

Assessment

As described by Engel (2006), meaningful occupation-based treatment plans establish a connection between the components of function and actual occupational performance. E. W. desired to return to her pre-CVA role of successful violinist, a role she felt defined her existence. Thus, a top-down approach was used during the intake interview to gain insight into E. W.’s role competency and meaningfulness.

As noted by Engel (2006), “a top-down approach to assessment … is applicable to the evaluation of the client who sustained a stroke” (p. 810). Engel further stated that during top-down assessments, “inquiry [should be] focused on the roles that are important to the client who sustained a stroke, particularly those in which the client was engaged before the stroke” (p. 810). During the intake assessment, attention was paid to E. W.’s desired goals (return to violin playing in the orchestra) and to the underlying skills that would allow her to return to this valued occupation.

Information regarding E. W.’s goals for the mCIMT program, her thoughts about the program, and her progress during the course of treatment were obtained through daily conversations and review of a personal treatment journal she maintained for the program’s duration. E. W. was instructed by the therapist to write in this journal on a daily basis throughout the 4-wk program and was invited to record information regarding topics such as any noticeable changes in the function of her affected upper extremity, treatment-related frustrations, or new ideas or goals for treatment.

The Motor Function Assessment (MFA; Earley, 2005b) revealed deficits in strength and speed of fine and gross motor coordination in the affected right upper extremity (Table 2). Results from a modified version of the Fugl-Meyer Sensorimotor Evaluation (Fugl-Meyer, Jääskö, Leyman, Olsson, & Steglind, 1975) indicated deficits in total active motion in the affected extremity in all anatomical planes of motion; distal motion was intact but lacked control. Strength testing demonstrated the presence of strength deficits in the affected extremity, including gross upper-extremity strength (evaluated through manual muscle testing) and grip and pinch strength (Table 3). Finally, a Nine Hole Peg Test (Mathiowetz, Weber, Kashman, & Volland, 1985) completed as part of the modified Fugl-Meyer Sensorimotor Evaluation indicated deficits in fine motor coordination abilities, speed, and dexterity in the affected right hand. However, sensation and proprioception were intact.

Table 2.

Results of Motor Functioning Assessment

Right Affected Extremity	Initial Evaluation (s)	Reevaluation (s)
Task
Jux-A-Cisor (Sammons Preston, Bolingbrook, IL)	12	7
Pegboard	13	14
Hook-and-loop board	7	6
Shoulder arc	13	8
Checker piece in slot	13	6
BAPS board	49	38
Dice cup	12	9
Theraputty (Sammons Preston, Bolingbrook, IL)	24	12
Total	143	100

Note. BAPS = Biomechanical Ankle Platform System.

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Table 2.

Results of Motor Functioning Assessment

Right Affected Extremity	Initial Evaluation (s)	Reevaluation (s)
Task
Jux-A-Cisor (Sammons Preston, Bolingbrook, IL)	12	7
Pegboard	13	14
Hook-and-loop board	7	6
Shoulder arc	13	8
Checker piece in slot	13	6
BAPS board	49	38
Dice cup	12	9
Theraputty (Sammons Preston, Bolingbrook, IL)	24	12
Total	143	100

Note. BAPS = Biomechanical Ankle Platform System.

Table 3.

Results of Modified Fugl-Meyer Evaluation of Physical Performance

Activity	Pretest	Posttest
Active range of motion (ROM), degrees
Shoulder: Flexion	150	170
Abduction	150	170
External rotation	45	88
Internal rotation	50	71
Wrist: Flexion	53	80
Extension	40	65
Ulnar deviation	20	30
Radial deviation	10	19
Forearm: Pronation	74	80
Supination	70	80
Motion scoring (digits)^a	2	2
Manual muscle testing^b
Shoulder: Flexion	3–/5	5/5
Extension	3–/5	5/5
Abduction	2/5	5/5
Adduction	3/5	5/5
Elbow: Flexion–extension	3–/5	5/5
Wrist: Flexion	3–/5	5/5
Extension	3–/5	5/5
Digit grasp	Limited	Intact
Sensation	Intact	Intact
Proprioception	Intact	Intact
9-Hole Peg Test (s)	28	21
Pinch strength (lb)
Tripod	10	20
Lateral–key	8	17
Pad to pad	8	13
Jamar Dynamometer (lb)
Trial 1	40	62
Trial 2	41	60
Trial 3	38	63

^a0 = only a few degrees of motion; 1 = decreased passive ROM; 2 = normal passive ROM.

^b0 = no movement; 1 = a flicker of movement is seen or felt in the muscle; 2 = muscle moves the joint when gravity is eliminated; 3 = muscle cannot hold the joint against resistance but moves the joint fully against gravity; 4 = muscle holds the joint against a combination of gravity and moderate resistance; 5 = normal strength.

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Table 3.

Results of Modified Fugl-Meyer Evaluation of Physical Performance

Activity	Pretest	Posttest
Active range of motion (ROM), degrees
Shoulder: Flexion	150	170
Abduction	150	170
External rotation	45	88
Internal rotation	50	71
Wrist: Flexion	53	80
Extension	40	65
Ulnar deviation	20	30
Radial deviation	10	19
Forearm: Pronation	74	80
Supination	70	80
Motion scoring (digits)^a	2	2
Manual muscle testing^b
Shoulder: Flexion	3–/5	5/5
Extension	3–/5	5/5
Abduction	2/5	5/5
Adduction	3/5	5/5
Elbow: Flexion–extension	3–/5	5/5
Wrist: Flexion	3–/5	5/5
Extension	3–/5	5/5
Digit grasp	Limited	Intact
Sensation	Intact	Intact
Proprioception	Intact	Intact
9-Hole Peg Test (s)	28	21
Pinch strength (lb)
Tripod	10	20
Lateral–key	8	17
Pad to pad	8	13
Jamar Dynamometer (lb)
Trial 1	40	62
Trial 2	41	60
Trial 3	38	63

^a0 = only a few degrees of motion; 1 = decreased passive ROM; 2 = normal passive ROM.

^b0 = no movement; 1 = a flicker of movement is seen or felt in the muscle; 2 = muscle moves the joint when gravity is eliminated; 3 = muscle cannot hold the joint against resistance but moves the joint fully against gravity; 4 = muscle holds the joint against a combination of gravity and moderate resistance; 5 = normal strength.

The Arm Improvement and Movement (AIM) checklist (Earley, 2005a) was used to gather information regarding E. W.’s abilities in valued areas of occupation in her life (Table 4). AIM results indicated that E. W. had difficulty with ADL fasteners, basic grooming tasks, bilateral meal preparation activities, and activities requiring overhead reach. They also verified the presence of learned disuse in the affected extremity.

Table 4.

Results of the Arm Improvement and Movement Checklist

	Self-Rating (Quantity/Quality)
Activity	Mid-Way Progress	Final Evaluation
Buttons	3/2	4/3
Zippers	4/3	4/4
Tie shoe lace	4/3	4/4
Thread needle	3/2	4/3
Type	4/2	4/2
Use remote for TV	3/2	4/4
Brush/comb hair	4/2	4/4
Clip/file finger nails	4/2	4/4
Wash hair	4/2	4/3
Open bottle lid	4/3	4/4
Open condiment packs	4/3	4/4
Pass dishes	4/3	4/4
Put dishes in overhead cabinet	3/2	4/3
Screwdriver	4/2	4/3
Wrench	4/2	4/4
Total	56/35	60/53

Note. The use of your weak arm during daily activities: Quantity—0 = not used, 1 = rarely used, 2 = use half as much as before stroke, 3 = frequently used but not as much as I did, 4 = normal use. The use of your weak arm during activities: Quality—0 = not used, 1 = poor, 2 = fair (slow with effort), 3 = good, 4 = normal. Arm Improvement and Movement Checklist copyright © 2008 by Donald Earley. Reprinted with permission of the author.

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Table 4.

Results of the Arm Improvement and Movement Checklist

	Self-Rating (Quantity/Quality)
Activity	Mid-Way Progress	Final Evaluation
Buttons	3/2	4/3
Zippers	4/3	4/4
Tie shoe lace	4/3	4/4
Thread needle	3/2	4/3
Type	4/2	4/2
Use remote for TV	3/2	4/4
Brush/comb hair	4/2	4/4
Clip/file finger nails	4/2	4/4
Wash hair	4/2	4/3
Open bottle lid	4/3	4/4
Open condiment packs	4/3	4/4
Pass dishes	4/3	4/4
Put dishes in overhead cabinet	3/2	4/3
Screwdriver	4/2	4/3
Wrench	4/2	4/4
Total	56/35	60/53

Note. The use of your weak arm during daily activities: Quantity—0 = not used, 1 = rarely used, 2 = use half as much as before stroke, 3 = frequently used but not as much as I did, 4 = normal use. The use of your weak arm during activities: Quality—0 = not used, 1 = poor, 2 = fair (slow with effort), 3 = good, 4 = normal. Arm Improvement and Movement Checklist copyright © 2008 by Donald Earley. Reprinted with permission of the author.

Procedures

E. W. participated in the mCIMT portion of the AIM program, which was held at a university-based treatment site 3 hr/day, 5 days/wk, for 4 wk. In addition to clinic-based activities, E. W. was required to complete a home exercise program (HEP) throughout the program. The HEP required E. W. to wear a constraint on her affected right hand for the top 5–6 arm-use hr every day, outside of therapy (including weekends).

Constraint

The constraint was a mitt with padding on the palmar aspect and breathable netting on the dorsal aspect. A hook-and-loop wrist strap allowed for independent donning and doffing of the constraint. E. W. was required to wear the mitt during therapy and during the top 5–6 arm-use hr outside of therapy. E. W. was instructed to remove the mitt to allow for safe completion of activities requiring bilateral arm usage, such as community mobility and toileting activities. The padded safety mitt was selected as a constraint over a more rigid distal constraint (such as a splint) because it was felt that the mitt would be more comfortable and appealing to clients, thereby increasing compliance.

Occupation-Based mCIMT intervention

Activities and occupations used as preparatory methods, purposeful activities, and occupation-based activities were selected on the basis of E. W.’s overarching goal for therapy (to improve her ability to play the violin) and the previously identified deficits in client factors that affected her ability to return to this valued occupation. By focusing on this goal throughout treatment, the client and clinician were able to collectively develop a meaningful occupation-based treatment plan.

The Framework defines preparatory methods as interventions that are used to prepare a client for participation in meaningful occupations (AOTA, 2008). During mCIMT treatment, the therapist engaged E. W. in a variety of preparatory activities. Manual stretching in all anatomical motions was completed to promote good scapulohumeral rhythm, stability, and mobility (see Table 1). Progressive resistive exercises were completed to facilitate proximal shoulder stability and strengthening. Weight bearing and joint compression of the affected extremity was used to normalize muscle tone. These preparatory activities served as a foundation for participation in purposeful and occupation-based activities completed later in treatment.

Once preparatory methods were completed, purposeful activities were implemented to allow E. W. to practice specific skills and movements that were necessary for her to complete skilled occupations in natural environments (AOTA, 2008). Purposeful activities were used repetitively at an intense dose throughout therapy in an attempt to overcome learned disuse in E. W.’s affected extremity. Activities such as exercises on the Baltimore Therapeutic Equipment machine (BTE Technologies, Inc., Hanover, MD) were used to simulate the motions required for playing the violin. Fine motor coordination activities were carried out to target intrinsic–extrinsic strengthening, in-hand manipulation, and speed and dexterity of the affected hand, all of which are required for skillful violin playing. E. W. even practiced holding onto a simulated violin to address stability and strengthening to the affected extremity, without fear of dropping her actual violin (see Table 1).

The Framework defines occupation-based activity as those activities that promote client completion of actual occupations in natural contexts (AOTA, 2008). During the mCIMT intervention, E. W. participated in a variety of meaningful activities that also addressed deficits in client factors that affected her ability to play the violin. For example, during therapy E. W. expressed that she enjoyed viewing photos and putting together photo albums. Therefore, during one therapy session, the therapist engaged E. W. in making a scrapbook of meaningful violin experiences. E. W. also noted that she enjoyed preparing food for others; thus, she was encouraged to take an active role in preparing the weekly potluck lunches held throughout the course of the mCIMT intervention. Occupation-based tasks such as these promoted self-expression and client-centeredness, while simultaneously addressing deficits in client factors that affected E. W.’s ability to play the violin.

As noted previously, in addition to using her affected extremity in meaningful, therapeutic occupations and activities during mCIMT sessions, E. W. was expected to use her affected extremity in a variety of meaningful occupation-based activities for a minimum of the 5 top arm-use hr at home during each weekday of the 4-wk program. Because these activities were personally meaningful, E. W. put forth her best effort, with a resulting improvement in upper-extremity function. Thus, by integrating functional home-based occupations and activities into treatment, a connection was made between function and occupational performance.

Results

Notable improvements in function of the affected upper extremity were observed as treatment progressed. In particular, results of qualitative and quantitative data collection completed at the end of the 4-wk mCIMT program indicated the presence of improvements in gross and fine motor coordination, upper-extremity strength, and spontaneous use of the affected extremity (see Table 4).

Motor Function Assessment

E. W. demonstrated improvement in MFA scores (see Table 2). She increased her speed when performing all motor function tasks with the right affected hand. Moreover, in-hand manipulation was more controlled when completing handling tasks, as evidenced by decreased time required for completion of relevant assessment activities. The total time required to complete all MFA tasks at intake was 143 s. At discharge, E. W. required only 100 s to complete all tasks (a 31% decrease in total time required).

Modified Fugl-Meyer Evaluation

Improvements in active range of motion were also made in all joints of the affected upper extremity during the course of mCIMT intervention. During the intake evaluation, E. W.’s total active motion of the right upper extremity was 662°. At discharge, she displayed a total active motion measurement of 789°, a 16% increase in total active motion from intake to discharge in the affected upper extremity.

E. W. also displayed improvements in gross upper-extremity strength (as assessed via manual muscle testing) from intake to discharge. At intake, E. W. demonstrated overall muscle strength of 3-/5 for all movements in the affected upper extremity; at discharge, she demonstrated strength of 5/5 in the affected upper extremity, a notable increase in strength in the affected arm.

E. W.’s grip strength at intake was 39.6 lb; at discharge, her grip strength was 61.6 lb. Her pinch strength also improved, from 26 lb (sum of scores for tripod, lateral, and pad-to-pad pinches) at intake to 50 lb at discharge, representing almost a 50% increase in strength. E. W. also demonstrated a 7-s decrease in time required to complete the Nine Hole Peg Test from intake to discharge (intake score = 28 s; discharge score = 21 s).

AIM Checklist

Data for initial evaluation using the AIM were not available because of errors in completion of checklist by E. W. at the time of intake. However, AIM scores were obtained at the midpoint of the program (after 2 wk of therapy) and at the time of discharge. At the midpoint, E. W.’s scores on the AIM were 56 (quantity of movement) and 35 (quality of movement). At that point in therapy, E. W. reported that the activities that continued to cause her the most difficulties included those requiring precise use of the affected upper extremity, such as buttoning, tying shoelaces, typing on the computer, using the TV remote control, brushing and washing her hair, and putting dishes away on overhead shelves. At discharge, E. W. demonstrated improvements in both quantity and quality of movement, with scores of 60 and 53, respectively. In particular, she reported 1- to 2-point improvements (on a 5-point scale) in the quality and quantity of all activities identified as problematic (with the exception of typing and computer use) during the midprogram evaluation (Table 4). Thus, E. W. demonstrated improvements in both quantity and quality of movement of the affected upper extremity from midway to discharge, with the most drastic improvements noted in quality of movement.

Client Comments

E. W. was conscientious about wearing her constraint as directed by the therapist and recording in a daily journal when and why she removed her constraint at home, as well as any milestones noted throughout the course of therapy. As treatment progressed, E. W. reported many daily activities in which she noted improvements in right upper-extremity functioning. For example, in one entry, E. W. noted, “I can feel my hand getting stronger; I have no pain.” Another day, E. W. stated, “When doing my [therapy] homework and rating myself on different tasks, I [have] noticed much improvement.”

Follow-Up

One month after completing therapy, E. W. sent the therapist an unsolicited letter describing the effects of the mCIMT therapy on her valued role of playing the violin:

I played a program on my violin at a senior center today and just had to tell you how I felt. Before my stroke 4 years ago, I never had to worry about how I was holding my bow—it was always natural. I was about halfway through my program and all of the sudden I noticed that my bow hold was perfect, I wasn’t correcting it all the time, and my bow was nice and straight going across my violin. Not to mention, no scratching noises. Everything was just fluid. Only a few people noticed my big smile during the song. But it was enough that I know it felt good again. Nice strong bow strokes and confident playing. It’s been so long since that’s happened. (E. W., personal communication, July 2007)

Soon thereafter, E. W. returned to her skilled role of playing the violin in a community symphony orchestra.

Discussion

This investigation demonstrated that the use of therapeutic occupations and activities within a mCIMT approach were effective in allowing 1 client to return to participation in a valued occupational role in the community. Most published mCIMT studies have focused on the improvement of motor skills, without regard to functional outcomes in the areas of occupation (Bonaiuti et al., 2007; Hakkennes & Keating, 2005; Van Peppen et al., 2004). Unfortunately, these studies did not address how therapists can use information regarding clients’ valued occupational roles and self-identified goals to design mCIMT treatment programs that are both methodologically sound and personally meaningful to clients.

This case report demonstrates how mCIMT fits into, and is consistent with, the scope of occupational therapy as highlighted in the Framework. The treatment approaches used throughout the mCIMT program were aligned with the values inherent in the occupational therapy intervention process. The rationale used by the treating therapist in this case report was not a new approach to mCIMT. Indeed, the selected occupational therapy treatment approach paralleled other interdisciplinary motor control approaches to mCIMT by integrating part–whole and whole practice approaches (Carr & Shepherd, 2000). However, by using a client-centered, top-down approach to assessment and treatment and using the Framework as a guide to the selection of therapeutic interventions, the therapist was able to integrate meaningful occupational therapy interventions (including occupations and activities) into treatment to promote achievement of client-identified goals. Through participation in this mCIMT program, the client regained the performance skills that were necessary for her to return to a valued occupational role in the community, that of skilled orchestral violin player.

In completing a quantitative comparative analysis of this mCIMT protocol’s efficacy with E. W., this study’s results are consistent with improvements seen in the literature. Typical gains include an improvement of approximately 33% on the MFA. Similarly, on the scales that measured perception of the quality and quantity of arm use with routine and customary ADLs, E. W. made approximately one level of improvement on a 5-point scale (Pierce et al., 2003). The mCIMT program appeared to push E. W.’s advancement from the plateau that she was experiencing relative to motor control and motor functioning of the involved upper limb. Although E. W. was performing at a high-functioning level before her participation in mCIMT, notable improvements were observed after her involvement in the program.

This case report confirms and corroborates that both sensorimotor and functional improvement can be made relative to the chronic residual disability resulting from the effects of stroke, even when significant time has passed (in E. W.’s case, 4 yr; for examples, see Bonaiuti et al., 2007; Taub et al., 1993; Wolf et al., 1989, 2006). Thus, it demonstrates how this contemporary approach to stroke rehabilitation (mCIMT) fits into client-centered practice following Framework guidelines (AOTA, 2008). Using preparatory methods, purposeful activities, and occupation-based tasks in a mCIMT program helped E. W. overcome disability attributed to the chronic effects of her stroke. As a result, E. W. met her established goal of returning to playing violin in the local orchestra, a valued role that was disrupted by her stroke.

Because a case report is considered the lowest level of research based on the Hierarchy of Levels of Evidence-Based Practice (as described in Holm, 2000), the results of this case report cannot be generalized to other people. Moreover, although the three assessments used to evaluate client performance (the AIM Checklist, the MFA, and a modified form of the Fugl-Meyer Evaluation of Physical Performance) were administered following a strict protocol, they are not standardized and have no established reliability or validity. Additionally, therapists must be cautious when generalizing the results of this case to people who want to participate in mCIMT programs because client motivation and compliance is critical to improved outcomes. However, case reports do inform practice such that clinicians may use this information to make clinical decisions about future patients.

Conclusion

This case report highlights how therapeutic occupations and activities within a mCIMT approach were used with a 52-yr-old woman 4 yr after ischemic stroke to enable her to return to her valued occupational role of skilled violinist. The case report demonstrates that preparatory methods, purposeful activities, and occupation-based tasks delivered through a mCIMT program that is focused on assisting the client to achieve self-identified, personally meaningful goals can help a client overcome sensorimotor disability and improve occupational performance. Future research using both quantitative and qualitative research methodologies would be useful to examine mCIMT’s effect on people’s performance patterns. In particular, studies integrating greater elements of control (such as randomized controlled studies) could help provide stronger evidence of mCIMT interventions’ effectiveness in using therapeutic occupations and activities to help clients with chronic hemiparesis return to valued occupations.

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Table 1.

Occupational Therapy Intervention

Therapeutic Use of Occupations and Activities	Definition	Examples of Intervention
Occupation-based activity	Allows the client to engage in actual occupations that are part of their own context and that match their goals (AOTA, 2008)	Home program; constraint worn during daily activities for 5-6 hr Craft activity; making scrapbook of meaningful violin experiences. Promoted self-expression, client-centeredness, and in-hand manipulation for affected extremity.
Purposeful activity	Allows the client to engage in goal-directed behavior or activities within a therapeutically designed context that lead to an occupation or occupations (AOTA, 2008)	Use of the Baltimore Therapeutic Equipment; simulation of violin playing by implementing the primary movements needed to play the violin Simulated playing the violin, which related to a dominant role in her life Opening jars; incorporated ulnar–radial deviation needed in violin playing, strengthening of intrinsic–extrinsic musculature, and also related to leisure activity of cooking which client enjoyed doing for comrades in orchestra.
Preparatory methods	Prepares the client for occupational performance Used in preparation for purposeful and occupation-based activities (AOTA, 2008).	Therapeutic stretching in all anatomical planes of motion Progressive resistive exercises Weight bearing and joint compression to affected extremity.

Note. AOTA = American Occupational Therapy Association.

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Table 1.

Occupational Therapy Intervention

Therapeutic Use of Occupations and Activities	Definition	Examples of Intervention
Occupation-based activity	Allows the client to engage in actual occupations that are part of their own context and that match their goals (AOTA, 2008)	Home program; constraint worn during daily activities for 5-6 hr Craft activity; making scrapbook of meaningful violin experiences. Promoted self-expression, client-centeredness, and in-hand manipulation for affected extremity.
Purposeful activity	Allows the client to engage in goal-directed behavior or activities within a therapeutically designed context that lead to an occupation or occupations (AOTA, 2008)	Use of the Baltimore Therapeutic Equipment; simulation of violin playing by implementing the primary movements needed to play the violin Simulated playing the violin, which related to a dominant role in her life Opening jars; incorporated ulnar–radial deviation needed in violin playing, strengthening of intrinsic–extrinsic musculature, and also related to leisure activity of cooking which client enjoyed doing for comrades in orchestra.
Preparatory methods	Prepares the client for occupational performance Used in preparation for purposeful and occupation-based activities (AOTA, 2008).	Therapeutic stretching in all anatomical planes of motion Progressive resistive exercises Weight bearing and joint compression to affected extremity.

Note. AOTA = American Occupational Therapy Association.

Table 2.

Results of Motor Functioning Assessment

Right Affected Extremity	Initial Evaluation (s)	Reevaluation (s)
Task
Jux-A-Cisor (Sammons Preston, Bolingbrook, IL)	12	7
Pegboard	13	14
Hook-and-loop board	7	6
Shoulder arc	13	8
Checker piece in slot	13	6
BAPS board	49	38
Dice cup	12	9
Theraputty (Sammons Preston, Bolingbrook, IL)	24	12
Total	143	100

Note. BAPS = Biomechanical Ankle Platform System.

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Table 2.

Results of Motor Functioning Assessment

Right Affected Extremity	Initial Evaluation (s)	Reevaluation (s)
Task
Jux-A-Cisor (Sammons Preston, Bolingbrook, IL)	12	7
Pegboard	13	14
Hook-and-loop board	7	6
Shoulder arc	13	8
Checker piece in slot	13	6
BAPS board	49	38
Dice cup	12	9
Theraputty (Sammons Preston, Bolingbrook, IL)	24	12
Total	143	100

Note. BAPS = Biomechanical Ankle Platform System.

Table 3.

Results of Modified Fugl-Meyer Evaluation of Physical Performance

Activity	Pretest	Posttest
Active range of motion (ROM), degrees
Shoulder: Flexion	150	170
Abduction	150	170
External rotation	45	88
Internal rotation	50	71
Wrist: Flexion	53	80
Extension	40	65
Ulnar deviation	20	30
Radial deviation	10	19
Forearm: Pronation	74	80
Supination	70	80
Motion scoring (digits)^a	2	2
Manual muscle testing^b
Shoulder: Flexion	3–/5	5/5
Extension	3–/5	5/5
Abduction	2/5	5/5
Adduction	3/5	5/5
Elbow: Flexion–extension	3–/5	5/5
Wrist: Flexion	3–/5	5/5
Extension	3–/5	5/5
Digit grasp	Limited	Intact
Sensation	Intact	Intact
Proprioception	Intact	Intact
9-Hole Peg Test (s)	28	21
Pinch strength (lb)
Tripod	10	20
Lateral–key	8	17
Pad to pad	8	13
Jamar Dynamometer (lb)
Trial 1	40	62
Trial 2	41	60
Trial 3	38	63

^a0 = only a few degrees of motion; 1 = decreased passive ROM; 2 = normal passive ROM.

^b0 = no movement; 1 = a flicker of movement is seen or felt in the muscle; 2 = muscle moves the joint when gravity is eliminated; 3 = muscle cannot hold the joint against resistance but moves the joint fully against gravity; 4 = muscle holds the joint against a combination of gravity and moderate resistance; 5 = normal strength.

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Table 3.

Results of Modified Fugl-Meyer Evaluation of Physical Performance

Activity	Pretest	Posttest
Active range of motion (ROM), degrees
Shoulder: Flexion	150	170
Abduction	150	170
External rotation	45	88
Internal rotation	50	71
Wrist: Flexion	53	80
Extension	40	65
Ulnar deviation	20	30
Radial deviation	10	19
Forearm: Pronation	74	80
Supination	70	80
Motion scoring (digits)^a	2	2
Manual muscle testing^b
Shoulder: Flexion	3–/5	5/5
Extension	3–/5	5/5
Abduction	2/5	5/5
Adduction	3/5	5/5
Elbow: Flexion–extension	3–/5	5/5
Wrist: Flexion	3–/5	5/5
Extension	3–/5	5/5
Digit grasp	Limited	Intact
Sensation	Intact	Intact
Proprioception	Intact	Intact
9-Hole Peg Test (s)	28	21
Pinch strength (lb)
Tripod	10	20
Lateral–key	8	17
Pad to pad	8	13
Jamar Dynamometer (lb)
Trial 1	40	62
Trial 2	41	60
Trial 3	38	63

^a0 = only a few degrees of motion; 1 = decreased passive ROM; 2 = normal passive ROM.

^b0 = no movement; 1 = a flicker of movement is seen or felt in the muscle; 2 = muscle moves the joint when gravity is eliminated; 3 = muscle cannot hold the joint against resistance but moves the joint fully against gravity; 4 = muscle holds the joint against a combination of gravity and moderate resistance; 5 = normal strength.

Table 4.

Results of the Arm Improvement and Movement Checklist

	Self-Rating (Quantity/Quality)
Activity	Mid-Way Progress	Final Evaluation
Buttons	3/2	4/3
Zippers	4/3	4/4
Tie shoe lace	4/3	4/4
Thread needle	3/2	4/3
Type	4/2	4/2
Use remote for TV	3/2	4/4
Brush/comb hair	4/2	4/4
Clip/file finger nails	4/2	4/4
Wash hair	4/2	4/3
Open bottle lid	4/3	4/4
Open condiment packs	4/3	4/4
Pass dishes	4/3	4/4
Put dishes in overhead cabinet	3/2	4/3
Screwdriver	4/2	4/3
Wrench	4/2	4/4
Total	56/35	60/53

Note. The use of your weak arm during daily activities: Quantity—0 = not used, 1 = rarely used, 2 = use half as much as before stroke, 3 = frequently used but not as much as I did, 4 = normal use. The use of your weak arm during activities: Quality—0 = not used, 1 = poor, 2 = fair (slow with effort), 3 = good, 4 = normal. Arm Improvement and Movement Checklist copyright © 2008 by Donald Earley. Reprinted with permission of the author.

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Table 4.

Results of the Arm Improvement and Movement Checklist

	Self-Rating (Quantity/Quality)
Activity	Mid-Way Progress	Final Evaluation
Buttons	3/2	4/3
Zippers	4/3	4/4
Tie shoe lace	4/3	4/4
Thread needle	3/2	4/3
Type	4/2	4/2
Use remote for TV	3/2	4/4
Brush/comb hair	4/2	4/4
Clip/file finger nails	4/2	4/4
Wash hair	4/2	4/3
Open bottle lid	4/3	4/4
Open condiment packs	4/3	4/4
Pass dishes	4/3	4/4
Put dishes in overhead cabinet	3/2	4/3
Screwdriver	4/2	4/3
Wrench	4/2	4/4
Total	56/35	60/53

Note. The use of your weak arm during daily activities: Quantity—0 = not used, 1 = rarely used, 2 = use half as much as before stroke, 3 = frequently used but not as much as I did, 4 = normal use. The use of your weak arm during activities: Quality—0 = not used, 1 = poor, 2 = fair (slow with effort), 3 = good, 4 = normal. Arm Improvement and Movement Checklist copyright © 2008 by Donald Earley. Reprinted with permission of the author.