Running head CONSTRAINT INDUCED MOVEMENT THERAPY - PDF document

CIMT 1 Running head: CONSTRAINT INDUCED MOVEMENT THERAPY The Effects of Constraint - Induced Movement Therapy and Modified Constraint - Induced Movement Therapy on Quality of Life among Persons with Chronic Hemiparesis Ashley Morrow, Elizabeth Ballor, Jill Kil lingbeck, and Megan Haskin Saginaw Valley State University CIMT 2 Abstract Purpose: This study examined the effects of constraint - induced movement therapy (CIMT) and modified constraint - induced movement therapy (mCIMT) on quality of life among persons demo nstrating learned nonuse of an affected upper extremity status post CVA. Method: A mixed methods approach, consisting of both qualitative and quantitative methodology , was used to examine the impact of CIMT and mCIMT on quality of life for persons demonst rating upper extremity learned nonuse following a CVA. Results: The Stroke Impact Scale showed im provement in all areas of quality of life in both CIMT and mCIMT groups . However, the CIMT group showed greater gains than the mCIMT group over the assessment areas. Conclusion: The data collected suggested t hat both CIMT and mCIMT can produce increased overall gains in quality of life among persons demonstrating learned nonuse of an affected upper extremity status post CVA . CIMT 3 The Effects of Constraint - Induced Movement Therapy and Modified Constraint - Induced Movement Therapy on Quality of Life Among Persons with Chronic Hemiparesis Cerebral vascular accidents (CVAs), otherwise known as strokes, account for nearly 7

80,000 deaths annually in the United States. A CVA occurs as a result of the blood and oxygen supply to the brain becoming disrupted, causing an insufficient amount of nutrients to reach the brain. CVAs are the third most common cause of death, and impact the lives of Americans eve ry 40 seconds in the United States. CVAs are also the leading cause of long - term disability among Americans (“Stroke Statistics,” 2008). Hemiparesis, or weakness on one side of the body, is one deficit that may be experienced by individuals who have sust ained CVAs. Learned non - use is a common condition that often arises when hemiparesis is present, as an individual begins to rely on his or her unaffected side to compensate for weakness to the contralateral side. Learned non - use or inactivity of the affect ed side may further contribute to disability and hinder occupational performance in areas of daily life activities and experienced quality of life (Wu et al., 2007). Quality of life has been identified as a problem for many people post - st roke. As discussed by King (1996), there is a need to assist stroke survivors in coping with the effects of stroke. In a study examining quality of life, 30 percent of the 86 participants were measured to be within a depressed range. Within the four doma ins examined, the quality of life of stroke survivors was measured as lowest in health and functioning. Objectives such as participation in leisure recreations, usefulness to others, and general mobility were some of the are as most affected by stoke observ ed in this study (King, 1996).

Constraint - induced movement therapy (CIMT) is a promising approach for the treatment of hemiparesis and learned non - use following a CVA. CIMT involves forcing the use of the CIMT 4 affected limb in order to improve functi on of a partially paralyzed upper extremity in clients who have experienced a stroke. The unaffected limb is immobilized by a constraint as a part of an intense treatment protocol that involves therapy for six hours a day for two weeks, as well as in a ho me program, with a goal of forcing movement of the affected extremity (Caimmi et al., 2008). A modified version of this protocol, called modified constraint - induced movement therapy (mCIMT), involves constraint of the unaffected extremity for three hours per day, five days per week, for a total of four weeks. A home program is also included with this protocol (Earley, 2008). Research Problem Limited research has been completed to examine the effects of CIMT/mCIMT on quality of life post - stoke. For examp le, Dettmers and colleagues found in a study of 11 participants, that some aspects including quality of life were improved after completing a modified CIMT program (Dettmers et al., 2005). However, there is an overall lack of literature discussing the effe ctiveness of CIMT/mCIMT on the improvement of quality of life. Yet it appears that, due to its reputation as having a posit i ve i mpact on individuals with chronic hemiparesis and learned non - use, CIMT and mCIMT may have a positive effect on the quality of l ife for those who are post stroke (Jamison & Orchaniam, 2007). Purpose of the Study The purp

ose of this two - phase, sequential, mixed methods research study was to examine the effects of constraint - induced movement therapy (CIMT) and modified constraint - induced movement therapy (mCIMT) . This study focused on the effects of the programs on the quality of life of persons who had sustained a stroke and who demonstrated learned nonuse of the affected upper extremity. CIMT 5 Research Questions and Hypotheses The fi rst two research questions were answered through the use of quantitative data collected through the Stroke Impact Scale. 1) Does participation in mCIMT improve the quality of life for clients who have experienced chronic hemiparesis status post CVA? Nul l hypothesis: There is no significant difference in the pre - to post - intervention Stroke Impact Scale Version 3.0 scores among participants involved in a mCIMT program. H O : µ 1 = µ 2 , where µ 1 = Stroke Impact Scale Version 3.0 pretest scores µ 2 = Stroke I mpact Scale Version 3.0 posttest scores Alternative Hypothesis: There is a significant difference in the pre - to post - intervention Stroke Impact Scale Version 3.0 scores among participants involved in a mCIMT program. H A : µ 1 ≠ µ 2 2) Does participation i n CIMT improve the quality of life for clients who have experienced chronic hemiparesis status post CVA? Null hypothesis: There is no significant difference in the pre - to post - intervention Stroke Impact Scale Version 3.0 scores among participants involve d in a CIMT program. H O : µ 1 = µ 2 , where µ 1 = Stroke Impact Scale Version 3.0 pretest scores µ

2 = Stroke Impact Scale Version 3.0 posttest scores Alternative Hypothesis: There is a significant difference in the pre - to post - intervention Stroke Impact Sca le Version 3.0 scores among participants involved in a CIMT program. H A : µ 1 ≠ µ 2 CIMT 6 The final two research questions were answered through the use of qualitative data collected through post treatment focus groups. 3) Does participation in mCIMT/CIMT impro ve the occupational performance of clients who have experienced chronic hemiparesis status post CVA? 4) Does participation in mCIMT/CIMT improve the client’s perceived quality of life status post CVA? Definition of Terms Brain plasticity. Brain plasticit y is the capability of the brain to compensate for loss of function due to a possible disruption of neuronal organization or damage to the brain (Kolb & Whishaw, 2003). Cerebral vascular accident. A cerebral vascular accident, or stroke, is a disorder of t he blood vessels within the brain that is the result of an interrupted blood flow. Disruptions of the blood and nutrient supply to the brain will cause subsequent neuronal death to the brain vessels, and cause neurological symptoms (Eckert, 2007). Constrai nt induced movement therapy. Constraint Induced Movement Therapy (CIMT) is a treatment program that is implemented by forcing the use of the affected limb in order to improve function of a partially paralyzed upper extremity among clients who have experien ced a stroke (Caimmi et al., 2008). Hemiparesis. Hemiparesis is weakness or partial paralysis affecting one side of the body. It i

s frequently caused by a cerebral vascular accident, or brain lesion. Paresis typically occurs on the side of the body opposi te to the lesion, due to the decussating or crossing of the motor tracts of the brain (Eckert, 2007). CIMT 7 Learned non - use. Learned non - use is a condition that often results from the consequences of a stroke. This condition leads to the discontinuation of the client’s use of his/her affected extremity for daily life tasks due to sustained cortical disorganization. Permanent disability or dependency may result after continued disuse of an affected extremity, which can decrease occupational performance (Wu et al. , 2007). Modified constraint - induced movement therapy. Modified c onstraint i nduced m ovement t herapy (mCIMT) is a treatment protocol in which the duration and amount of therapy or the constraint regimen differs from original CIMT program ( Hakkennes & Keatin g, 2005 ). Treatment is implemented by forcing the use of the affected limb in order to improve function of a partially paralyzed upper extremity among clients who have experienced a stroke (Caimmi et al., 2008). Occupational performance. Occupational perf ormance is the act of being able to complete or participate in activities that are necessary for an individual to survive. These include any activity that an individual completes on a daily basis. Occupational performance allows the individual to learn a nd adapt to the environment and activities (Hansen, Dirette, & Atchison, 2007). Quality of life. Quality of life is an individual’s global feelings of well - being and satisfa

ction within the cultural context and value system within which one resides (Camp os & Johnson, 1990). For the purposes of this study, quality of life will be measured using the Stroke Impact Scale. This scale assesses how a stroke has affected an individual’s health and daily living. CIMT 8 Significance of the Study The study explored whe ther mCIMT/CIMT had an effect on the quality of life and occupational performance of clients who were post stroke. The results of this study showed that the use of the mCIMT/CIMT program improved the participant’s occupational functioning and quality of li fe after sustaining a stroke. The data obtained from this study also contributed to the body of knowledge concerning mCIMT/CIMT, and also supports the existing studies that suggest the use of mCIMT/CIMT for rehabilitation in clinical settings to address de ficits in quality of performance in occupations and quality of life post stroke. Review of the Literature Recently, there has been an increased amount of well - designed research studies that have investigated the therapeutic benefits of mCIMT/CIMT on physi cal functioning post - CVA. However, quality of life among stroke survivors who have received mCIMT/CIMT has yet to be thoroughly examined. This review will provide an overview of the existing literature related to mCIMT/CIMT and quality of life of individua ls post stroke. First, the literature review will discuss hemiparesis and its impact on learned non - use on the affected extremity. Second, the review will address the origins of CIMT in early CVA rehabilitation, and the gains achieved thro

ugh the use this approach to treatment. Finally, neuroplasticity will be discussed and the implications of cortical reorganization on improved brain recovery in chronic stroke patients. Constraint Induced Movement Therapy (CIMT) Constraint - induced movement therapy and mod ified constraint - induced movement therapy are rehabilitative treatment techniques that are used to improve the quality of function of an affected limb experiencing hemiparesis. Strokes may result in hemiparesis, which cause s weakness on one side of the bod y. Strokes are an increasingly common health problem in the CIMT 9 United States, with four million Americans struggling daily with the effects of a stroke. Strokes are the leading cause of sensorimotor disability in the United States (“Stroke Statistics,” 2008) . However, upper extremity (UE) function, which can be negatively affected by a stroke, is needed to complete activities of daily living, improve independence, and maintain a high quality of life (Hakkennes & Keating, 2005). Learned nonuse CIMT and mCI MT are therapeutic interventions that aim to restore upper extremity functioning that has been lost secondary to learned nonuse (Wolf et al., 2006). Learned nonuse is a phenomenon in which stroke survivors stop using their affected extremities, despite th e presence of intact motor ability in the affected extremity. Early research conducted by Taub in the S ilver Springs Monkey Experiment provided the first information regarding this phenomenon. During the Silver Springs experiment, sensation in one of the m onkeys’ arms was taken away, but the mot

or ability was left intact (a process known as deafferentiation ). Taub observed that, not long after sensation was taken away from the arm, the monkeys stopped using their affected arms, even though motor ability wa s present. The monkeys relied solely on their non - affected arm to perform within their environment. However, when Taub applied a constraint to the non - affected arm of the monkeys, and forced them to use their affected arms, functional use of the affected arm was gradually restored (Taub et al., 1999). The information learned from the Silver Springs experiment was later applied to research with humans who had sustained strokes and subsequently demonstrated learned nonuse. CIMT was first used on patients who were status post CVA by Taub in 1980. Taub’s treatment protocol required clients to have their unaffected limb restrained for 90% of their waking hours for two weeks, and participate in exercise training for six hours a day (Hakkennes & Keating, CIMT 10 2005) . Taub found that individuals with weakness of one side of the body (hemiparesis) could benefit from CIMT (Taub et. al., 1999). Therapeutic protocols Taub’s therapy has since evolved since the early research with monkeys, and today there are two main ty pes of CIMT used in the rehabilitation of persons with upper extremity hemiparesis status post CVA. Both CIMT and mCIMT involve constraining the unaffected limb, in efforts to force the affected arm to regain movement through participation functional movem ent. The CIMT constraint is worn for six hours a day, for five days a week, for a total of two complete week

s. The mCIMT protocol involves wearing a constraint on the unaffected extremity for three hours a day, five days a week for four total weeks of cons traint wear (Taub et. al., 1999). CIMT/mCIMT techniques include restricting the unaffected limb for a sustained period of time and encouraging client participation in exercises that are task - specific, to retrain the affected limb to do functional daily act ivities. CIMT/mCIMT therapy exercises consist of participation in activities requiring functional movement patterns including grasping, pinching, reaching, lifting, and placing. The participant completes these tasks in a repetitive fashion. Repetitive pra ctice and shaping are used to retrain the brain and rebuild the neuropathways that were damaged as a result of the stroke. Repetitive practice of specific tasks may encourage motor planning and experience - related adaptations. Daily tasks are also integrate d into the therapeutic protocol to increase strength, range of motion, and muscle tone in the affected upper extremity (Boake et al., 2007). Blanton and Wolf (1999) discussed the success of CIMT in terms of restoring upper extremity function 3 to 9 month s post CVA, compared to traditional stroke rehabilitation. The CIMT 11 researchers noted that the benefits of restricting the unaffected arm remain ed after the constraint was removed. Their research showed that learned non - use does exist , and when an individual i s forced to use their affected arm, the phenomenon can be reversed. With the help of an intense CIMT protocol, learned non - use can be overcome and client s can

regain some function and movement in their affected limb. Neuroplasticity When learned non - use o ccurs, the individual compensates for the lack of movement from the affected extremity, making the non - affected extremity more dominant. Individuals acquire non - use when they attempt to use their affected limb in an activity and fail at the task, after sus taining an injury. Unfortunately, individuals who do not use or ignore one side of the body are limiting their freedom and independence, and decreasing their quality of life (Bonifer, Anderson, & Arciniegas, 2005). The idea of neuroplasticity has been us ed to explain the effects of repetitive, forced use on upper extremity function post brain insult. Neuroplasticity is the brain’s ability to reorganize itself in efforts to compensate for loss of function due to damage to one area of the brain. Research co nducted by Dombovy (2004) demonstrated that repetitive use of an involved extremity is key to optimal brain reorganization status post CVA. According the neuroplasticity theory, the structures of the brain lying adjacent to the area where the damage (infar ct) occurred , will reorganize and function for that area. CIMT and mCIMT have indeed been shown to produce both clinical improvement and cortical reorganization in chronic stroke patients. Furthermore, e arly forced arm use or exercise of the affected extr emity post CVA has been shown to stop cell loss and di suse that will lead to degeneration (Kleim, Jones, & Schallert, 2003) . CIMT 12 Outcome Potential Hakkennes and Keating (2005) completed a

metaanalysis of a number of trials that examined the effectiveness of CIMT compared to other rehabilitative techniques in the areas of quality of life, patient satisfaction, health care costs, and improved function. Overall, it appears that CIMT benefits those who comply with the strict protocol and commit themselves fully t o the program. According to Wolf et al. (2006) , in the EXCITE r andomized c linical t rial , CIMT participants showed statistically significant improvements of upper extremity function in compar ison to participants receiving traditional therapy. The results of this study, which included 222 participants within seven clinical sites , were that arm mobility increased significantly a nd lasted for more than a year. According to Ching - yi, Chia - ling, Wen - chung, and Keh - chung (2007), learned non - use may also occur if patients ar e advised by others to rely on their unaffected arm to complete tasks, to avoid becoming frustrated with attempts to use their affected side. CIMT can be implemented with those who have experienced a stroke and have hemiparesis, to reverse the debilitation of learned non - use. Through consistent constraint wear, the individual will begin to relearn that it is possible to use the affected arm in daily tasks (Hakkennes & Keating, 2005). Quality of Life Quality of life may be simply described as a person’s individual perception and feelings of overall enjoyment and satisfaction with life. Quality of life after a stroke is evaluated by looking at various factors. Age, gender, the ability to perform activities

of daily living (ADL), level of disa bility, support of friends and family, the presence of depression, and living arrangements can all have a significant impact on the level of quality of life post stroke (Nichols - Larsen, Clark, Zeringue, Greenspan, & Blanton, 2005). Quality of life is an i mportant factor to CIMT 13 consider when investigating the effects of a stroke and outcomes of stroke rehabilitation. Feelings of well - being are important in order to promote the continuation of positive healthcare outcomes throughout rehabilitation and after. H owever, d espite the importance of quality of life at this time, there has been limited research exploring the impacts of various approaches to stroke rehabilitation on quality of life (Carod - Artal, Egido, Gonza´lez, & de Seijas, 2000). Carod - Artal et al. (2000) have suggested that four areas of health (physical, psychosocial, functional, and social) must be explored in the assessment of post - stroke quality of life. Physical health includes any physical symptoms experienced as a result of disease. Psycho logical health is described as functioning within the emotional and cognitive domains . Functional health refers to independent living capabilities, such as care of self, mobility and successful role opportunities and fulfillment. Social health includes t he presence and amount of support available through family, friends, and the community. Measuring Quality of Life Post - CVA As reported by Carod - Artal et al. (2000), quality of life is difficult to consistently measure , specifically in regards to a cerebra l vascular acc

ident, due to problems with construct validity . The quality of life an individual reports is based on his/her own perception, and may vary greatly when compared from person to person. In addition, it is difficult to compare statistics or op inions taken from patients who have variability in the effects of their condition, and treatment programs received (such as programs at general rehabilitation centers versus specialized stroke rehabilitation centers ). Despite these issues, i t is vital tha t therapists attempt to provide treatment that may address quality of life , and help promote functioning at the highest level possible , to ensure positive results are maintained and continued after the rehabilitation program has ceased (Carod - Artal et al. ) . However, there is minimal research exploring this CIMT 14 aspect of functioning after a CVA, or how specific types of treatment interventions affect quality of life (Hakkennes & Keating, 2005). The quality of life of an individual may be compro mised as a result of a stroke. Immediate changes in function that occur after a stroke may lead a person to believe that he/she may never use his/her extremities to their full potential again. L earned non - use occurs as a result of compensating for hemiparesis. CIMT forc es an individual to overcome learned non - use by using the affected limb as the primary limb in activities of daily living. CIMT has been gaining in popularity due to its consistent effectiveness in remediating deficits in upper extremity function resulting from CVA . However , there is very little research

available on the effects of CIMT on quality of life. Yet, the success of CIMT and mCIMT on individuals post stroke in other areas of function, such as improved performanc e and use of the affected limb aft er participating in such a program, provides reason to believe that quality of life may be a targeted outcome to be improved through mCIMT/ CIMT as well. Restoration of upper extremity function may lead to improved participation, promoting an increase in t he perception of quality of life. Method Research Design A mixed methods approach, consisting of qualitative and quantitative methodology, was used in this study. The quantitative portion of the study involved use of a quasi - experimental, nonequivalent, t wo - group pretest - posttest design (as described in Portney & Watkins, 2008). Qualitative data was collected via client journaling and a post - treatment focus group. Together, these approaches allowed the researchers to examine the effects of CIMT and mCIMT on quality of life. Treatment groups were determined via participants’ stated preference (CIMT vs. mCIMT CIMT 15 protocol), as well as participants’ individual capabilities and therapeutic tolerance for the requirements of each protocol. Participants In order t o participate in this study, participants were required to meet specific criteria for CIMT , as outlined by Blanton and Wolf (1999) . These criteria included the ability to complete a specific set of active movements with the affected arm. These movements included: 45 - 90 degrees of s houlder flexion and abduction; 45 degrees of external rot

ation at the shoulder; minimal active elbow extension ; 45 degrees of forearm supination and pronation ; at least five degr ees of wrist extension ; and five degrees of active digital extension (specifically in the thumb, index, and middle fingers). Each participant was also required to be able to grasp and release a washcloth three times within one minute (Blanton & Wolf ). Exclusion criteria included the presence of any prio r medical issues that could potentially interfere with CIMT/mCIMT treatment, such as recent myocardial infarction, seizures, severe osteoporosis, or any condition that a referring physician may have considered to be dangerous for participants’ health. Shou lder pain (such as rotator cuff pain, bursitis, or tendonitis), with the exception of arthritis, was also an exclusionary criterion. In addition, that participants had to be six months or more post - stroke at initial evaluation, able to understand verbal a nd written instructions, and have satisfactory activity tolerance. Potential clients also needed to have enough strength and endurance to complete each day’s therapeutic interventions, and be able to participate in the pre and post - test assessments and re assessments. The participants were also required commit to the two or four week program and adhere to the strict protocol. Ten participants were selected from a convenience sample of people who responded to advertisements for the study. The sample was split into two treatment groups, with four CIMT 16 participants in each based on client preference, individual capabilities, and therapeutic

tolerance for each protocol. Although ten participants began the study, eight participants followed protocol and completed the program. Instrumentation The Stroke Impact Scale Version 3.0 was used to gather quantitative data regarding participants’ quality of life in the areas of physical, mental, social, and emotional functioning . The Stroke Impact Scale (SIS) is a 60 - item self report that takes approximately 10 to 15 minutes to complete. It evaluates eight domains of functioning believed to impact an individual’s quality of life : strength, mobility, hand function, ADLs and IADLs, memory and thinking, emotion, communicatio n, and social participation . C lient s rate how their stroke has affected each domain, on a Lickert scale. The SIS also contains a final question that asks clients to rate their perception of overall recovery , from 0 (no recovery) to 100 (full recovery) (Ca rod - Artal et al. , 2008) . The Stroke Impact Scale 3.0 has been previously evaluated for validity and reliability. It was found to have satisfactory internal reliability, test - retest reliability, and adequate convergent validity. Thus, the Stroke Impa ct Scale has been deemed a valid tool to assess the quality of life of stroke patients (Carod - Artal et al. , 2008). In the present study, q ualitative data was collected throughout the program via progress notes and journals , as well as at the end of the p rogram through the use of a focus group. O verall s atisfaction with the CIMT/mCIMT program was determined from the clients ’ feedback r

ecorded in progress notes and how well they use their affected arm in daily occupations after participating in the program. Questions asked during the focus group were designed to facilitate communication bet ween participants and to allow the participant s to verbalize their perception s regarding quality CIMT 17 of life following a stroke. The q uestions focused on participant s ’ tho ughts regarding the CIMT/mCIMT program and protocol, and quality of life before and after participation in the program. Follow - up interviews with four participants were also carried out in the fall of 2009, three - month post - treatment. The purpose of the i nterviews was to evaluate the long - term effects of CIMT/mCIMT on the involved participants. Procedures Study site. The study was completed on the campus of a public medium - sized university in the Midwestern United States. All treatment was provided in a group setting. However, all participants worked individually with occupational therapy graduate students with advanced training in CIMT/mCIMT, under the supervision of at least one professor who was a registered occupational therapist (OTR). The student therapist to participant ratio was 1:1 or 2:1. The study was approved by the University’s Institutional Review Board prior to implementation. Data collection. The Stroke Impact Scale 3.0 was administered pre and post treatment within the treatment facili ty. Participants were instructed to complete the scale independently or with assistance from family or caregivers. A ssistance from the student therapist was provide

d if necessary for correct completion of the assessment. Researchers also took notes of pro gress or decline of individual participants throughout the completion of various exercises and activities, in order to effectively document responses for qualitative data collection. Additional data regarding the participants’ perception of themselves thr oughout the program was collected from several different sources to establish themes and enable the participants to be active members of the intervention process. The clients were given journals to log their experiences of the CIMT/mCIMT program and to ref lect on mini - milestones CIMT 18 achieved. They were encouraged to reflect upon their daily journal entries with their student therapist. Two focus groups were also conducted to allow the participants to share how CIMT/mCIMT treatment affected their perceived leve l of function. The first focus group took place two weeks into treatment , and included all participants. The second one took place four weeks post treatment on the final day of assessment ; it included only the mCIMT participants. Researchers took notes du ring the focus group s, noting client s ’ feelings of satisfaction about the program , as well as any issues or concerns that participants may have had regarding the treatment. Questions focused on changes in occupational performance or quality of life experi enced by participants from pre to post inte r vention. Both focus groups were digitally recorded. Intervention. During activities, each participant wore a mitt on the unaffected upper extremity to force the us

e of the affected upper extremity . Mitts were fabricated with cotton and netting to provide comfort and breathability for each client; the hand and wrist were kept in a neutral position during activities. The mitt served as a physical barrier and reminder to refrain from using unaffected upper extrem ity. Activities that the clients participated in were based on theories concerning shaping and repetition, with the overall goal being the reduction of the learned nonuse phenomenon that typically occurs with hemiplegia (Wolf et al., 2006). The particip ants completed many shaping/adaptive activities involving preparatory methods and purposeful activities, as well as occupation - based activities. Some examples of purposeful activities that were implemented include putting pennies in a bank, peg boards, an d manipulating nuts and screws. Some CIMT 19 examples of occupation - based activities included home maintenance, work - simulation, preparing and eating meals, and playing cards, board games, and outdoor games. Individuals’ treatment was centered on their goals, s trengths, weaknesses, and current recovery stage. Participants’ interests were considered during treatment planning so that clients would perceive treatment activities as being both meaningful and purposeful (Kramer, Hinojosa, & Royeen, 2003). All interv entions were planned with reference to the Occupational Therapy Practice Framework: Domain & Process in regards to activities of daily living (A merican O ccupational T herapy A ssociation , 2008) as well as theory of CIMT/mCIMT. Intervention activities focuse d on progres

sive arm movements deviating away from flexor synergy. Therapeutic activities (tabletop and functional tasks, such as use of clothespins and thera - putty) were used to facilitate repetitive use of the affected upper extremity. Neurorehabilitat ive techniques were incorporated in blocked and random practice. Rood techniques (or associated reactions), proprioceptive neuromuscular facilitation (PNF) methods, and Affolter techniques (hand over hand guidance) were also used during treatment sessions . There were no activities integrated into treatment specifically to address quality of life. However, in completing the previously mentioned activities, the goal of treatment was to increase independence and confidence in performing a variety of daily t asks, leading to an overall increase in quality of life. Furthermore, many activities were chosen to facilitate socializing and relationship building between the clients, in order to make treatment more enjoyable and encourage building of support systems. For participants at a Brunnstrom level four, the student therapists utilized a bottom - up approach to treatment with a focus on occupation as a means (Kramer et al., 2003), preparatory methods, and purposeful activity (AOTA, 2008). For participants at Bru nnstrom levels five or CIMT 20 six, therapy was based on a top - down approach, with increased focus on occupation - based activities (AOTA). This approach allowed clients to focus on fine motor abilities and successful task completion. For participants receiving t he traditional CIMT protocol, lunch was utilized as a part of the program inter

vention; for participants in the mCIMT g roup, snacks were provided as a chance to improve functional abilities and provide social interaction. Lunch was used as an opportunity to encourage social interaction and rapport building within the group of clients. Short breaks were given throughout the treatment session, and all tasks were graded to provide a just right challenge to control the level of fatigue of the participant. A nother aspect of the program was the daily review of clients’ journals. In these journals, the clients were asked to record the amount of time spent wearing the constraint, “mini milestones” achieved within occupational performance, and the participants’ feelings about the program. This was used so that both the therapist s and participant s could gain insight into client s ’ perception s of the program and of their progress. If a certain skill was found to be frustrating to a client at home, the client and s tudent therapist worked together to come up with a possible solution, such as treatments that focused on mastering the skill. Data analysis. Descriptive statistics were used to analyze the quantitative data collected from the Stoke Impact Scale. Analys es were done individually to examine each of the client’s scores within each question in order to average and group the scores. The percentage differences between individuals’ pre and post treatment scores were also determined. Calculations were also comp leted to find averages between treatment groups. Differences were compared between the CIMT and mCIMT groups; the researchers examin

ed which group benefitted the most concerning the impact each program had on quality of life. CIMT 21 Due to a small sample size, the researchers were unable to use inferential statistics to test for significance within the hypothes e s. The researchers sought to determine if there was a significant difference in the pre - to post - intervention Stroke Impact Scale Version 3.0 scores am ong participants involved in a CIMT and mCIMT program. While examining the results, researchers noted an inconsistency within two subquestions. These questions were eliminated upon investigation due to the confusing nature of the reve rsal of Lickert scal e values. Qualitative data was also used to evaluate the impact of CIMT/mCIMT treatment on the perceived quality of life and occupational functioning of participants. The coding process that took place after the focus group consisted of the student ther apists listening to the focus group transcription, recording notes, and referencing daily progress notes to identify themes to determine the effectiveness of CIMT/mCIMT in promoting quality of life in post - stroke clients. Trustworthiness was a priority w hile gathering and assessing qualitative data during the CIMT/mCIMT study. Any changes within the context are noted in limitations in order to increase the dependability of this study. The researchers gathered information from multiple sources at various t imes and contexts throughout the study, which supported triangulation on the data collected (including the focus group, journals, and conversations with the clients during each treatment sessi

on). Member checking was also completed to ensure that the clien t’s perceptions accurately matched the therapists’ interpretation of progress made in CIMT/mCIMT. Furthermore, data was themed and organized by thirteen student therapists involved with the project, to ensure multiple perspectives and viewpoints were utili zed to ensure content validity to the qualitative findings. Results Results of Quantitative Data Analysis CIMT 22 Eight participants ( four who received CIMT and four who received mCIMT) were evaluated in regards to their quality of life pre and post interventi on using the Stroke Impact Scale. Themes were derived (see Appendix A). The final analysis indicated that the four CIMT participants ( Appendix B, Table 1) showed improvements in all subquestions , with the exception of communication, of the Stroke Impact S cale. The mCIMT participants ( Appendix B, Table 2) showed positive improvements in all subsections of the Stroke Impact Scale. On average, the CIMT participants increased their overall quality of life perception of themselves by 24.3 % between pre and pos t testing periods. In comparison, the mCIMT participants increased their overall recovery perception by an average 17.9 percent . The percentage difference between pre and post individual scores is found in Appendix C, Tables 1 and 2. Results of Qualitat ive Data Analysis The qualitative data demonstrated that overall, there was a perceived positive change within the clients in their quality of life from pre to post intervention in both the CIMT and mCIMT groups . Sev

en themes were gained from the data an alysis of the qualitative portion of the study. The data was collected from daily journals, daily notes, and a focus group for which both two and four week participants were present. The themes identified included : 1) change of lifestyle; 2) positive imp rovement; 3) “I want to see how far I can go”; 4) “Yes, I got what I expected”; 5) decreased pain; 6) “It’s like having a job again”; and 7) overall enjoyment. These themes are described in the following paragraphs, using direct quotes as well as summariz ed thoughts from the participants. Change of l ifestyle. Participants were asked how their lifestyle was affected due to their stroke. The common theme was a complete change of lifestyle. One participant stated that his/her “lifestyle changed drastically, especially in the areas of work and leisure.” The stroke CIMT 23 impacted not only the physical aspect of the participants’ lives but also the mental aspect. One person described it as “a life - changing experience.” Yet, other participants were optimistic in say ing that you have to “accept it and make it better” and “if it takes me thirty years, I will get better.” Positive i mprovement . Participants noted high levels of satisfaction with mCIMT/CIMT in terms of its impact on final occupational performance. Ther e was a consensus of overall good improvement among the clients, based upon client feedback received during and after the program. One participant noted that now “I catch myself using my [affected] arm and hand” and another stated that

“other people are n oticing changes , ” as a result of participation in CIMT . Participants stated that they were feeling better about themselves and the potential for improved occupational performance. Several participants commented that they were doing “most everything with m y affected hand.” Another participant commented in a progress note, “I am happy I can straighten my hand out; my fingers were on vacation for ten years.” The progress that was seen during and after the program helped to improve the participants’ quality of life by increasing their motivation to attempt things that they were not able to do after experiencing the stroke. This motivation also improved their self - esteem and also encouraged them to be more independent while at home. “I want to see how far I c an go.” Another area examined during the final evaluation concerned how clients’ own perceptions of themselves changed as a result of the participation in the mCIMT/CIMT program. The comments were both positive and negative. A participant noted that “I c an’t get past it; I feel people look at me,” when discussing having difficulty confidently participating in activities without feeling self conscious due to the physical side effects of stroke. However, other participants said that the little gains in lif e are what keep them CIMT 24 going, one commented “look at it this way: people aren’t doing things like I am,” implying that they have found different ways to continue to complete tasks that are important to them. Expectations m et . The next question asked all of t he

participants if they were satisfied with the results obtained from participating in the CIMT/mCIMT program. There was an overwhelming, unanimous yes. One exclaimed, “Yes, I am thrilled” while another stated “I am seventy - five percent better [and] that ’s good.” Another client claimed, “Yes, I got what I expected.” Many of the participants were happy with the results of the program; one individual stated that he is “Glad to participate” and he noticed that his affected arm had more endurance when complet ing functional activities , contributing to his quality of life through participation . Several clients were impressed by the results in such a way that they added they would like to participate in the program again if it were to be offered. Decreased p ai n . Several participants noted during daily discussion, documented through SOAP notes, that they were experiencing noticeable changes in their pain. Pain experienced was primarily noted within the shoulder of most clients. Reduced pain contributed to incre ased function. One client stated, “I can button my shirt by myself now that my shoulder does not hurt as much.” This client initially reported pain at a level of eight out of ten; at the end of the study he reported a pain level of four out of ten. In a ddition, another client came in with low pain, which increased with the sudden addition of intense treatment. By the end of the study, he was experiencing no pain. Several clients noted d ecreased levels of pain contributed to improved quality of life thr ough enhanced sleep and functional skills. “It’s like having a j

ob again . ” The participants were then asked what aspect of their lives was most affected by participation in the CIMT/mCIMT program. One participant stated that the program provided a daily s chedule that made them feel like they had a job again. The early CIMT 25 morning start each day provided a reason to get up in the morning , as well as a structured environment for at least three hours on the weekdays. Having these resources gave the participants an opportunity to complete tasks that were valuable to them every day and give each day further purpose , contributing to their overall perception of quality of life . Overall enjoyment . When participants were asked whether or not they enjoyed the treatment activities, each responded positively. One participant responded, “Yes, I enjoyed it. You guys made it interesting and fun.” Another participant stated that they wanted to come back if the program were to be offered again. Overall, everyone enjoyed th e activities that were offered during the program, which helped make the program a success. Participants worked and played together, fostering encouragement and amiability throughout the program. Discussion This study examined the effects of CIMT and mCIM T on quality of life among persons demonstrating learned nonuse of an affected upper extremity status post CVA. The overall findings of this study conclude that participants experienced positive outcomes concerning improvement of quality of life a fter eac h of the programs. O ur results show that although both groups improved, mCIMT showed the biggest gains. The quali

tative informatio n gathered from the therapists observations and focus group resulted in seven themes, as earlier mentioned : change of lifesty le, positive improvement, “I want to see how far I can go”, “Yes, I got what I expected”, Decreased pain, “It’s like having a job again”, overall enjoyment). A common theme expressed among the research participants was a dramatic increase in positive impr ovements and motivation to continue therapeutic gains. Overall, participants met thei r expectations with the CIMT/mCI MT program stating that “ n ow I want to see how far I can go” because of participation in this study. In addition, another CIMT 26 participant co mmented, “After participating in this program, I feel like I’m not alone in the world” with this condition, and “Now I catch myself when I’m using my good hand and consciously switch to my other hand.” Limitations While gathering qualitative data , the res earchers noted that s ome participants were less apt to consistently fill out daily journal entries. Daily progress notes were not always completed throughout each session, causing post - session note s to be incomplete , which may have led to some subjective information being unnoted. The small sample size also prevented the researchers from testing for statistical significance in the Stroke Impact Scale. Portney and Watkins (2000) stated that the influence of sample size on the power of a test is critical . The larger the sample size, the greater the statistical power. Smaller samples are less likely to be good representatives of pop

ulation characteristics, and therefore, true differences between groups are less likely to be recognized. When very small samp les are used (n30), as is often the case in clinical research, power is substantially reduced. (pp. 403) In addition , neither single nor double blinding was used upon initial evaluation. Participants were also given the choice of which treatment group to be in, in effort to fit schedules and encourage attendance. Lack of randomization may have also been a limitation in this study. Small sample size prevented the use of inferential statistics in the data analysis of this study. Additional general limitat ions involving this CIMT/mCIMT study include having a small sample size of Caucasian participants, each of middle socioeconomic class , from a limited geographic region. The participants were screened for underlying conditions; however, clients who had ass istive devices and expressive aphasia were also accepted . Additionally, two CIMT 27 participants had prior obligations and were unable to make it to a few of the therapy sessions. Finally, inconsistency in cons traint - wearing schedule and attendance may have weak ened the ability to compare these results to future CIMT/mCIMT study results. Conclusions The results of this study indicated that quality of life in clients that have experienced stroke can be impacted through the use of this treatment protocol . In conc lusion, the quantitative findings show ed that both groups, the two week group and the four week group, showed improvement; the four - week group showed a greater incre

ase in their perception of their quality of life post treatment than the two - week group. The qualitative data gathered through daily notes, daily journals, and a focus group illustrated that participants found CIMT and mCIMT to be beneficial in impacting their recovery post - stroke. Seven themes were found to be relevant to participants, whic h included: change of lifestyle, positive improvement, “I want to see how far I can go”, “Yes, I got what I expected”, Decreased pain, “It’s like having a job again”, and overall enjoyment. Participants agreed that the treatment was worthwhile and althoug h the protocol was demanding, they would be willing to participate in a future program. Future recommendations for research in the impact of CIMT/mCIMT on clients with stroke include investigation in to (a) the adjustment of roles and (b) the effects of a follow - up CIMT/mCIMT program with adults. Role adjustment was shown to be a great impacting factor for participants’ quality of life in this study. Performance within these roles was very important to participants. Several participants also mentioned th at they would again participate in a CIMT/mCIMT program; a follow up program may show additional benefits for experienced clients. In addition, examining and utilizing a consistent warm up phase may show to be CIMT 28 beneficial for optimal results in future stud ies. Examination of these areas may further contribute to the knowledge of the most effective way to use CIMT protocol. Overall, this program showed that both groups experienced increases in function and

quality of life , especially in their perception of themselves in areas of : physical strength, memory, emotional control, communication skills, mobility, hand use, and performance of meaningful daily activities. The examination of these areas revealed that t he clients’ self efficacy of participation w as s hown to improve. Both CIMT and mCIMT groups expressed satisfaction with the program and the results. The results of this study will contribute to the current supportive evidence of the effectiveness of CIMT and mCIMT as a treatment for people who have ex perienced stroke and have lowered levels of quality of life . CIMT 29 Acknowledgments This study was completed in partial fulfillment of the requirements for the student researcher’s Master of Science in Occupational Therapy degree campus of a public state university campus in the Midwestern United States. We would like to thank Donald Ear ley, OTD, MA, OTR L, associate professor of Occupational Therapy, for the CIMT/mCIMT training, continuous support, guidance, and vast knowledge throughout the treatm ent sessions. We would also like to thank Ellen Herlache, MA, OTR L, Research C oordinator for the Occupational Therapy program, for supervising during the treatment sessions, and guidance throughout the research project design, implementation, and statisti cal analysis portion of our study. In addition, we thank Jill Ewend, OTR L , S imulation L earning L aboratory A ssociate for the OT department, for her supervision and assistance during the treatment sessions. We would like to thank J.J. Boeh

m for his assistan ce with advertising. Finally, we would like to thank our participants. Without their commitment and cooperation, our study would have not taken place. CIMT 30 References American Heart Association. (2008, June 9). Stroke statistics . Retrieved from h ttp://www.americanheart.org/presenter.jhtml?identifier=4725 . American Occupational Therapy Association (2008). Occupational therapy framework: Domain and process. American Journal of Occupational Therapy, 56 , 609 - 639. Blanton, S. , & Wolf, S. L. (1999). A n application of upper - extremity constraint - induced movement therapy in a patient with subacute stroke. Physical Therapy , 79, 847 - 853. Boake, C., Noser, E. A., Ro, T., Baraniuk, S., Gaber, M., Johnson, R., et al. (2007). Constraint - induced movement therapy during early stroke rehabilitation. Neurorehabilitation and Neural Repair , 21 , 14 - 24. Bonifer, N. M., Anderson, K. M., & Arciniegas, D. B. (2005). Constraint - induced movement therapy after stroke: Efficacy for patients with minimal upper - extremity motor a bility Archive Physical Medical Rehabilitation , 86, 1867 - 1873. Caimmi, M., Carda S., Giovanzana, C., Maini, E. S., Sabatini, A. M., S mania, N., et al. (2008). Using kinematic analysis to evaluate constraint - induced movement therapy in chronic stroke patie nts. The American Society of Neurorehabilitation, (22) 1, 31 - 39. Campos, S. S., & Johmson, T.M. ( 1990). Cultural considerations. In B. Spilker (Ed.), Quality of life assessment in clinical trials (pp. 163 - 170). New York: Raven. Carod -

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K., & A tchison, B. J. (2007). Thinking like an OT. In B. Atchison & D. Dirette (Eds.), Conditions in occupational therapy: Effects on occupational performance (pp. 6). Baltimore, MD: Lippincott Williams & Wilkins. Hakkennes, S. , & Keating, J. L. (2005). Constrai nt - induced movement therapy following stroke: A systematic review of randomized controlled trials. Australian Journal of Physiotherapy, 51, 221 – 231. CIMT 32 Jamison, P.W., & Orchanian, D.P. (2007). Cerebrovascular accident. In B. Atchison & D. Dirette (Eds.), Cond itions in occupational therapy: Effects on occupational performance (pp. 186). Baltimore: Lippincott Williams & Wilkins. King, R. B. (1996). Quality of life after stroke . Stroke, 27, 1467 - 1472. Kleim, J. A., Jones, T.A., & Schallert, T. (2003) . Motor enrich ment and the induction of plasticity before or after brain injury. Neurochemical Research , 28 (11). Kolb, B., & Whishaw, I. (2003). Fundamentals of human neuropsychology . New York, NY: Worth Publishers. Kramer, P., Hinojosa, J., & Royeen, C. B. (2003). Perspectives in human occupation: Participation in life. Baltimore, MD: Lippincott Williams & Wilkins. Lewis, C., Freeman, J., Fox, M., Bower, L., & Pena, F. (2005). Constraint - induced movement therapy as a home activity - A case report. Palaestra , 21 , 38 - 5 5. Macko, R. F., Benvenuti, F., Stanhope, S., Macellari, V., Taviani, A., Nesi, B., et al. (2008). Adaptive physical activity improves mobility function and quality of life in chronic hemiparesis. Journal of Rehabilitation Research and Development , 45 , 32 3 - 328.

Nichols - Larsen, D.S., Clark, P.C., Zeringue, A., Greenspan, A., & Blanton, S. (2005). Factors influencing stroke survivors’ quality of life during subacute recovery. Stroke, 36, 1480 - 1484 . Portney, L., & Watkins, M. (2009). Foundations of clinical research: Applications to practice (3 rd e d.). Upper Saddle River, N J : Pearson Prentice Hall. Wolf, S. L., Winstein, C. J., Miller, P., Taub, E., Uswatte, G., Morris, D., et al. (2006). Effect of constraint - induced movement therapy on upper extremity functi on 3 to 9 months after CIMT 33 stroke: The EXCITE randomized clinical trial. The Journal of the American Medical Association, 296 , 2095 - 2104. Retrieved from http://jama.ama - assn.org . Wu, Ching - yi, Keh - chung Lin, Hsieh - ching Chen, I - hsuen Chen, & Wei - hsien (2007). Effects of modified constraint - induced movement therapy on movement kinematics and daily function in patients with stroke: A kinematic study of motor control mechanisms. The American Society of Neurorehabilitation 21 (5) , 460 - 66. CIMT 34 Appendix A Table 1: Stroke Impact Scale Questionnaire Themes 1) Physical problems which may have occurred as a result of your stroke. 2) Memory and thinking 3) How you feel, about changes in your mood and about your ability to control your emotions. 4) Your ability to communi cate with other people, as well as your ability to understand what you read and what you hear in a conversation. 5) Activities you might do during a typical day. 6) Your ability to be mobile, at home and in the comm

unity. 7) Your ability to use your hand that was M OST AFFECTED by your stroke. 8) How stroke has affected your ability to participate in the activities that you usually do, things that are meaningful to you and help you to find purpose in life. 9) On a scale of 0 to 100, with 100 representing full recovery and 0 representing no recovery, how much have you recovered from your stroke? CIMT 35 Appendix B: CIMT & mCIMT Raw Scores Table 1. CIMT Raw Scores Test Areas Client #2 Client #3 Client #7 Client #10 Total Score % Change (+/ - ) Pre Post Pre Post Pre Post Pre Post Pre Post Physical 10 13 14 16 12 15 12 14 48 58 20.8 Memory & Thinking 31 32 30 32 22 25 34 35 117 124 6.0 Emotions 27 31 26 27 25 33 28 28 106 119 12.3 Communication 35 31 14 31 27 30 35 35 131 127 - 3.1 ADLs/IADLs 45 47 30 49 40 44 49 50 181 190 5.0 Mobility 36 42 44 45 36 43 30 40 146 170 16.4 Hand Function 15 22 13 14 12 20 21 25 61 81 32.8 Social Participation 32 39 36 38 30 35 22 41 120 153 27.5 Total Recovery 60 80 50 60 75 90 0 0 185 230 24.3 CIMT 36 Table 2. mCIMT Raw Scor es Test Areas Client #4 Client #5 Client #8 Client #9 Total Score % Change (+/ - ) Pre Post Pre Post Pre Post Pre Post Pre Post Physical 11 12 12 15 9 12 14 20 46 59 28.3 Memory &

Thinking 31 34 35 35 31 31 32 32 129 132 2.3 Emotions 31 31 30 31 2 4 28 11 29 96 119 24.0 Communication 31 35 30 35 27 33 28 25 116 128 10.3 ADLs/IADLs 29 39 36 42 31 40 44 46 140 167 19.3 Mobility 21 35 36 36 30 30 43 44 130 145 11.5 Hand Function 9 14 12 18 10 17 10 8 41 57 39.0 Social Participation 21 24 31 31 26 28 23 32 101 115 13.9 Total Recovery 20 40 65 70 50 60 60 60 195 230 17.9 CIMT 37 Appendix C: Percentage Difference of CIMT & mCIMT Clients Table 1. CIMT Percentage Difference Between Client’s Pre and Post Test Area Perception Client #2 Client #3 Clie nt #7 Client #10 Physical 15 10 15 10 Memory & Thinking 2.9 5.7 8.6 2.9 Emotions 11 2.9 22.9 0 Communication - 11 - 8.6 6 0 ADLs/IADLs 4 4 8 2 Mobility 13 2.2 15.5 2.2 Hand Function 28 4 32 16 Social Participation 17.5 5 12.5 47.5 Total Recovery 20 10 15 N/A Table 2. mCIMT Percentage Difference Between Client’s Pre and Post Test Area Perception PPPPerPercePerception Client #4 Client #5 Client #8 Client #9 Physical 5 15 15 30 Memory & Thinking 8.6 0 0 0 Emotions 0 2.9 11.4 51 Communication 11.4 14.3 17.1 - 8.6 ADLs/IADLs 20 12 18 4 Mobility 31 0 0 2.2 Hand Function 20 24 28 - 8 Social Participation 7.5 0 5 22.5 Total Recovery 20 5 10 N/A CIMT