Date Presented 4/7/2016
Eight intervention sessions using mCIT or occupation-based activities was effective for motor recovery. The mCIT group improved most on motor assessments, and the occupation-based group had more change in the occupational performance assessments. Changes were also noted with the experience of moving.
Primary Author and Speaker: Camille Skubik-Peplaski
Additional Speakers: Robin Stroud, Dana Howell, Melba Custer
Contributing Author: Lumy Sawaki
PURPOSE: The purpose of this study was to create science-driven and evidence-based knowledge by investigating changes in motor performance and the extent of neuroplastic change associated with modified constraint-induced and occupation-based interventions in the recovery of motor function.
RATIONALE: Two-thirds of stroke survivors experience upper-extremity (UE) impairment, leading to difficulty with UE motor function and performing meaningful occupations. Evidence suggests that occupation-based (OB) interventions are highly concordant with principles that drive neuroplastic change. Modified constraint-induced therapy (mCIT), a technique using high-repetition movement patterns, is effective in improving UE function. To date, no studies have compared these two types of interventions. Evidence is needed to guide clinicians in their clinical reasoning skills to understand which technique is more effective for stroke recovery.
DESIGN: A mixed-method study was conducted from August 2013 through June 2015.
PARTICIPANTS: Sixteen participants diagnosed with chronic stroke were recruited. Stroke onset ranged from 1-20 yr post with an average age of 54.06.
METHOD: Participants were randomized into eight sessions of interventions after pretesting by a blinded occupational therapist and then posttesting. Outcome tools were Fugl–Meyer Assessment (FMA), Stroke Impact Scale (SIS), Canadian Occupational Performance Measure (COPM), Goal Attainment Scale, and transcranial magnetic stimulation (TMS). Additionally, qualitative data in the form of audiotaped, transcribed interviews and journaling was collected to better understand the clinical reasoning used by the treating therapists.
ANALYSIS: Average change scores were calculated between the two groups to identify change in motor recovery, role performance and satisfaction, and perception of stroke recovery. Transcripts were hand coded, and analytic coding followed. Self-reflective journals were kept to help the investigators address bias and foster honest narratives. Member checking occurred during follow-up assessments.
RESULTS: Participants in both intervention groups demonstrated increases in motor performance with results as follows: Average change scores—FMA, mCIT 15.00, OB, 12.37; SIS, mCIT 9.37, OB 4.56; SIS overall recovery, mCIT 4.37, OB 8.75; COPM Participation, mCIT .65, OB 3.00; COPM Satisfaction, mCIT .65, OB 3.17. TMS results revealed larger motor mapping postintervention. Qualitative themes included remembering affected arm is part of me, hands on—what I want to do and doing it normally.
DISCUSSION: After receiving eight sessions of occupational therapy, the participants in the mCIT group made larger increases in motor assessments, FM, and SIS. Participants in the OB group demonstrated more gains in the occupation assessments, COPM, and the overall Stroke Recovery Scale of the SIS. Participants shared about learning to move their bodies again, that their arm was still part of their body, using their affected side to resume valued roles, and their satisfaction with client-centered care. The small sample size and variability of time since stroke onset limits the generalizability of the results.
IMPACT STATEMENT: This study provides evidence that both mCIT and OB interventions create changes in motor recovery and that a combination may be most beneficial. Results can guide clinical reasoning to select the intervention approach that best matches the client's goals to ensure optimal outcomes.
