CASE STUDY | Stroke Rehabilitation: Constraint Induced Movement Therapy

Updated: Feb 16

By Jamie Grant, Occupational Therapist; Director, The Occupational Therapy Hub

[Setting: Stroke early supportive discharge (ESD), community team based in the UK]



Occupational therapy assessment and intervention


I visited 'Pete' (name changed for confidentiality) regularly for 5 weeks, following and shaping his rehabilitative journey after a stroke. He engaged with an evidence-based constraint-induced movement therapy programme (CIMT). Multidisciplinary input included occupational therapy, physiotherapy, speech and language therapy and nursing.



Background
  • Diagnosis: Right Temporal ICH (Intra-cerebral Haemorrhage); left side affected

  • Dominant hand: Right hand

  • Relevant past medical history: Right ICH 3 years ago

  • Physical environment: 2-storey house; 1 flight of stairs, 2 rails; upstairs toilet/mowbray; upstairs bathroom (shower over bath)

  • Social environment: Lives with wife, children and grandchildren live elsewhere

  • Meaningful occupations: Reading; shared cooking, gardening and walking with his wife


  • Ward outcome measures: Montreal Cognitive Assessment (MoCA) = 23/30 Motor Assessment Scale (MAS) = 6/18 9-hole peg test = 29 secs (right hand); left hand unable to complete



Initial visit: presenting symptoms and ability level
  • Left-sided weakness in upper limb (U/L) and lower limb (L/L), needing assistance of 1

  • Significantly reduced dexterity

  • Reduced balance

  • Proprioception impairment

  • Dysarthria

  • Cognitive deficits – slowness of thought, impulsivity, poor attention (including L hand)


Pete was reliant on a stick to mobilise around the house. He required supervision to scale his flight of stairs, with his left foot often dragging. Transfer into and out of the bath was a challenge and, on observation during an initial visit, the occupational therapist deemed this a health and safety risk. It was recommended he refrain from washing in the usual way until adaptations were made. He was unable to execute or complete some tasks requiring fine and gross motor skills of the hand and was not engaging with activities in his garden or out of the house.


The service user’s communication with relatives and therapists was largely unaffected. However, he was conscious of some slurred speech and occasional dribbling, as a result of dysarthria.



Home adaptations

Bath rails (x2) were fitted around the bath, in consultation with Pete and his wife. A bath board was also provided. An additional rail had been fitted to his flight of stairs, prior to the stroke discharge team's involvement.



Goal Attainment Scale (GAS) goals

The following were established in collaboration with Pete and his wife, all deemed of equal importance:


  • To be independent with personal care

  • To be independent bathing

  • To walk inside without a stick

  • To walk outside

  • To be independent making breakfast



CIMT Programme

Clinical reasoning

Intensive practice using the affected hand for daily activities discourages reliance on the unaffected hand and aids to regain fine and gross motor strength and dexterity. To reduce functional deficits, a mitt is used as a restraint for up to 6 hours a day, for 2 weeks (Curtin et al, 2010). The biological mechanisms responsible for the benefits are unknown. However, according to Spence and Barnett (2012, p.276), CIMT treatment ‘shows promise, especially for survivors with moderate disability following stroke.’



CIMT and Pete


The service user agreed to engage with a 2 week CIMT programme. This was altered to a modified programme, as 4 hours was deemed more manageable and would complement his unstructured, ad hoc approach to daily activity. The following tasks were selected to focus on, after initial brainstorming by the physiotherapy team...


  • Lifting weighted bag, from extended arm to chair and from chair to table: Developing strength of bicep, deltoid, pectoralis major and rotator cuff muscle; encouraging movement in a straight, sagittal plane

  • Transfer of cans from one kitchen surface to another: Developing flexion and extension of muscles that mobilise digits of the affected hand; improving balance and proprioception

  • Tipping water from cup to cup, through supination of the hand: Rebalancing the tendency to over-pronate during reaching tasks

  • Buttoning up shirt

  • Tying shoe laces

  • Turning book pages; reading is a meaningful occupation to Pete




Evaluation of engagement and progress in rehabilitation


Pete’s balance has improved to the point that he neither requires a stick to mobilise, nor supervision to complete the flight of stairs. He has developed increased strength in the muscles supporting and moving his upper and lower limbs. Range of movement and dexterity have improved to some degree. However, on discharge, he still had some deficit, struggling to smoothly supinate whilst picking up, turning and placing down coasters on a table. Complete control of his 4th/5th digits is yet to be recovered.


Cognitively, Pete feels his previous slowness of thought has reduced and the stroke therapy team have observed improved attention during conversation and task execution. Symptoms of dysarthria have also improved; he no longer complains of being self-conscious from slurred speech.


Focus on occupation…

In terms of occupational performance and engagement with ADLs, Pete now bathes independently, with assistance of the fitted hand rails. This was the main self care activity he struggled with post stroke. He now also able to tie his laces and button his shirt, although this still takes longer than pre-stroke. He shares some kitchen tasks with his wife, including breakfast and clear up. In terms of productivity and leisure, he reported to be back outside mowing the lawn and has recently been on walks everyday with his wife. He enjoys reading, often referencing the dictionary.



Pete has not been disciplined with the CIMT programme, admitting not to completing a full 4 hours of the modified programme or keeping to routine. This could be explained by his ad hoc and spontaneous daily routine, coupled with the fact that the affected left hand is not his dominant hand, leading to reduced motivation to improve its function. However, with the stroke discharge team's intervention, personal determination and the continued encouragement and guidance by his wife, this service user acknowledges significant improvements in motor function.

In terms of ongoing support post-discharge, Pete is to be referred to a neurology outpatients ward by the physiotherapist. He will continue to practise the exercises taught to him by our multidisciplinary team.




Personal practice reflection


I have enjoyed being part of Pete’s rehabilitation, working closely with both service user and family to maximise his recovery potential. My confidence working with him developed on each visit, in terms of explaining clinical reasoning, suggesting variations around intervention and physically assessing motor function of the upper limb and back muscles. Pete was my first occupational therapy service user; I am pleased with how quickly I felt comfortable with assessing tone and range of movement.


I was able to creatively problem solve, when guiding the service user to move in a straight sagittal plane, during functional strength training. I suggested he imagined an egg was resting on his upturned clenched hand during shoulder flexion exercises, so as to discourage pronation of the hand and abduction of the elbow. This distraction and visual imagery was well received by Pete, with performance observed to improve as a result.


Pete chose his own GAS goals and any intervention introduced was always with these in mind. Although functional strength training exercises were not always meaningful in themselves, they were chosen to focus on regaining skills Pete required for his daily occupations. For example, he shares shopping tasks with his wife, so repetitions lifting a weighted bag were useful for developing strength in the muscles required for this task. I believe this is reflective of the client-centred approach I adopted whenever possible during the rehabilitative programme.



References


  • Curtin, M., Molineux, M. and Supyk-Mellson, J. (2010) Occupational Therapy and Physical Dysfunction: Enabling Occupation. 6th ed. Edinburgh: Churchill Livingstone Elsevier.

  • Spence, D. and Barnett, H.J.M. (2012) Stroke Prevention, Treatment and Rehabilitation. New York: McGraw Hill.

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