Running Head: POWERING BACK FROM STROKE

Powering Back from Stroke: Finding Ways to Increase Rates of Upper Extremity Recovery

Combining Constraint-Induced Movement Therapy and Neuro-Developmental Treatment

Emily Sosa, Hazley Kelly, Jarrett Henderson, Jordan Fish, Linda Ng

University of Utah
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Introduction
Stroke is estimated to occur every 40 seconds in the United States and affects more
than 795,000 individuals annually, with 610,000 of those being first time strokes (CDC, 2017).
Stroke results in loss of mobility in over half of its survivors and often leads to disability and pain
(CDC, 2017). A recent study by Roosink et al. (2011) found that persistent shoulder pain can
begin as early as two weeks post stroke and this pain leads to impaired motor control,
decreased proprioception, tactile extinction, and injuries. These injuries may increase
experienced levels of pain and overall participation in various activities.
Current treatments rely on therapy and medication to help control the pain.
Unfortunately, these medications can be over used and according to Longo, Volkow, and
McLellan (2016), addiction and overdoses have become a national epidemic. As occupational
therapists, it is imperative to develop best practice measures that will ensure overall wellness for
our clients. Including finding ways to decrease pain levels and increase upper extremity (UE)
function. Roosink et al. (2011) found that pain is often a predictor of decreased range of motion
(ROM). To date, individual therapy treatments like neurodevelopmental treatment (NDT),
functional electronic stimulation (FES), and constraint induced movement therapy (CIMT) have
offered some level of UE recovery for adult stroke survivors (El-Helow et al., 2015;
Huseyinsinoglu, Ozdincler & Krespi, 2012; Howlett, Lannin). This proposed study is needed to
not only reduce the estimated $34 billion-dollars spent annually in stroke related health care
cost (CDC,2017), but also find better ways to increase recovery rates while decreasing pain in
order to provide a better quality of life post stroke.
Aim 1. Determine whether combining two effective treatments (CIMT and NDT) will
increase UE function sooner, as seen in Fugl-Meyer Assessment (FMA) of Motor Recover
after Stroke and Action Research Arm Test (ARAT) measures, in adult post-stroke
survivors in comparison to CIMT alone. Hypothesis: Significantly Faster improvement
combining CIMT and NDT as measured by UE outcome measures.
Aim 2. Determine if combining CIMT and NDT decrease self-reported shoulder pain levels
during recovering in adult post-stroke survivors in comparison to CIMT alone.
Hypothesis: By combining CIMT and NDT, adult post-stroke survivors will report significantly
less pain after intervention? as measured by the PROMIS Pain measure.
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Background

Rehabilitation after stroke is geared towards remediating impairments and improving

quality of life, so that individuals can return to engaging in day-to-day activities with as much

independence as possible. Caglar et al. (2016) found that localized shoulder pain was a

frequent experience of post-stroke survivors and often affected their quality of life along with

preventing them from participating in therapies. Pain caused by injury, physical pressure or

inflammation of some part of the body, referred to as nociceptive pain, was the prevailing type of

pain noted in participants. Using best practices to improve functional outcomes while preventing

UE pain, can prevent the pain from impeding rehabilitative practices (Dromerick, Edwards &

Kumar, 2008).

CIMT Research

A common effective approach used to treat neuromotor deficits in stroke survivors is

CIMT. CIMT protocol uses a combination of different factors to encourage use of a more-

affected UE in a variety of settings (e.g. hospital or home). The three main components of CIMT

include: repetitive task practice, adherence-enhancement behavioral techniques and restraint of

the less-affected UE—often through use of a mitt. These components are systematically

implemented and prescribed by therapists, for many hours a day and typically for two to three

weeks, in order to activate and increase functional use of the more-affected UE in daily routines

(Fleet, Page, MacKay-Lyons, & Boe, 2014; Morris, Taub & Mark, 2006).

Multiple studies have been done that support Fleet et al. (2014) findings that CIMT

produces favorable functional UE outcomes for post-stroke adults. Research on CIMT also

shows that follow-ups on CIMT found similar, if not equal, outcomes to other therapies at around

six-months post intervention. This may easily be interpreted to mean that CIMT is no better than

any other well-known treatment. However, this view may be disputed by considering the

psychological effects that a more efficient intervention can have on a patient. Further analysis is

needed to consider those effects (i.e. quality of life, increased volition, and mood). The benefits
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of CIMT is that an individual can recover functional movement of an affected UE post-stroke

faster than traditional rehab.

NDT Research

Neuro-Developmental Treatment was developed in the 1940s by Keral and Berta

Bobath, for individuals with dysfunction in their central nervous system; primarily children with

cerebral palsy and adults post-stroke. A therapist treating with NDT works directly with a client

to improve integration of the client’s affected and unaffected limbs during functional tasks.

Therapeutic handling is carried out by the therapist and consists of hands-on techniques used to

inhibit abnormal movements, increased tone and spasticity and facilitate postural alignment,

normal tone and stability during purposeful movements (Instructors group of Neuro-

Developmental Treatment Association, 2016).

A number of studies to date determining the effects of NDT on UE function in adults

post-stroke have shown positive results in a variety of assessments, measuring items such as

motor activity and functional use and independence during activities of daily living (ADLs).

Pelocini et al. (2016) and Kollen et al. (2009) found the functional movements often incorporated

into NDT significantly improved Fugl-Meyer Assessment scores equally to interventions

focusing on repetitive exercise that did not replicate motor patterns performed during everyday

tasks. NDT has been compared to CIMT in studies performed during post-stroke rehabilitation

and results are often in favor of CIMT in subjective motor activity assessments and Wolf Motor

Function Test scores, though both groups show significant improvements (Huseyinsinoglu,

Ozdincler & Krespi, 2012; Tariah, Almalty, Sbeih & Al-Oraibi, 2010).

Combined NDT and CIMT Research

Minimal research has been conducted to determine the effects of combining CIMT and

NDT to elicit greater improvements in UE recovery in adults post-stroke. A systematic search

yielded only two relevant studies to date, examining effects of the combined therapies in

participants experiencing hemiplegia, affecting the UE. Haynes and Phillips (2012) described an
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intervention protocol for two children with hemiplegia that utilizes CIMT and NDT principles.

Taub et al. (2013) studied the effects of combining CIMT, NDT and other therapy techniques on

meaningful motor function, in six adults experiencing chronic stroke and severe UE impairment.

In both studies, participants demonstrated improvement in affected UE motor and functional

use; however, this outcome is expected since we know that both CIMT and NDT treatments are

effective. We would like to determine how much more effective this treatment is compared to

just traditional CIMT treatment, due to the fact that previous research showed that CIMT is more

effective than NDT treatment.

Objective of Proposed Study

A gap in current research exists in relation to specific CIMT and/or NDT effects on

frequently occurring shoulder pain in adult post-stroke survivors, as most studies relevant to the

proposed research focus primarily on functional outcomes related to strength, range of motion,

amount of use and quality of movement. CIMT strategies are utilized to encourage increased

use of the affected upper limb and NDT principles promote optimal stabilization and alignment

during movement patterns of the upper limb. The purpose of this study is to determine whether

a combined therapy approach using CIMT and NDT will yield improved and faster outcomes in

functional use, as well as improve self-reported shoulder pain in the affected UE of adults who

have recently experienced a stroke, compared to CIMT alone. Results from? the aims of the

proposed study will add evidence to shape the most efficacious? rehabilitation practices used by

occupational therapists working with post-stroke survivors, to facilitate and improve UE use and

participation in rehabilitation and functional daily activities.

Methods

Design

For this study, a quantitative randomized control trial design will be used with two

treatment groups, each with pre- and post-testing. Participants will be randomly assigned to a

control (CIMT) group or an experimental (CIMT combined with NDT) treatment group. The pre-
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and post- test design aims to identify the similarities at baseline and changes in outcomes within

and between groups. The ARAT, FMA, and PROMIS Numeric Rating Scale will be used to

assess? quantitative outcome measures.

Participants

University of Utah Health Care, St. Mark’s Hospital, and Intermountain Health Care

acute stroke admissions will be screened by researchers for study eligibility (see eligibility

criteria in Table 1). Study flyers will be posted in participating outpatient and inpatient neurologic

rehabilitation facilities to recruit? participants. Physicians will also be informed about the study

and asked to refer eligible stroke patients. The study does not intend to set a gender ratio that

would limit participants from joining. Two assessments will be used for inclusion/exclusion

criteria: The Manual Muscle Test (MMT), and the Montreal Cognitive Assessment (MoCA).

Table 1.
Inclusion Criteria Exclusion Criteria
18+ years of age Pre-morbid conditions that affect ability in UE
2 weeks – 3 months post-stroke More than 3 months post-stroke
Strength, coordination is affected in UE by MMT of affected UE is < Poor- (2-): shoulder
stroke flexion, wrist flexion/extension, and
pronation/supination
Must be first stroke Severe cognitive impairment, determined by
MoCA
Receptive or global aphasia and severe
neglect
Measures

Three assessments will be used to evaluate outcomes measures and include the

following tests: ARAT, PROMIS Numeric Rating Scale for Pain Intensity 1a, and FMA.

ARAT. The ARAT is a 19-item measure aimed to assess ADLs, coordination, dexterity,

and UE function, and also includes sub-tests for grip, pinch, grasp, and gross movement of the

arm. The test is rated by a 4-point ordinal scale that comprises of the following: 0 – can perform

no part of test, 1 – Performs test partially, 2 – Completes test, but takes abnormally long or has
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great difficulty, 3 – Performs test normally. Lin et al. (2009) concluded that the ARAT showed

good interrater reliability, test-retest reliability, and high concurrent validity.

PROMIS Numeric Rating Scale. This rating scale is used to indicate how much pain a

person is experiencing. The pain intensity scale looks at pain in two ways. PROMIS Scale v1.0 -

Pain Intensity 3a pain a patient has experienced within the last seven days and pain they may

be experiencing right now. The PROMIS Pain Intensity scale is on a numeric scale of 0 (no

pain) to 10 (worst pain). The scale can be administered in short form with a value of 1-5. One

being that the participant has no pain, while five indicating severe pain. It will be used in two

ways for this research: level of pain within the last seven days, and level of pain being

experienced currently. This assessment of pain has shown adequate test-retest reliability and

excellent internal consistency for inter-rater reliability (Jensen & McFarland, 1993).

Fugl-Meyer Assessment of Motor Recovery. For this study, four of the five domains of

the assessment will be used for UE function; these sub-scales include: motor function, joint

range of motion, and joint pain. The items are scored on a 3-point ordinal scale of the following:

0 – cannot perform, 1 – performs partially, 2 – performs fully. Lin et al. (2009) concluded that

FMA was comparable to the ARAT in both reliability and validity.

Procedures

Once the study is approved by the Institutional Review Board (IRB), participant

recruitment will begin. Physicians and rehabilitation therapists at participating locations will be

briefed about the study and will be encouraged to recommend qualifying patients to contact the

study coordinators. Flyers will also be posted in participating rehabilitation centers throughout

Salt Lake City, Utah to recruit participants. If participants fit the inclusion criteria, they will be

informed of the study and written consent will be obtained. Baseline measure will be performed

before beginning treatment. Participants will then be randomly assigned to either CIMT or

CIMT/NDT group. Both groups will receive the respective treatment for 6 weeks and will be

assessed with the same baseline measures within 1 week of ending treatment. All assessments
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will be delivered by a blinded assessor at a convenient place to the participant (e.g. home,

hospital, or outpatient clinic).

Data Analysis

Quantitative statistics will be used to analyze the data. Inferential statistics such as the

independent t-test will be utilized to look at the change between the groups and paired t-test

(pre and post) used in measuring within subgroups. In performing data analysis, a p-value of

<.05 will suggest that participants experience greater range of motion and less pain when

receiving CIMT/NDT treatment as compared to CIMT solely.

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