Jing Cao Rachel Booth Estee Woods

Impact/Effects
A stroke can cause lasting brain damage, skills must be relearned. Common effects of a stroke include:
Paralysis or problems controlling movement (motor control). Sensory disturbances including pain and temperature discrimination. Problems using or understanding language (aphasia). Problems with memory of recent or past events.
(Atchison & Dirette, 2007)

Walter Experienced a left-sided

thrombotic stroke to the middle cerebral artery, 5 weeks ago. TPA was administered two hours after symptom onset. Doctors referred him to our out-patient clinic with orders to treat.

What we found with Walter

Spasticity of the group 1 muscles in his right UE

Brunnstrom Muscle Tone Score of 4
Spasticity and synergy is lessening Gross motor movements up to 90 degrees of shoulder flexion and abduction

Cognitively aware, some confusion with steps and procedures. Requires minimal verbal cues at initiation of task Can stabilize himself in upright position with support of unaffected limb Word articulation is mildly affected, can communicate if given enough time to talk Learned non-use of the right UE

Why NDT?

Neurodevelopmental FOR

Neurodevelopmental Treatment (NDT) provides treatment focused on neurorecovery rather than functional recovery. Goal is to get quality(as well as before) and quantity (as much as before) back. Remediate foundational skills (sitting balance) by re-experiencing what normal movement is like. Reorganize the brain by practicing skills the right way-Neuroplasticity. Developed to enhance the function of adults who have difficulties in controlling movement resulting from neurological challenges. Individuals who have minimal to severe motor difficulties can benefit from the NDT approach to become as independent as possible. Intervention involves direct handling and guidance to optimize outcomes. The approach is guided by the client's reactions throughout every treatment session (client-centered). (NDTA.org)

Assessments
Canadian Occupational Performance Measure (COPM) Wolf Motor Function Test Fugl-Meyer Test Mini Mental Motor Activity Scale

 Client-centered, semi-structured interview format Clients rate importance of activities

Self-care, productivity, and leisure

COPM

Clients perception and satisfaction with performance Used as outcome measure and client satisfaction survey Credible, outcome based, and accepted as evidence in research (Gillen, 2006) Test-retest reliability good for performance and satisfaction scores, however unique problems were unable to be evaluated with standardized methods (Cup, E., WJM, Thijssen, M., & van Kuyk-Minis, M., 2003).

COPM Results
He wants to get back to fishing Return to work at the theatre Walter recognizes he has spatial and perceptual deficits Walter is aware of his mild loss of coordination on the right side and poor standing balance.

 Assesses motor ability in upper extremities with a specific

Wolf Motor Function Test(WMFT)

task and verbal instructions Tasks 1 to 6 of the WMFT involve timed joint-segment movements, and tasks Tasks 7 to 15 consisted of timed integrative functional movements All tasks are performed as quickly as possible and are truncated at 120 seconds. (Wolf,& et al, 2001) A study of 97 people with chronic stroke and 75 with subacute stroke revealed that WMFT is a reliable and valid (construct) tool to assess UE function (Hui-fang, C., Ching-yi, W., Kehchung, L., Hsieh-ching, C., Chen, C. C., & Chih-kuang, C. , 2012).

WMFT Example

General Description of the Wolf Motor Functional Test

1. Forearm to table (side): Subject attempts to place forearm on the table by abduction at the shoulder. 2. Forearm to box (side): Subject attempts to place a forearm on the box by abduction at the shoulder. 3. Extend elbow (side): Subject attempts to reach across the table by extending the elbow (to the side). 4. Extend elbow (to the side), with weight: Subject attempts to push the sandbag against outer wrist joint across the table by extending the elbow. 5. Hand to table (front): Subject attempts to place involved hand on the table. 6. Hand to box (front): Subject attempts to place hand on the box.

 7. Reach and retrieve (front): Subject attempts to pull 1-lb weight across the table by using elbow flexion and cupped wrist. 8. Lift can (front): Subject attempts to lift can and bring it close to lips with a cylindrical grasp. 9. Lift pencil (front): Subject attempts to pick up pencil by using 3-jaw chuck grasp 10. Pick up paper clip (front): Subject attempts to pick up paper clip by using a pincer grasp. 11. Stack checkers (front): Subject attempts to stack checkers onto the center checker. 12. Flip cards (front): Using the pincer grasp, patient attempts to flip each card over. 13. Turning the key in lock (front): Using pincer grasp, while maintaining contact, patient turns key fully to the left and right. 14. Fold towel (front): Subject grasps towel, folds it lengthwise, and then uses the tested hand to fold the towel in half again. 15. Lift basket (standing): Subject picks up basket by grasping the handles and placing it on bedside table.

Functional Ability Scale

0Does not attempt with upper extremity (UE) being tested. 1 UE being tested does not participate functionally; however, attempt is made to use the UE. In unilateral tasks the UE not being tested may be used to move the UE being tested. 2 Does, but requires assistance of the UE not being tested for minor readjustments or change of position, or requires more than two attempts to complete, or accomplishes very slowly. In bilateral tasks the UE being tested may serve only as a helper. 3 Does, but movement is influenced to some degree by synergy or is performed slowly or with effort. 4 Does; movement is close to normal, but slightly slower; may lack precision, fine coordination or fluidity. 5 Does; movement appears to be normal. (Taub, Morris & Crago, 2011)

Results of the Wolf Motor Function Test

Walter scored in the 3-4 range for task 1-6 assessing joint segment movements
He is slightly lacking in fine motor coordination and timing

Items 7-15 are more difficult for Walter when fine motor is incorporated
He averaged a score of 2-3 on these tasks He needs assistance or requires extra time to complete the items on the test

Motor Activity Log

(MAL)

A scripted, structured interview that was developed to measure the effects of Constraint-Induced Movement Therapy (CIMT) on the use of the affected arm in individuals with stroke.
Client is asked about the use and quality of movement "Considering your activities during the past week, did you use your weaker arm to (state the activity)?" 0-5 scales measuring how well and the amount (Uswatte,& et al., 2005) A randomized control trial was conducted among 30 participants who experienced a sub-acute stroke. Findings revealed that the MAL is a responsive way to measure daily hand use (Hammer, & Lindmark, 2010).

Motor Activity Log

Amount Scale

How Well Scale

0 - Did not use my weaker arm (not used). .5 1 - Occasionally used my weaker arm but only very rarely (very rarely). 1.5 2 - Sometimes used my weaker arm but did the activity most of the time with my stronger arm (rarely). 2.5 3 - Used my weaker arm about half as much as before the stroke (half pre-stroke). 3.5 4 - Used my weaker arm almost as much as before the stroke (3/4 pre-stroke). 4.5 5 - Used my weaker arm as often as before the stroke (same as pre-stroke).

0 - My weaker arm was not used at all for that activity (not used). .5 1 - My weaker arm was moved during that activity but was not helpful (very poor). 1.5 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). 2.5 3 - My weaker arm was used for that activity but the movements were slow or were made only with some effort (fair). 3.5 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). 4.5 5 - The ability to use my weaker arm for that activity was as good as before the stroke (normal).

Results of Motor Activity Log

Walter responded within the 3-4 (fair to almost normal) range when asked how well he performs activities, however he scores a 0-2 (not used- to rarely used) when asked about the amount of time he uses his affected arm.
May be due to his unilateral neglect

Mini Mental State Examination (MMSE)

Used to systematically and thoroughly assess mental status An 11-question measure that tests five areas of cognitive function (orientation, registration, attention and calculation, recall, and language) The maximum score is 30 (score < 23 indicates cognitive impairment) Only 5-10 minutes to administer (Folstein, Folstein & McHugh, 1975) Folstein and associates conducted a study concluding that the MMSE is reliable on a 24 hour/28 day retest schedule by one or multiple examiners (Agostinelli, B., Demers, K., Garrigan, D., & Waszynski, 1994).

Mini Mental State Examination (MMSE)

Results of the Mini Mental State Exam

Walter scored a 28 out of 30

He was able to respond to most of the assessment but had a difficult time in a couple areas responding in a timely manner. Walter has a difficult time with pronunciation due to the weak muscles around the mouth on the right side.

 First quantitative instrument to measure sensorimotor recovery after stroke Excellent intrarater and interrater reliability as well as construct validity Inter-rater and test-retest reliability scored high on a study conducted on 37 participants who expirienced a stroke
(Platz, T., Pinkowski, C., van Wijck, F., Kim, I., di Bella, P., & Johnson, G., 2005).

Fugl-Meyer Test

5 Domains, 155 Items, 3-Point Scale

Motor functioning (UE/LE) Sensory functioning Balance (seated/standing) Joint ROM Joint pain Watch Video

Fugl-Meyer Test

 Motor functioning (UE/LE)

Fugl-Meyer Results

Mild impairment of voluntary movement and coordination on right side including face, extremities and trunk

Balance (seated/standing)
Dynamic sitting and static standing balance affected

Joint ROM
Minimal limitations in right side extremities in all planes

Joint pain
Reports pain as a 3/10

Client-Centered Practice
According to Glen Gillen (Pedretti) its important to:
Offer the client a more active role in defining goals and desired outcomes Evaluation and interventions focusing on the contexts in which clients live, their roles and interests and their culture Allowing the client to be the problem definer so that the client will in turn become the problem solver Allowing the client to evaluate his or her own performance and set personal goals. (Gillen, 2006)

Client-Centered Practice The goal is to give the

client a feeling of empowerment, an understanding of the desired outcomes that need to be met and that these are what the client chose to accomplish. (Gillen, 2006)

Focus on what Walter wants: Get back to fishing and work

 Restore range of motion in the right shoulder joint to within functional limits. Normalize muscle tone in his right upper extremity to increase strength and support of the right shoulder joint. Increase dynamic and static standing balance by strengthening the trunk. Normalize movement to facilitate controlled & coordinated motor movements in the right shoulder joint. Increase Walters independence with ADL performance to within functional limits. Facilitate Walters return to his leisure activity of fishing. Increase proximal stability, oral motor control and right shoulder joint strength and stability so Walter can return to work in the theatre.

Goals for Walter

Walter is a good candidate for Constraint Induced Movement Therapy

Suffered a stroke that left him with mild spasticity in the R UE Qualifying score on the Mini Mental State Exam (at least a 24) Has some gross motor movement at the shoulder, elbow and wrist joint
10x10x10 rule 10 of active wrist extension, at least 10 of thumb abduction/extension, and at least 10 of extension
in at least two additional digits (Wolf,& et al, 2001)

Has postural stability of the trunk Learned non-use of the affected side Walter is motivated to regain his independence so he can go fishing and be independent with his ADLs (Wolf,& et al, 2001)

Evidential Support of CIMT to be an effective treatment

A systematic review and a Meta analysis found:

30 papers on constraint-induced movement therapy, including 27 randomized controlled trials published between 2001 and 2011 There was improved mobility (ability to carry, move and handle objects) after treatment lasting 60-72 hrs over 2 weeks
As well as: 20-56 hrs over 2 weeks, 30 hrs over 3 weeks and 15-30 hrs over 10 weeks

Self-care outcome measures: Improvements were found with 30 hours of treatment over a 2 week period. (Peurala, Kantanen, Sjgren, Paltamaa, Karhula & Heinonen, 2012)

The EXCITE trial: Retention of Improved Upper Extremity Function Among Stroke Survivors Receiving CI Movement Therapy 727 participants 2 week intervention saw substantial improvement in functional use of the affected limb
(Wolf,& et al, 2001)

EBP continued

CIMT administered 3-9 months post-stroke, resulted in statistically significant and clinically relevant improvement in upper extremity function during the first year compared to those achieved by participants undergoing usual and customary care (Wolf,& et al, 2001, p. 2 )

Protocol
Based off the EXCITE trial Treatment time: One-on-one 6 hour treatment sessions 5 days a week in the clinic Continuous wearing of the mitt at home while performing ADLs- up to 90% of waking hours for 2 weeks Re-evaluate after 2 weeks of treatment..
(Wolf,& et al, 2001)

Treatment
Adaptive task practice Work on other functional (arm training based upon movements shaping principles) Feeding Repetitive practice of certain tasks, such as combing Walters hair or picking up objects performed continuously for 20 minutes.
Transfers Dressing Bathing etc

CIMT
http://Constraint Induced Movement Therapy

Agostinelli, B., Demers, K., Garrigan, D., & Waszynski, C. (1994). TARGETED INTERVENTIONS: Use of the mini-mental state exam. Journal of Gerontological Nursing, 20(8), 15-23. Retrieved from http://search.proquest.com/docview/1021720395?accountid=960; http://linksource.ebsco.com/linking.aspx?genre=article&issn=00989134& volume=20&issue=8&date=1994-0801&spage=15&title=Journal+of+Gerontological+Nursing&atitle=TARGET ED+INTERVENTIONS%3A+Use+of+the+MiniMental+State+Exam&au=A gostinelli%2C+Blanche%3BDemers%2C+Kathleen%3BGarrigan%2C+Debb ora%3BWaszynski%2C+Christine&isbn=&jtitle=Journal+of+Gerontologica l+Nursing&btitle= Atchison, Ben J.; Dirette, Diane K. (2007). Conditions in occupational therapy : effect on occupational performance. Philadelphia: Lippincott Williams & Wilkins. Cup, E., WJM, Thijssen, M., & van Kuyk-Minis, M. (2003). Reliability and validity of the Canadian Occupational Performance Measure in stroke patients. Clinical Rehabilitation, 17(4), 402-409. Folstein,M.F., Folstein,S.E.,& McHugh,P.R. (1975)"Mini-mental state": A practical method for grading the cognitive state of patients for the clinician.Journal of Psychiatric Research, 12(3):189-198.

References

Gillen, G. (2006). Pedretti's occupational therapy : practice skills for physical dysfunction. Pendleton, H & Schultz-Krohn (eds) St. Louis, Mo: Elsevier. Hammer, Ann & Lindmark, Brigitta. (2010). Responsiveness and validity of the Motor Activity Log in patients during the subacute phase after stroke. Disability and Rehabilitation32:14, 1184-1193. Retrieved from http://0informahealthcare.com.library.svsu.edu/action/showCitFormats? doi=10.3109%2F09638280903437253 Hui-fang, C., Ching-yi, W., Keh-chung, L., Hsieh-ching, C., Chen, C. C., & Chih-kuang, C. (2012). Rasch Validation of the Streamlined Wolf Motor Function Test in People With Chronic Stroke and Subacute Stroke. Physical Therapy, 92(8), 1017-1026. doi:10.2522/ptj.20110175 "NDTA: Neuro-Developmental Treatment Association ." NDTA: Neuro-Developmental Treatment Association . N.p., n.d. Web. 9 Oct. 2012. Retrieved from http://www.ndta.org Peurala, S., Kantanen, M., Sjgren, T., Paltamaa, J., Karhula, M., & Heinonen, A. (2012). Effectiveness of constraint-induced movement therapy on activity and participation after stroke: a systematic review and metaanalysis of randomized controlled trials. Clinical Rehabilitation, 26(3), 209223. doi:10.1177/0269215511420306


Platz, T., Pinkowski, C., van Wijck, F., Kim, I., di Bella, P., & Johnson, G. (2005). Reliability and validity of arm function assessment with standardized guidelines for the Fugl-Meyer Test, Action Research Arm Test and Box and Block Test: a multicentre study. Clinical Rehabilitation, 19(4), 404-411. Rensink M, Schuurmans M, Lindeman E, Hafstennsdottir T: Task-oriented training in rehabilitation after stroke: systematic review, J Adv Nurs 65 (4): 737-754, 2009. Taub,E., Morris,D.M., & Crago,J.(2011)Wolf Motor Function Test (WMFT) Manual. UAB Training for CI Therapy. Retrieved from http://www.uab.edu/citherapy/images/pdf_files/CIT_Training_WMFT_ Manual.pdf Uswatte, G., Taub, E., Morris, D., Vignolo, M., McCulloch, K.(2005) Reliability and validity of the upper-extremity motor activity log-14 for measuring real-world arm use. Stroke.2005;36: 2493-2496. doi: 10.1161/01.STR.0000185928.90848.2e Wolf, S.L., Catlin,P.A., Ellis,M. Archer,A.,L.,Morgan, B., & Piacentino, A.(2001). Assessing Wolf Motor Function Test as outcome measure for research in patients after stroke. Stroke.2001;32:1635-1639. doi: 10.1161/01.STR.32.7.1635


Wolf, S., Winstein, C., Miller, J., Thompson, P., Taub, E., Uswatte, G., et al. (2008). Retention of upper limb function in stroke survivors who have received constraint-induced movement therapy: the EXCITE randomised trial..Lancet Neurol, 7(1), 33-40. Retrieved from Responsiveness and validity of the Motor Activity Log in patients during the subacute phase after stroke