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Evidence-Based Medicine Comes to Neurorehabilitation

Evidence-Based Medicine Comes to Neurorehabilitation. Welcome.

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Evidence-Based Medicine Comes to Neurorehabilitation

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  1. Evidence-Based Medicine Comes to Neurorehabilitation

  2. Welcome Presenters:Stephen E. Nadeau, MD.Medical Director BRRC, Chief of Neurology Malcom Randal NF/SG VAMCUniversity of Florida Neurology snadeau@ufl.eduSandra E. Davis, Research P.T. BRRCUniversity of Florida Physical Therapysandra.davis2@va.govLorie G. Richards, OTR/L, PhDResearch Scientist BRRCUniversity of Florida Occupational Therapylrichard@phhp.ufl.edu

  3. Objectives • As a Participant you will be able to:* describe EBM in stroke rehabilitation* identify individuals for constraint induced movement therapy (CIMT)* list key components of CIMT* implement a CIMT session* explain the scientific basis for CIMT* identify limitations in evidence for CIMT

  4. Introduction to Constraint Induced Movement TherapyCIMT

  5. EXCITE TRIALWolf SL et al. Effect of constraint-induced movement therapy on upper extremity function 3 to 9 months after stroke. JAMA 2006;296:2095-2104 • Prospective, randomized, parallel group, multicenter, phase III, single blind trial of 2 weeks of CIMT, 3 & 9 months after acute stroke • Subjects: • CIMT: N = 106 • Usual and customary care : N = 116 • Inclusion criteria: • High functioning: 20˚ wrist ext, 10˚ finger ext. • Low functioning: 10˚ wrist ext, 10˚ ext. thumb & ≥ 2 other fingers. • Motor Activity Log (MAL) < 2.5 • CIMT: up to 6 hrs/day + mitt worn 90% of waking hrs. • Outcome measures: Wolf Motor Function Test MAL- Quality of motion at 1-year.

  6. EXCITE Trial

  7. First: Identify Individuals for CIMT • CIMT is a beneficial treatment for patients post stroke exhibiting some active wrist and hand movement.Wolf et al 2006,Dromerick et al 2000, Van der Lee et al1999Minimum Motor Criteria:Active extension must be repeated 3x in one minute: From a relaxed resting position, Not from a neutral wrist position.At least 10 degrees: wrist, thumb and 2 digits

  8. Include Key Components of CIMT • Add these elements to each session:* Massed Repetition* Graded/progressed activities* Objective Feedback* Restraint of the less involved UE* Intensive Practice: Original CIMT included 6 hours/day for 5 days a week for 2 weeks

  9. What does a CIMT Session Look Like? • Choose Shaping (lower functioning) or Task Practice (higher functioning)Shaping: Components of the task are made more difficult in a more structured way to attain the task. Detailed feedback & progress only when attain set goalExample: reach - to grasp - to lift a glass – to drinkTask Practice: Functionally based activities performed continuously 15-20 minutes or until the task is attained.Example: fix a sandwich & eat lunchMore general feedback & graded progressionTo Progress:Add specific challenges i.e.speed, height, distance, weight, #’s, dual task, quality of movement

  10. Choose CIMT tasks to match the Individual

  11. Design CIMT Menu of Unique Tasks • To meet the unique individual’s needs:* impairment level* interests* roles inventory* meaningful activities* functional needs* strength* coordination* range of motion* sensation* personal goals* endurance* sense of humor

  12. Creative Considerations for CIMT and modified mCIMT *Setting*Acuity*Length of Stay*Staffing*Support*Modifications*Home Program*Charge and Reimbursement*Legal and Ethical considerations

  13. Standardized tests to take to clinic • Measure your Outcomes!MAL- Amount & QualityBox and Blocks Fugl Meyer Wolf Motor FunctionKinematicsActual Amount Use TestAccelerometryQuality of MotionQoL- SISCaregiver Strain

  14. Compliance Measures • Translational PackageMorris,Taub,Mark,2006* Contract 90% mitt wearing* Diary* Coach agreement* Daily cues: Motor Activity Log* Home Practice* Weekend Practice* Daily Schedule* Agreed upon appointments* Agreed upon time to remove mitt

  15. Constraint Induced Movement Therapy • A family of therapies • Developed from deafferented monkey studies(Knapp, Taub, et al., 1958; Taub, 1976, 1977) • Without sensation, monkey did not use the limb • Would use the arm if the other arm were restrained • Restraint of 1-2 days = revert after restraint removal, but not after 1-2 weeks • Shaping also increased ability and use of limb

  16. Behavioral suppression Unsuccessful attempts to move Punishment (pain, can’t) Compensatory behavior strengthened Compensatory Behavior patterns Positive Reinforcement Constraint Induced Movement Therapy • Developed to improve motor skill and to decrease learned non-use Injury

  17. (Sterr, et al., 2002)

  18. (Dettmers, et al., 2005) Does it need to be given 6 hours every day?

  19. ACUTE STROKE Traditional therapy: Compensatory ADLs, ROM, strengthening, dexterity practice mCIMT – 1/2 hrs/d 3x/wk shaping, 5 hr/d mitt Page, et al., 2005

  20. ACUTE STROKE Traditional therapy: Compensatory ADLs, ROM, strengthening Low CIMT – 2 hrs/d shaping, 5 hr/d mitt High CIMT – 3 hr/d shaping, mitt 90% waking hrs Dromerick, et al., 2009

  21. Cortical Map Reorganization Proximal Distal (Kleim et al, 2004)

  22. Is there evidence that CIMT changes the brain? 2 most common methods: Transcranial Magnetic Stimulation (TMS) Functional Magnetic Resonance Imaging (fMRI)

  23. Is there evidence that CIMT changes the brain?(Hamzei, et al., 2006) Participants with intact M1 and MEPs at baseline Participants with lesioned M1 and disturbed MEPs at baseline

  24. CIMT now Paired • With other Therapies:* Drugs* Strengthening* Rhythm Cues

  25. Remaining Questions • Future Research Needs to Demonstrate* What is the Best CIMT Schedule:- Distributed versus Massed- # of Hours- Maintenance of the gains

  26. Summary • Evidence shows:- CIMT is efficacious- Variations of the original protocol are efficacious and can translate to clinic- More therapy is generally better- CIMT is reimbursable Thank you! Questions & Discussion

  27. CE Credit • For any questions about the monthly GRECC Audio Conference Series please contact Tim Foley at tim.foley@va.gov or call (734) 222-4328 • To evaluate this conference for CE credit please obtain a ‘Satellite Registration’ form and a ‘Faculty Evaluation’ form from the Satellite Coordinator at you facility. The forms must be mailed to EES within 2 weeks of the broadcast

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