Kayla Pace, OTS Chatham University EBP Capstone November 11, 2014

1. Comparing Constraint-Induced Movement Therapy and Functional Electrical Stimulation with Upper Extremity Impairments Kayla Pace, OTS Chatham University EBP Capstone November 11, 2014

2. PICO Question Do adults with upper extremity impairment due to stroke (P) have more positive results (O) with Functional E-Stim (FES)(I) compared to Constraint – Induced Movement Therapy (CIMT) (C) ?

3. CIMT and FES • “CIMT is a family of techniques that have been implemented to increase the amount and quality of function of an affected upper limb. These techniques involve restraint of the intact limb over an extended period, in combination with a large number of repetitions of task-specific training of the affected limb” (Hakkennes& Keating, 2005). • “FES integrates electrical stimulation to peripheral sensory and motor nerves with repetitive functional movement of the paretic arm in people with hemiplegia or hemiparesis” (Kawashima, Popovic, & Zivanovic, 2013).

4. Significance of CIMT/FES • Adults with hemiparesis have limited arm/hand use with daily functional activities which decrease independence with work, home, and leisure. • Hemiparetic patients tend to only use unaffected arm • Observation of FES in Inpatient Rehabilitation • Literature search showed lack of evidence on the comparison of topics and proves need of more studies • UE impairments decrease performance included in OTPF -3 • ADLs, IADLs, Performance Skills, Performance Patterns, Activity Demands, Client Factors, Context and Environment • General interest in Neuroscience • Cortical Plasticity

5. Search Strategy • Keywords: • Upper extremity impairments • Occupational therapy • Occupational therapy interventions • Hemiparesis • CVA • CIMT • mCIMT • FES • Adult population • Stroke • Chronic stroke • Databases: • CINAHL • Google Scholar • American Journal of Occupational Therapy (AJOT)

6. Search Strategy • Inclusion criteria: • Adult population (18 year old +) • Hemiparesis • CVA/stroke with UE impairments • Interventions using CIMT and/or FES • Exclusion criteria: • Hemiplegia • Pediatric population

7. Evidence Found • Level 1 • Systematic Review (1) • RCT’s (3) • Level 2 • Small RCT’s (2) • Level 3 • Quasi-experimental (1) • Level 4 • Case Study (1)

8. Article 1 • Hakkennes, S., & Keating, J. L. (2005). Constraint-induced movement therapy following stroke: a systematic review of randomised controlled trials. Australian Journal of Physiotherapy, 51(4), 221-231.

9. CIMT • Objectives: To review the effectiveness of CIMT with the use of upper extremities after a stroke. Quality of life and ADL ability was also assessed within these studies. Due to the nature of the systematic review, 14 RCT’s reviewed different protocols used to test the effectiveness of CIMT and the limitations of this intervention. • Methods: Included trials were assessed using the PEDroscale. 13 out of the 14 RCTs compared CIMT to an alternative treatment and/or a control group. The final RCT compared two CIMT protocols with varied stroke conditions. • PEDro Scale  “Assesses randomization, allocation concealment, comparability at baseline, blinding of subjects and therapists, measurement of at least one key outcome obtained from more than 85% of the subjects initially allocated to groups, intention to treat analysis, and between-group comparison tested statistically for at least one key outcome measure”(Hakkennes & Keating, 2005). • Results: Results were significant and in favor of CIMT in eight of these RCT’s for at least one measure of UE function. Results show CIMT may improved UE function following a stroke for hemiparetic patients when compared to a conventional form of treatment. Results also show more evidence is needed.

10. Article 2 • McCall, M., McEwen, S., Colantonio, A., Streiner, D., & Dawson, D. R. (2011). Modified constraint-induced movement therapy for elderly clients with subacute stroke. American Journal of Occupational Therapy, 65(4), 409-418.

11. CIMT • Objectives: To determine the effectiveness of the modified CIMT protocol on participation, activity, and impairment in a population of older adults experiencing a strokecompared with natural recovery in elderly people due to a stoke using multiple measures. • Methods: Participants (n=4) were instructed to wear the mCIMT mitt on their unaffected arm for a total of 6 hours per day/5days a wk for a total of 2 weeks. Participants were assessed 4-5 times before and after the 2 week treatment session. “Treatment was broken up into 3 sections which included motor tasks in relation to their individual goals (e.g., grasping and releasing plastic cones), goal-specific functional tasks (e.g., picking up a glass and drinking from it), and other daily living activities (e.g., using a telephone)” (McCall, McEwen, Colantonio, Streiner, & Dawson, 2011). They were measured using the COPM for satisfaction and performance based upon the participation of intervention, the FIM/CAHAI measured activity limitations, and the ARAT measured impairment of their weakened arm. • Functional Independence measure (FIM) • Chedoke Arm and Hand Activity Inventory (CAHAI) • Action Research Arm Test (ARAT) • Outcomes: Positive change scores were found for all participants on all participation (COPM), activity (FIM and CAHAI), and impairment measures (ARAT) with two exceptions. (See next slide for positive mean differences of participants.) Small negative changes were noted on participant 3 using the FIM and participant 2 on the ARAT for pinch. Overall, within 2 weeks positive changes were seen in 3 significant categories improving their mood and quality of life, improved their ability to participate in the activity, and finally improved impairments of their affected arm.

12. Table 2  Pre and Post Scores and Mean Difference

13. Article 3 • Tarkka, I. M., Pitkänen, K., Popovic, D. B., Vanninen, R., & Könönen, M. (2011). Functional electrical therapy for hemiparesis alleviates disability and enhances neuroplasticity. The Tohoku journal of experimental medicine, 225(1), 71-76.

14. FES • Objectives: To study the effects of FES on UE hemiparesis and returned motor recovery of the hand along with neuroplasticity. • Methods: Hemiparetic patients (n=20) were chosen to be assigned into two different groups called functional electrical therapy or the conventional physiotherapy group. Both groups received UE treatment for 2 sessions/day for 2 weeks. Behavioral motor hand function and neurophysiologic transcranial magnetic stimulation was applied to test cortical plasticity of the brain pre/post treatment and at 6 months follow up. • Outcomes: The results showed faster corticospinal (primary motor cortex) conduction, newly found muscular responses, and faster movement times observed in the paretic upper extremity in the FES group versus the conventional group.

15. What Does the Evidence Say? • Evidence • Both show improved results with chronic stroke patients • Both show improved results with hemiparesis patients • FES shows increased results for cognitively impaired patients; CIMT does not work as well with these individuals • FES is faster for treatment intervention and does not include extra time outside of therapy services • So what does this mean? • Must weigh out pros/cons of each when providing treatment • Everyone is different but each show improvements in motor return and recovery • An investigation of comparing these two interventions is needed for research to obtain clearer results • Results are inconclusive

16. References • Alon, G., Levitt, A. F., & McCarthy, P. A. (2007). Functional electrical stimulation enhancement of upper extremity functional recovery during stroke rehabilitation: a pilot study. Neurorehabilitation and neural repair, 21(3), 207-215. • Chae, J., Harley, M.Y., Hisel, T.Z., Corrigan, C.M., Demchak, J.A., Wong, Y., & Fang, Z. (2009). Intramuscular Electrical Stimulation for Upper Limb Recovery in Chronic Hemiparesis: An Exploratory Randomized Clinical Trial. Neurorehabilitation and Neural Repair, 23, 569. • Hakkennes, S., & Keating, J. L. (2005). Constraint-induced movement therapy following stroke: a systematic review of randomised controlled trials. Australian Journal of Physiotherapy, 51(4), 221-231. • McCall, M., McEwen, S., Colantonio, A., Streiner, D., & Dawson, D. R. (2011). Modified constraint-induced movement therapy for elderly clients with subacute stroke. American Journal of Occupational Therapy, 65(4), 409-418.

17. References • Kawashima, N., Popovic, M. R., & Zivanovic, V. (2013). Effect of Intensive Functional Electrical Stimulation Therapy on Upper- Limb Motor Recovery after Stroke: Case Study of a Patient with Chronic Stroke. Physiotherapy Canada, 65(1), 20-28. • Page, S. J., Murray, C., & Hermann, V. (2011). Affected upper- extremity movement ability is retained 3 months after modified constraint-induced therapy. American Journal of Occupational Therapy, 65(5), 589-593. • Tarkka, I. M., Pitkänen, K., Popovic, D. B., Vanninen, R., & Könönen, M. (2011). Functional electrical therapy for hemiparesis alleviates disability and enhances neuroplasticity. The Tohoku journal of experimental medicine, 225(1), 71-76. • Taub, E., Uswatte, G., King, D. K., Morris, D., Crago, J. E., & Chatterjee, A. (2006). A placebo-controlled trial of constraint- induced movement therapy for upper extremity after stroke. Stroke, 37(4), 1045-1049.