Using constraint induced movement therapy as a home activity.

Strokes are the leading cause of disability in the United States (over 4 million people) with an estimated 750,000 people having strokes each year (William, 2001; National Stroke Association, 2003). The American Heart Association predicted an increase in patients who will have and survive a stroke due to the general aging of our population and new medical treatments available for acute stroke (Gresham, Alexander, Bishop, Giuliani, Goldberg, Holland, Kelly-Hayes, Linn, Roth, Stason, & Trombly, 1997).

Regaining upper extremity (UE) function presents much difficulty for patients with hemiparesis (weakness of one side). Because a majority of patients are able to perform most of their activities of daily living (ADLs) with their non-involved UE, they tend not to use their involved, less functional UE. Taub and Berman (1968), as well as Knapp, Taub, Berman (1963), explained that compensatory strategies eventually become a habit. The resultant over reliance on one side of the body has a variety of possible consequences, such as: contractures and reduced strength in the affected extremity, overuse syndromes and pain in the unaffected extremity, embarrassment and frustration, and an overall decrease in function with ADLs (Taub, Miller, Novack, Cook, Fleming, Nepomuceno, Connell, & Crago, J.E. 1993; Taub, Crago, & Uswatte, 1998).

Treating patients with UE hemiparesis can be challenging and frustrating, especially with patients' early discharges due to managed care. As a result of these short post-stroke hospital stays, it has become increasingly vital in rehabilitation to concentrate on primary functional activity essential for a patient to return home safely, often at the expense of a concerted effort toward recovery of the hemiplegic limb (Blanton & Wolf, 1999).

Therapy aimed at the involved upper extremity is needed to overcome a phenomenon called learned nonuse (Blanton & Wolf, 1999). Learned nonuse refers to the problem of unwillingness of patients who had a stroke or brain-injury to use the affected upper extremity when the unaffected extremity is available (Shumway-Cook & Woollacott, 1995). Taub, et al. (1963, 1968) described the learned nonuse behavior in research studies using monkeys. They suggested that the behavior was a result of the inability to move the deafferented extremity due to the presence of a shock-like condition that persists weeks or months after removal of sensory input through all cervical dorsal roots (dorsal rhizotomy).

Knapp, et al. (1963) reported that in monkeys, an impaired limb can be forced into use by restraining the unimpaired limb. This knowledge has been applied to humans who have had a stroke to create a forced-use model to encourage use of a chronically impaired upper extremity (Shumway-Cook, & Woollacott, 1995).

Constraint-Induced Therapy (CIT) was developed from behavioral and neuro-scientific research on monkeys by Taub and co-workers (Taub et al., 1993: Tuab et al., 1998; Morris, Crago, De Luca, Pidikiti, Taub, 1997; Taub, Uswatte, & Pidikiti, 1999), and first used in an attempt to improve motor recovery after stroke by Steven Wolf (Taub et al., 1998; Blanton, & Wolf, 1999: Morris et al., 1997). CIT is said to reverse learned nonuse. It consists of two primary steps--constraining the unaffected UE with a sling or mitten worn over the hand during waking hours, combined with concurrent intensive use of the affected UE in a variety of motor tasks translating to the real-world environment (Taub et al., 1999).

A comprehensive review of literature reveals several CIT studies that have proven effective for recovery of use of the impaired UE of both acute and chronic patients who have survived a stroke (Taub et al., 1993; Blanton, & Wolf, 1999; Taub et al., 1999: Kunkel. Kopp, Muller, Villringer, K., Villringer, A., Taub, & Flor, 1999; Liepert, Bauder, Wolfgang, Miltner, Taub, Weiller, 2000; Miltner, Bauder, Sommer, Dettmer, & Taub, 1999; van der Lee, Wagenaar, Lankhorst, Vogelaar, Deville, & Bouter, 1999; Candia, Elbert, Altenmueller, Rau., Schafer, & Taub, 1999; Page, Sisto, Levine, Johnson, & Hughs, 2001; Sabari, Kane, Flannigan, & Steinberg, 2001; Levy, Nichols, Schmalbrock, Keller, & Chakeres, 2001; Ostenforf, & Wolf, 1981; Page, Sisto, Johnson, Levine, & Hughs, 2002).

Despite these positive findings, there are some disadvantages of the CIT training protocol. For example, CIT requires a concentrated period of the health practitioner's time. Another disadvantage of CIT is that not all patients who have had a stroke have sufficient use of their involved upper extremity to be eligible for this type of intervention according to the inclusion criteria (Morris, Uswatte, Crago, Cook, & Taub, 2001). On the other hand, if a patient has had a stroke and has very good but not 100% function of the upper extremity, this patient, too, may not be an appropriate candidate for CIT. Part of the reason for this is that the patient may feel the gains made might be so small as to not warrant the expense of CIT training. In addition, the current method for measuring improvement after CIT training may not be able to pick up on the subtle nuances of improvement that only the patient may be able to articulate (as appeared to be the case for one of the patients in this case study). Because of these and possibly other reasons, CIT is not yet being routinely embraced throughout the country as customary stroke rehabilitation, due in part to the time, patient appropriateness, and financial restraints imposed on hospitals and rehabilitation units in today's managed care environment.

The literature reveals a dearth of studies utilizing CIT in the patient's home environment. This lack of utilizing CIT in the home demonstrates the need for experimentation with application of a CIT home activity program in an effort to develop an alternative delivery model of rehabilitation services to patients who have had a stroke or brain injury (Taub et al., 1998; Morris et al., 1997). The protocol utilized in this study can be taught to and administered by a caregiver or significant other in the patient's home with visits to outpatient physical therapy for pre-, post-, and follow-up assessment testing. The same frequency and duration previously proven successful and necessary to affect a change (Page et al., 2001) could be applied: 6 hours a day on weekdays, during a 2-week period, for the same 60-hour total as in the published CIT studies. The expectation is that using this protocol may retain the laboratory's treatment effectiveness and allow the patient access to this form of concentrated repetitive practice in the home environment.

The purpose of this multi-case-design study was (1) to determine if the existing CIT laboratory protocol, modified to fit the home environment, could be applied to patient treatment in the form of a home activity program completely supervised and implemented by the caregiver who had received instructions from a physical therapist and student physical therapy (SPT) research team, and (2) to compare outcomes of the two patients in this case study(s) with those reported in the literature in regard to CIT (Taub et al., 1993; Blanton, & Wolf, 1999; Taub et al., 1999; Kunkel et al., 1999; Liepert et al., 2000: Miltner et al., 1999; van der Lee et al., 1999; Candia, et al., 1999; Page et al., 2001; Sabari, Kane, & Flannigan, 2001; Levy et al., 2001; Ostenforf, & Wolf, 1981; Page et al., 2002).

Case Description

Participants

Participants were recruited from a local stroke support group. Ten members of the support group initially volunteered to participate: however, only two of the volunteers met the inclusionary criteria as set forth by the University of Alabama (UAB) Spain Rehabilitation Center (SRC) Project (Morris et al., 1997). The two participants had to demonstrate 20[degrees] of wrist extension and 10[degrees] of finger extension (metacarpophalangeal and interphalangeal joints), yet demonstrate significant disability. Participants also had to demonstrate good balance assessed by the ability to withstand moderate perturbations in standing, walk safely while wearing a sling, rise independently from a chair (with or without use of the more affected upper extremity), and walk up/down two stairs consecutively. Emphasis on balance was for safety purposes, as the participants wore a sling for extended periods at home. Besides meeting the inclusionary requirements, both participants had caregivers who were willing to implement the CIT protocol.

The first patient (P1) was a 48-year-old male, who prior to his stroke 5 years earlier, had been extremely physically active, participating in such activities as wind-surfing, rock climbing, and biking down Mount Whitney. His stroke occurred while he was undergoing a necessary heart procedure, resulting in left-sided hemiparesis. He was right-hand dominant. He received limited physical therapy under his HMO plan. He felt he needed further treatment and was frustrated and angered when he was told no further treatment was necessary, as it would not be beneficial.

The patient ambulated without assistive device, but had a very observable limp. His involved upper extremity was in a sling because of extreme pain and hypersensitivity. The skin of his left hand and wrist was red and shiny. The passive range of motion (ROM) of his left upper extremity (UE) was only slightly limited. His strength was poor to fair throughout his left UE. He was currently unemployed and limited in his daily activity--in part because of the pain he experienced. He spent most of his day watching television and using a computer.

The second patient (P2) was a 72-year-old retired male, 4 years post-stroke who had arrhythmias, resulting in a slight stroke. He had very slight left-sided hemiparesis and was right-hand dominant. On visual inspection, no motor deficit was apparent. He ambulated without assistive device and without any observable gait deviation. The active ROM of his left UE was within normal limits (WNL) and his strength was good. Since he was considered to be quite functional, he had received little physical therapy. The second patient was not satisfied with his current physical status. He complained of loosing his grip and dropping things. In addition, he avoided fine motor activities, like buttoning shirts, as he felt this was awkward and clumsy for him to do. He was very motivated and very much desired to participate in CIT even though he had been rejected from the UAB SRC project because he was told he was too high functioning.

Procedure

Parameters used to measure each subject (1) An initial screening evaluation was used to determine whether the patients fit the inclusionary criteria, or had any serious medical problems, cognitive and/or visual neglect that could prevent participation (Morris et al., 1997). The tests included:

(a) Balance and range of motion (ROM) assessments as described;

(b) Mini Mental State Exam (minimal score = 19, maximum score = 30), and, [c] Test of visual neglect.

(2) The actual assessment measurements used included:

(a) Wolf Motor Function Test (WMFT, see components of this test in Table 3);

(b) Motor Activity Log (MAL, see Appendix 1).

The WMFT and MAL were chosen as they are the same measures used in previous studies done on CIT and due to the high interrater reliability range reported (Wolf, Catlin, & Ellis, 2001 ; Lewis, Freeman, Bower, Fox, & Pena, 2005). The WMFT is an assessment tool made up of 15 physical tasks used to evaluate motor performance of the upper extremities. The MAL shows improvements in the amount of use of the affected limb with daily functional activities. The inter-rater reliability reported for the WMFT is .95 to .97. The MAL has a reported inter-rater reliability of r = 0.90 (Miltner et al., 1999) In addition, the MAL has been reported to have a high internal consistency (Cronbach's a = 0.88 to 0.95), and r = 0.94quality of movement portion (Blanton, & Wolf, 1999). The MAL has high test-retest reliability (r = 0.94, P<0.01) and criterion validity includes the 0.90 correlation between patient and caregiver reports (Candia et al., 1999).

The research team utilized measurements from the WMFT, timed and analyzed for quality and functionality of movement as defined by the recording sheet. All tests were videotaped as a back up to give confirmation of time and to assist with rating quality and functionality of movement. The MAL is a perceived (ordinal) scale the subjects used to rate their function at home during daily activities engaged in outside the training protocol at home. Tests were administered before the start of the 12-day study and at the conclusion of the study. Comparisons of pre- and post-measurement outcomes were used to signify change.

Treatment Intervention

Prior to treatment the patients signed an informed consent delineating the purpose of the study, the benefits and risks incurred by participating, statement of protection of human subjects, and the fact that the information was to be reported. They also signed a behavioral contract for use of the sling listing the activities for which it was donned and doffed. In addition, they signed a Patient/Caregiver Agreement to assure safety and maximum benefit of the intervention along with agreeing to perform a home diary exercise everyday to stress the patient's awareness of all activities performed outside of the therapy sessions.

Caregiver Training

Caregivers were trained to utilize CIT exercises prior to the beginning of the study. The training was commenced immediately after evaluations of the patients were completed. Only one training session was needed as the actual CIT exercises consist of everyday activities with which the caregiver and patient were familiar. The training session took approximately 20 minutes. Each caregiver was given a list of suggested activities that could be performed during the 6 hours a day intervention. The patient and caregiver were asked to come up with specific activities the patient would like to do that were not specifically on the list of suggested activities. For example, one of the patients had, prior to his stroke, enjoyed golfing. He decided he would try one-handed putting.

Caregivers were told the 6 hours of treatment time per day were to be broken up after 4 hours for a break, and then resumed for 2 more hours rather than have the patient perform 6 hours of continuous activity. The caregiver (with input from the patient) was instructed to make up a list with the time of day, the activity performed, and the length of time the patient performed each activity. A suggested format was given to each caregiver and patient. In addition it was suggested the activities be varied each day to ensure variety and prevent boredom, as well as continuing to challenge the patient.

Exercise Program (modeled after the laboratory studies)

Duration: 12 consecutive days (to include 1 weekend);

Frequency: 6 hours per day on the weekdays (a 1-hour break was given after the first 4 hours of intervention) for a total of 60 hours of supervised task practice. No supervised task practice occurred on the intervening weekend other than those tasks the subjects normally engaged in during customary activities of daily living (ADL).

Constraint device

An over-the-counter standard shoulder sling was worn on the non-involved arm for 90% of subject's waking hours, both during and after therapy sessions, with the exception of tasks that could potentially place the subjects in danger without the use of the restrained arm (i.e., not to use sling when using water, or when the task was two-handed by nature).

Daily treatment sessions followed a general daily schedule, taken from the UAB laboratory protocol, (Morris et al., 1997) and modified for the purposes of home use. Activities were varied from day to day to avoid monotony and to fit our home-based approach.

Data Analysis

Data collected from the WMFT were analyzed by comparing pre-treatment and post-treatment measurements and calculating the difference in seconds. This was done to determine if there was any difference in the time it took for the patients to complete each of the timed tasks. The overall mean, median, and minimum to maximum change scores (range) for pre- and post-treatment scores were then analyzed to get an overall value of change between pre- and post-treatment (Blanton & Wolf, 1999).

Data collected from the MAL was analyzed by calculating any change in the scores from pre- and post- treatment and by calculating the mean. This was done in order to compare patient's self-perceived progress over the course of the intervention period (Blanton, & Wolf, 1999).

Outcomes

Wolf Motor Function Test (WMFT)

P1 demonstrated significant improvements in both median and mean values for time to complete WMFT (see Table 2) from pretreatment to post-treatment (mean time decreased by 5.598 seconds while median time decreased by .660). With the exception of lift paper clip, all of P1 's WMFT tasks showed faster post treatment times (see Table 1). It was apparent on review of the video tape that the subject knocked the underside of the table in his attempt to reach for the paper clip; this action most likely slowed his overall time. The Functional Ability Scale (FAS) is a component of the WMFT. It measures quality of performance for each of the 15 tasks making up the WMFT. Although the reliability and validity of the FAS has not been reported, it is a standard part of CIT protocol. P1 improved in 10 of the 15 tasks, an improvement of 22.4% (see Table 4).

P2's post treatment results were less significant and in some areas regression occurred. P2 displayed increased post-treatment times for both mean (.416 seconds) and median (.01 seconds) values on the WMFT (see Table 2). Only 4 of the 15 timed tasks were found to be faster following CIT (see Table 1), though P2 reported paying greater attention to the quality of movement during the post-treatment evaluation. FAS score for P2 increased by 2.96%. He improved in 3 of 15 tasks.

Grip Strength and Weight in Box Task

P1 demonstrated an 8.09% increase in his grip strength on his affected side following treatment (see Table 4). He also increased the amount of weight he was able to lift post-treatment by 15.38% (see Table 4).

P2 exhibited increased grip strength of his affected arm following treatment by 2.77% (see Table 4). No post treatment change was observed during the weight in box task for P2, but it should be noted that the maximum weight available (20 lbs) was used for both attempts and the patient reported feeling stronger during the post-treatment evaluation.

Motor Activity Log

P1 showed improvement in his MAL mean scores. He improved by 2.035 (on a scale of 1-5) in the amount of use category (AU), and he improved by 1.5 in how well used category (HWU) (see Table 5).

P2 displayed improvements in his mean MAL scores. In the AU category he improved by .155 (on a scale of 1-5) and in the HWU scale he improved by .294.

Subjective Reports

Both patients commented on being pleased with changes in their affected upper extremity over the two-week treatment period and stated they were highly motivated to improve upon the gains made during this study. Both patients' caregivers agreed with the subjects' perceptions of improvement following the home-based CIT program. Here is what P1 stated after completing the program. " What has come back in the last two weeks is the dexterity in my thumb and fore-finger in my left hand ... I can even eat soup with my left hand." P1's sister (the caregiver) stated, "Eating with his hand is much more graceful." When P1's sister was asked how it was for her to be involved in CIT she stated, "It was only 2 weeks, and I'd do anything for my baby brother. To see a smile on his face again has made this a totally satisfying experience for me."

What P2 stated after completing the program was, "The biggest thing I've noticed by being able to do it [use my affected arm], forced to do it, it has built up my confidence that it can be done. There are things I wouldn't have attempted to do with my left hand. Now by being forced to do it, I'm finding it gets easier, the fear is gone. I think the big thing is you're not able to do it [use your affected arm] so you don't do it ... now it's just no problem. I'll reach and use my left hand more than I had in the past. I would totally recommend to anyone to try it because there is always that fear you have that hand, it's not working. In the hospital they had me sitting with the thing [the affected arm] on the pillow so it wouldn't move, but then you carry that out of the hospital with you into your life. [By having my hand in the sling] I can use this [affected arm] I find that it does things I want it to do. I can pick up screws." P2's wife (the caregiver) stated, "We went to a potluck and he would have a tendency to fill his plate up with his right hand...I watched to see how he was holding the plate [with his affected hand] and it was held much straighter. Even in eating, he ate all of his meals left handed even though it was beyond the six hours and he did very well." When P2's wife was asked how she felt about being involved in CIT she stated, "I have been involved in my husband's care since he had his stroke. We go to stroke support group meetings every week. I did not see my involvement as a burden, and he is so happy with his improvement after just 2 weeks that he is much more tolerable to be around. I would say my time was extremely well spent by participating in the project!"

Three month follow-up

Both patients were re-assessed using the WMFT at three months in order to determine if they had retained any gains initially achieved. Both patients indicated they had been using their involved upper extremities more in ADL's; however, neither patient had continued doing CIT activities. P1 indicated he had recently cut his finger nails for the first time since his stroke, as he has gained the confidence to use his involved upper extremity more. His chief complaint as to what limits him from progressing further is pain from what has been diagnosed as Central Post-Stroke Pain Disorder. P2 indicated he has seen improvement in his golf game over that last 3 months. He noted his control was better. He indicated that being involved in the intervention helped him to realize how much he could actually do with his involved upper extremity. P2's wife felt the discipline of the CIT activity was really the key to her husband's improvement.

Results of the timed tasks showed that P1 not only maintained his gains for most of the timed tasks, but actually improved in several areas and only digressed in 3 measures (see Table 1). P2 varied in his results for the timed tasks, but improvement was seen in 4 of the timed tasks (see Table 1), and an overall improvement was seen since post-intervention looking at median, mean, and range scores (see Table 2).

Discussion

These two case studies used CIT as a treatment intervention in the home setting. What was unique about the intervention was that the treatment was administered and supervised by a primary caregiver; an older sister in the case of P1 and the wife of P2. Both patients and caregivers completed the two-week intervention without interruption or problems. In the case of these two patients, CIT was successfully applied in the form of a home activity program completely supervised and implemented by a caregiver. In addition, both patients showed an overall measured improvement in their scores from pre- to post-treatment (at 3-month follow-up for P2). Motor activities improved for each patient even though their brain injuries were sustained over 5 years (P1), and 4 years (P2) ago. The fact that these improvements were found, suggests that each patient had possibly suffered from learned nonuse phenomenon. The magnitude of P1's improvement in both components of the WMFT and the MAL strongly suggests that home-based CIT may help overcome effects of learned nonuse. Results for P2 were less compelling at two weeks, though the EAS portion of the WMFT, MAL scores, and the observations of the caregiver appear to indicate improved motor performance. It could, however, be a case of bias by either the patient and/or caregiver in favor of positive outcomes in the study measures. Both patient and caregiver have invested a considerable amount of time and energy by participating in CIT, and no one who has invested this much time likes to think they have wasted this time and effort. This might be especially true for P2 as his objective changes were small, but his perceptions of his CIT training outcomes were very favorable. P2 was very personally invested in obtaining the CIT training, as he had been rejected from the UAB SRC project.

An important consideration in reviewing this data at the end of the two-week study period is the patient's level of function prior to the initiation of CIT. P1's degree of upper extremity impairment was far more significant than P2's, thus having greater room for improvement. On the other hand, P2's higher level of function which does not permit the same amount of improvement would magnify the importance of what appears to be less significant in terms of raw numbers. P2 was not accepted into the UAB SRC project after his initial evaluation because his affected arm functioned at such a high level. It was felt he would be bored and disappointed in his results after participating in the two-week program.

The indications of improvement are based on each patient's ability to complete tasks that they could/would not perform previously, improvements in the speed and/or force during the activity (WMFT), or an improved perception of how often or how well the patient performed functional tasks (MAL). When the patients were asked directly whether or not they thought their improvements were due to the treatment itself or just using the affected extremity more, both patients stated they felt the changes were due to the treatment. P1 was now using the affected extremity in activities (mostly activities involving fine motor control) he had not attempted before because he did not believe he could complete those activities by himself. Additionally, both patients mentioned they thought the intensity of the treatment helped them make gains they would not have made otherwise in the same amount of time.

One possible explanation for each patient's improved use of the affected extremity could be neural reorganization. The theory of neural reorganization suggests axonal sprouting as a precursor to improved performance. However, because of the short duration of treatment it seems unlikely that a significant portion of the changes observed could be attributed to neural reorganization.

The treatment provided could have addressed the phenomenon of learned nonuse, which may have occurred (especially in the case of P1), because both patients used the affected extremity. Prior to the intervention, the affected extremity was rarely used by P1, and P2 avoided certain activities because of his lack of confidence in using his involved upper extremity (avoided wearing button up shirts for example). By constraining the unaffected extremity, each patient was forced to use the affected extremity for all activities. Preventing the unaffected extremity from being used may have addressed the behavioral habit of learned nonuse. Continued supervised task practice may result in long-term benefit and enhance synaptic efficiency. Using components of restraint and supervised task practice may be the reason why CIT seems to be effective.

One point of interest is the timed scores for P2. Some tasks took longer for P2 to complete following treatment. Taking a longer amount of time to complete tasks was not what one would expect. It was noted, however, that P2's quality of performance completing tasks did improve. Results of the FAS and the MAL exhibited improvement following treatment. Based upon these results, P2 most likely had slower post-treatment times because he took more time to perform the tasks with better quality of movement, despite the fact he was instructed to complete the tasks as quickly as possible. Contributing factors to the disparity of test results between each patient could be due to different neurophysiologic effects of CIT on patients with different degrees of brain damage, a smaller percentage of available improvement in patients closer to a normal level of function, and the practical problems associated with obtaining an accurate test result when attempting to score a timed test on an individual with a high level of function.

For P1, results of this intervention were similar to the gains reported by Lewis et al. (2005). The Lewis et al. study (2005), used a single case design, while this study used a multi case design, but both studies used the same tools of measurement (WMFT and the MAL). Both of the patients involved in this case-study(s) and the patient in the previous case-study had functional limitations related to brain trauma, and all patients felt they benefited from treatment. The only notable differences between the previous case-study and the current case-studies were the individuals supervising the treatment (caregivers instead of students) the level of pretreatment function of one of the patients (P2's degree of function was not as severe as the patient in the previous case-study), and the ages of the patients (previous case-study was a 28-year-old, P1 was 48 years old and P2 was 72 years old).

The combined reason for doing these case-studies was to see if CIT done in a home setting with the supervision of the patient's caregiver would create benefits comparable to treatment rendered by professionals in a clinical setting. These two case-studies obtained findings similar to, but not as universally significant as those obtained by Blanton and Wolf (1999). While the data generated from P1's intervention compare favorably to those obtained from Blanton and Wolf (1999), P2's outcomes, though positive overall, were not significant enough to draw a definitive conclusion regarding effectiveness of the treatment at two weeks. Although at three-months follow-up P2 did show significant improvement in the timed tasks.

Differences seen in the outcomes of these two home-based case studies compared to laboratory studies may be due in part to having family members administer the intervention. Although it appears (by looking at the dairies) that both patients diligently complied with the intervention (and also by self-report), it is impossible to know if the rigor of intervention was comparable to the lab studies, and also if the self-reports were accurate. The time commitment required of the family members administering the intervention in these two case studies was major. Although each caregiver denied their involvement as being problematic or overly burdensome, they may have tired at the intensity required and may not have kept up the required pace for the entire 2-week period of intervention. In addition since both of the primary caregivers were also family members, the emotional intensity of spending six hours a day of one-on-one time with their loved one in a position of authority may have caused some emotional tension. On the other hand, having a caregiver who is also a loved one could impact the intervention in a number of positive ways. A sister or a wife of a patient is likely to be very encouraging of her loved one. These caregivers were both personally vested and in a position to benefit from a positive outcome from CIT. Both of these caregivers wanted only the best for their loved one's and given their comments it appears they may have been partly responsible for the positive outcomes seen. It is impossible to know if the outcomes for these two patients would have differed if they had received CIT in the laboratory, but having a person who is a loved one doing the intervention could make an important difference. Both these patients may have actually worked harder knowing that their loved one was selflessly sacrificing her time to help them get better.

Further research needs to be conducted to see if age of the patient, level of function, time of onset of injury, setting of treatment, and amount of training (or lack thereof) of the supervisory staff can affect the treatment outcome. In addition, other assessment measures besides those used in the current protocol may be helpful in tracking improvement that cannot be adequately measured by the current protocol.

Conclusion

For the two patients who participated in these case-studies, CIT in the home setting with a caregiver implementing the treatment appears to be a viable method of delivery. Outcomes seen in these two patient cases appear to give some indication that a home-based CIT program supervised by caregivers was successful in improving perceived and actual levels of function of the observed patients involved UE. Further studies using an experimental design need to be conducted to validate this treatment approach.

Appendix 1: Motor Activity Log

Amount Scale

0--Did not use my weaker arm (not used).

1--Occasionally tried to use my weaker arm (very rarely).

2--Sometimes used my weaker arm but did most of the activity with my stronger arm (rarely).

3--Used my weaker arm about half as much as before the stroke (half pre-stroke)

4--Used my weaker arm almost as much as before the stroke (3/4 pre-stroke).

5--Used my weaker arm as much as before the stroke (same as pre-stroke).

How Well Scale

0--My weaker arm was not used at all for that activity (not used).

1--My weaker arm was moved during that activity but was not helpful (very poor).

2--My weaker arm was of some use during that activity but needed some help from the stronger arm, moved very slowly, or with difficulty (poor)

3--My weaker arm was used for that activity but the movements were slow or were made only with some effort (fair).

4--The movements made by my weaker arm for that activity were almost normal but not quite as fast or accurate as normal (almost normal).

5--The ability to use my weaker arm for that activity was as good as before the stroke (normal).

Introductory paragraph:

"The purpose of this test is to examine how much and how well you use your more-affected arm when you are not in our laboratory. You will use two separate rating scales to describe how much and how well you use your weaker arm while you are doing specific activities. Please note that you can give half ratings if that best describes the activity in question. If for some reason you do not perform these tasks, we will try to determine why. We will first discuss how much you do each of the activities with your weaker arm and then we will discuss how well you do each of the activities when using your weaker arm. It is important that you realize that these questions are about what you actually do outside of the laboratory setting not what you think you may be able to do with your weaker arm. Do you have any questions?"

Acknowledgements

We would like to thank Janet Freeman, Mark Fox, Laura Bower, and Fran Pena, all physical therapy students at the time of their involvement, for providing the foundation for our study. We would also like to thank David Morris, physical therapist for his input resolving occasional problems we encountered during the completion of the study.

Selected References

Blanton S., & Wolf, S.L. (1999). An application of upper-extremity constraint-induced movement therapy in a patient with subacute stroke. Physical Therapy, 79, 847-853.

Candia, V., Elbert, T., Altenmueller, E, Rau., Schafer, T., & Taub, E. (1999). Constraint-induced movement therapy for local hand dystonia in musicians. Lancet, 353, 1273-4.

Gresham, G.E., Alexander, D., Bishop, D.S., Giuliani, C., Goldberg, G., Holland, A., Kelly-Hayes, M., Linn, R.T., Roth, E.J., Stason, W.B., & Trombly, C.A. (1997). Prevention and rehabilitation of stroke. Stroke, 28,1522-1526.

Knapp, H.D., Taub, E., & Berman, A.J. (1963). Movements in monkeys with deafferented limbs. Experimental Neurology, 7, 305-315.

Kunkel. A., Kopp, B., Muller. G., Villringer, K., Villringer, A., Taub, E., & Flor, H. (1999). Constraint-induced movement therapy for motor recovery in chronic stroke patients. Archives of Physical Medicine and Rehabilitation, 80(6)624-628.

Levy, C.E., Nichols, D.S., Schmalbrock, P.M., Keller, P., & Chakeres, D.W. (2001). Functional MRI evidence of cortical reorganization in upper-limb stroke hemiplegia treated with constraint-induced movement therapy. American Physical Medicine of Rehabilitation, 80(1), 4-12.

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Clare Lewis is an Associate Professor, California State University, Sacramento (CSUS), Department of Physical Therapy. Erik Iversen, Walter Crawford, and Andrew Linder student physical therapists at California State University, Sacramento, at the time of the completion of this study, and participated in this study in partial fulfillment of graduation requirements for the CSUS, Department of Physical Therapy.

Table 1
Components of the WMFT and Patient Score Time (in seconds)

                                           Patient #1

TASK                             Pre-Rx      Post-Rx     3 month f/u

1. Forearm to Table *             1.25        0.53        0.41
2. Forearm to Box *               0.60        0.53        0.53
3. Extend Elbow *                 0.60        0.63        0.47
4. Extend Elbow *
  (moving 1 lb)                   1.60        0.59        0.41
5. Hand to Table **               1.70        0.50        0.34
6. Hand to box **                 1.125       0.65        0.69
7. Reach and Retrieve **          1.00        0.47        0.50
8. Lift Can **                    4.28        3.78        2.41
9. Lift Pencil **                 2.93        2.25        1.75
10. Lift Paper Clip **            2.91        4.69        2.00
11. Stack Checkers **            40.47        8.31       15.43
12. Flip Cards **                42.57       14.31        26.81
13. Turn Key in Lock              6.94        4.63        4.56
14. Fold Towel **                17.60        3.44        9.28
15. Lift Basket                   5.82        2.47        1.90

                                            Patient #2

TASK                              Pre-Rx      Post-Rx    3 month f/u

1. Forearm to Table *              0.31        0.28        0.34
2. Forearm to Box *                0.32        0.62        0.62
3. Extend Elbow *                  0.22        0.15        0.29
4. Extend Elbow *
  (moving 1 lb)                    0.19        0.22        0.22
5. Hand to Table **                0.18        0.28        0.37
6. Hand to box **                  0.19        0.22        0.22
7. Reach and Retrieve **           0.25        0.22        0.25
8. Lift Can **                     1.09        1.10        0.87
9. Lift Pencil **                  3.35        5.41        1.12
10. Lift Paper Clip **             1.88        1.19        1.21
11. Stack Checkers **              4.78        5.75        4.88
12. Flip Cards **                 10.72       12.50        6.65
13. Turn Key in Lock               2.44        2.69        2.87
14. Fold Towel **                  4.18        6.00        4.09
15. Lift Basket                    1.47        1.19        1.35

* patient seated at side of table

** patient seated facing table

Note: The two other components of the WMFT are not timed and
are included in Table 4.

Table 2
Mean, Median, and Range of Values for WMFT
(timed in seconds)

              PATIENT #1           PATIENT #2

                     Post-Rx              Post-Rx
            Pre-Rx    Change    Pre-Rx     Change

1. Median   2.91      2.25      1.09       1.10
                     -.660 *               0.01
2. Mean     8.783     3.185     2.105      2.521
                     -5.598 *               .416
3. Range   41.97      13.84    10.54      12.35
                              -28.13 *     1.81

           PATIENT #1      PATIENT #2

            3-month        3-month
            follow-up      follow-up

1. Median   1.75           .87

2. Mean     4.499         1.69

3. Range   26.47          6.43 *

* Negative number indicates decrease in Median, Mean, and Range
from pre- to post- Rx

Table 3
* Functional Ability Scale (a component of the WMFT
with a range of 0-5)

                                   Patient #1           Patient #2

          TASK                 Pre-Rx     Post-Rx   Pre-Rx      Post-Rx
1. Forearm to Table (side)        4           5        5           5
2. Forearm to Box (side)          4           4        5           5
3. Extend Elbow (side)            5           4        5           5
4. Extend Elbow (weight)          4           4        5           5
5. Hand to Table (front)          3           4        5           5
6. Hand to Box (front)            4           4        5           5
7. Reach and Retrieve             3           5        5           5
8. Lift Can                       3           4        4           5
9. Lift Pencil                    3           4        4           3
10. Lift Paper Clip               3           4        4           5
11. Stack Checkers                2           4        4           4
12. Flip Cards                    2           3        4           4
13. Turn Key in Lock              3           4        5           5
14. Fold Towel                    3           3        4           4
15. Lift Basket                   3           4        4           5

* FAS does not have reported reliability or validity, however, data is
presented here so as to be consistent with the Birmingham, AL protocol.

Note: 0 indicates poorest performance, 5 indicates the best
performance.

Table 4
Mean and Percent Change of Functional Ability Tasks, Grip
Strength, and Weight in Box Task (all components of the WMFT)

Functional                 PATIENT #1                  PATIENT #2
Ability Tasks

Grip Strength (kg.)   3.267   4.000  +22.4%      4.533    4.667  +2.96%
Weight in Box        17.3    18.7     +8.09%    25.3     26.0    +2.77%
Task (lbs.)          13      15      +15.38%  * 20     * 20       0.0%

* 20 lbs. was the maximum amount of weight available.

Table 5
Mean and Change Scores on the MAL
(Range is 0 represents poorest score to 5 the highest score)

                        Patient #1                  Patient #2

                   Pre-Rx  Post-Rx  Change  Pre-Rx   Post-Rx     Change

1. Amount of Use   0.0379   2.41    +2.035   2.879     3.034     +0.155
2. How Well Used   0.224    1.72    +1.500   2.965     3.259     +0.294