Six hours in the laboratory: a quantification of practice time during constraint-induced therapy (CIT)

Abstract

Objective: To quantify supervised in-laboratory time and practice intensity during the signature protocol specified as 6 hours/day over 10 days for the EXtremity Constraint-Induced Therapy Evaluation (EXCITE) randomized clinical trial.

Design: Retrospective analysis of constraint-induced movement therapy training documentation acquired at the University of Southern California site from EXCITE (n = 38). Training documentation was reviewed and analysed to determine average and between-subject variability of supervised in-laboratory time and actual task-specific practice time for concurrence with the specified constraint-induced movement therapy protocol.

Setting: Motor Behavior and Neurorehabilitation Laboratory, Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA, USA.

Subjects: Data from 38 participants (35 met inclusion criteria) who, upon enrolment in the EXCITE trial, were between 3 and 10 months post stroke and between 47 and 81 years of age.

Results: The training records revealed an average of 64 hours (SD = 2.6) supervised in-laboratory time for 35 participants across 10 days of training. More importantly, the average time on task-specific practice was 3.95 hours per day (SD = 5.7) representing 62% of the in-laboratory time. Supervised in-laboratory time for

10 training days was consistent across the sample as was total practice time for days 2—10, with a substantially lower practice time on the initial training day. Conclusions: Participants tolerated an intense task-specific practice schedule that consisted of approximately two-thirds of the specified minimum 6 hour in-laboratory time and was distributed evenly between adaptive task practice (shaping) and task practice components.

Get full access to this article

View all access options for this article.

References

Taub E. , Miller NE , Novack TA , Cook EW III et al. Technique to improve chronic motor deficit after stroke. Arch Phys Med Rehabil 1993; 74: 347—54.

Taub E. , Uswatte G. , Morris DM Improved motor recovery after stroke and massive cortical reorganization following constraint-induced movement therapy. Phys Med Rehabil Clin N Am 2003; 14: S77—91.

Page SJ , Sisto SA , Levine P. , Johnston MV , Hughes M. Modified constraint induced therapy: a randomized feasibility and efficacy study. J Rehabil Res Dev 2001; 38: 583—90.

Page SJ , Sisto S. , Levine P. , McGrath RE Efficacy of modified constraint-induced movement therapy in chronic stroke: a single-blinded randomized controlled trial. Arch Phys Med Rehabil 2004; 85: 14—18.

Page SJ , Levine P. , Leonard AC Modified constraint-induced therapy in acute stroke: a randomized controlled pilot study. Neurorehabil Neural Repair 2005 ; 19: 27—32.

van der Lee JH , Wagenaar RC , Lankhorst GJ , Vogelaar TW , Deville WL , Bouter LM Forced use of the upper extremity in chronic stroke patients: results from a single-blind randomized clinical trial. Stroke 1999; 30: 2369—75.

Dromerick AW , Edwards DF , Hahn M.

Does the application of constraint-induced movement therapy during acute rehabilitation reduce arm impairment after ischemic stroke?

Stroke 2000; 31: 2984—88.

Roberts PS , Vegher JA , Gilewski M. , Bender A. , Riggs RV Client-centered occupational therapy using constraint-induced therapy. J Stroke Cerebrovasc Dis 2005; 14: 115.

Wolf SL , Lecraw DE , Barton LA , Jann BB Forced use of hemiplegic upper extremities to reverse the effect of learned nonuse among chronic stroke and head-injured patients. Exp Neurol 1989; 104: 125—32.

10.

Ploughman M. , Corbett D. Can forced-use therapy be clinically applied after stroke? an exploratory randomized controlled trial. Arch Phys Med Rehabil 2004; 85: 1417—23.

11.

Pierce SR , Gallagher KG , Schaumburg SW , Gershkoff AM , Gaughan JP , Shutter L. Home forced use in an outpatient rehabilitation program for adults with hemiplegia: a pilot study. Neurorehabil Neural Repair 2003; 17: 214—19.

12.

Winstein CJ , Miller JP , Blanton S. et al. Methods for a multisite randomized trial to investigate the effect of constraint-induced movement therapy in improving upper extremity function among adults recovering from a cerebrovascular stroke. Neurorehabil Neural Repair 2003; 17: 137—52.

13.

Wolf SL , Winstein CJ , Miller JP et al. Effect of constraint-induced movement therapy on upper extremity function 3 to 9 months after stroke: the EXCITE randomized clinical trial . JAMA 2006; 296: 2095—104.

14.

Sterr A. , Elbert T. Berthold I , Kolbel S. , Rockstroh B. , Taub E. Longer versus shorter daily constraint-induced movement therapy of chronic hemiparesis: an exploratory study. Arch Phys Med Rehabil 2002; 83: 1374—77.

15.

Plautz EJ , Milliken GW , Nudo RJ Effects of repetitive motor training on movement representations in adult squirrel monkeys: role of use versus learning. Neurobiol Learning Memory 2000; 74: 27—55.

16.

Nudo RJ , Plautz EJ , Milliken GW Adaptive plasticity in primate motor cortex as a consequence of behavioral experience and neuronal injury. Semin Neurosci 1997; 9: 13—23.

17.

Wolf SL , Blanton S. , Baer H. , Breshears J. , Butler AJ The emergence of repetitive task practice in upper extremity neurorehabilitation of patients with stroke: a critical review of constraint induced movement therapy and mechanisms related to TMS. The Neurologist 2002; 8: 325—38.

18.

Winstein CJ , Prettyman M. Constraint-induced therapy for functional recovery after brain injury: unraveling the key ingredients and mechanisms. In Baudry M , Bi X , Schreiber S eds. Synaptic plasticity. Marcel Dekker, 2005.

19.

Schmidt RA , Lee TD Motor control and learning: A behavioral emphasis, fourth edition. Human Kinetics, 2005.

20.

Lee TD , Genovese ED Distribution of practice in motor skill acquisition: learning and performance effects reconsidered. Res Q Exerc Sport 1988 ; 59: 277—87.

21.

Whyte J. , Hart T. It's more than a black box; it's a Russian doll. Am J Phys Med Rehabil 2003; 82: 639—52.

22.

DeJong G. , Horn SD , Gassaway JA , Slavin MD , Dijkers MP Toward a taxonomy of rehabilitation interventions: using an inductive approach to examine the `black box' of rehabilitation. Arch Phys Med Rehabil 2004; 85: 678—86.

23.

Page SJ

Intensity versus task-specificity after stroke: how important is intensity?

Am J Phys Med Rehabil 2003; 82: 730—32.

24.

Yen JG , Wang RY , Chen HH , Hong CT Effectiveness of modified constraint-induced movement therapy on upper limb function in stroke subjects. Acta Neurol Taiwan 2005; 14: 16—20.

25.

Sterr A. , Szameitat A. , Shen S. , Freivogel S. Application of the CIT concept in the clinical environment: hurdles, practicalities, and clinical benefits. Cogn Behav Neurol 2006 ; 19: 48—54.

26.

Chan DY , Chan CC , Au DK Motor relearning programme for stroke patients: a randomized controlled trial . Clin Rehabil 2006; 20: 191—200.

27.

Siegert RJ , Lord S. , Porter K.

Constraint-induced movement therapy: time for a little restraint?

Clin Rehabil 2004; 18: 110—14.

28.

Whyte J.

Clinical trials in rehabilitation. What are the obstacles?

Am J Phys Med Rehabil 2003; 82(suppl): S16—S21.

29.

Schmidt RA A schema theory of discrete motor learning. Psychol Rev 1975; 82: 225—60.