CIMT
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Retention of Upper Limb Function in Stroke Survivors Who Have Received Constraint-Induced Movement Therapy: The EXCITE Randomised Trial
Wolf et al. (2008)
Purpose
To assess the retention effects and ongoing improvement in upper limb functions of patients who received constraint-induced movement therapy (CIMT) 3-9 months post-stroke.
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Design
This study used a single-blind, cross-over, randomized controlled trial design. Randomization was adapted to establish equal allocation of sex, pre-stroke dominant side, side of stroke, and extent of paretic arm function.
Methods
Participants
Patients that were selected via purposive sampling on the basis that they experienced a disability caused by an initial stroke within the past 3-9 months and were contacted by telephone
Sample size
The total number of participants in the study was 222 and of them, 106 were randomly assigned to receive CIMT
Eligibility Criteria
Patients cognitive function on MMSE were required to be a score of at least 24.
- Categorized as being either high functioning or low functioning with high functioning individuals defined as those that could actively extend their wrist by at least 20 degrees. They were also able to extend the metacarpophalangeal and interphalangeal joints of each digit by at least 10 degrees. Those that were considered low functioning demonstrated only 10 degrees of active wrist extension, 10 degrees of thumb abduction and extension, and 10 degrees of extension in at least two digits.
- All participants were required adequate balance without support while wearing a restraint and performing tasks.
Intervention
Control
Participants was delayed treatment for 1 year and received customary care in the meantime. Customary care consisted of no treatment to varying amounts of orthotics, occupational therapy, or physiotherapy. Provision of care was assessed through telephone calls that occurred every 4 months
Results
- The average WMFT time for task completion was lower after 24 months for all CIMT subgroups.
- WMFT grip strength improved after 12 and 24 months from baseline irrespective of participants` sex or cognitive functioning. WMFT weight strength improved in all subgroups except lower functioning group.
- MAL scores for CIMT participants were greater at 12 and 24 months compared to baseline.
- Scores in all the SIS domains for CIMT participants improved after 12 months from baseline and were higher at 24 months post-CIMT treatment. However, scores for SIS domain for memory and thinking appeared consistent from baseline to 24 months.
- Differences in concordance, sex, and level of functioning subgroups affected SIS domain scores. Scores were higher in concordance group and in males and higher functioning group.
Experimental
The treatment group received CIMT up to 6 hours per day, 5 days a week, and for 2 consecutive weeks. During this treatment period, the participants wore a mitt for 90% of waking hours in addition to practicing adaptive tasks or repetitive practice of a specific task. Adaptive tasks involved training the arm based on shaping principles. The repetitive tasks included grooming or eating for 15-20 minutes. Adherence to the treatment was managed by a monitoring and homework assignments.
Discussion
Improvements in function gains after 12 months of receiving two weeks of CIMT was retained for another year with improvements in quality of life and strength continuing to increase in the second year. Findings from this study suggest that long-term follow-up rehabilitation clinical trials are important for elucidating the effects of therapeutic interventions.
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