Abstract
Roger’s Diffusion of Innovation theory was used to examine the extent to which practitioners have adopted the use of constraint-induced or modified constraint-induced movement therapy, both well supported by research, into neurorehabilitation practice. Though perceived to be effective, few use either, even with eligible clients. Findings of this study provide insight into strategies that may increase consumer access to evidence-based practice to improve occupational performance and participation after stroke.
Primary Author and Speaker: Shannon Scott
Additional Authors and Speakers: Hannah Shade, Margaret Crowell, Mollie Lynch
Contributing Authors: Leah Arpadi, Alexis Levine, Alexandra Muro, Taylor Van Meter, Dana Ware, Sebastian Harenberg
Nearly 80% of stroke survivors have upper extremity (UE) hemiparesis (National Stroke Association, 2018); 93% continue to struggle with impaired use even after traditional therapies (Barker, Gill, & Brauer, 2007). UE recovery is relevant as it promotes increased occupational performance (Nilsen et al., 2015). Evidence supports task practice of the affected limb to include Constraint-Induced Movement Therapy (CIMT) and modified versions (mCIMT, Nilsen et al., 2015). However, prior studies exploring OT neurorehabilitation practice found that traditional approaches, not supported by evidence, were predominantly used (Latham et al., 2006, Natarajan et al., 2008). With Vision 2025 and the profession’s commitment to evidence-based practice (AOTA, 2017) and the historical support of CIMT/mCIMT in the literature over the past decade, what is the current extent of evidence based practice?
The purpose of this study was to examine the adoption of CIMT/mCIMT into OT practice through the lens of The Diffusion of Innovation Theory (DoIT), which defines stages and characteristics of the person and the innovation as factors that impact adoption (Rogers, 1962).
An electronic survey was developed based on DoIT, literature review, and piloting. Participants were recruited via email, social media, and AOTA CommunOT over 8 weeks. Inclusion criteria were active OT licensure and currently working, or worked in the last 10 years, with stroke survivors in any practice setting. Data were descriptively and statistically analyzed.
A total of 227 eligible practitioners responded to the survey; most were occupational therapists (92%). Most had at least 5 years or more of experience working with stroke survivors (69%); over half of who had greater than 15 years. Most worked in outpatient (31%), inpatient, (26%), and skilled nursing (16%) settings.
Two-thirds of respondents learned about CIMT/mCIMT in school, with the primary method being lecture; only 25% experienced simulated or real practice and less than 25% observed these approaches on fieldwork. Though many pursued additional information after graduation (65%), the majority utilized didactic methods through colleagues, the internet, and scholarly journals.
Most respondents had awareness of CIMT/mCIMT (94%) and perceived both to be effective (91%). Most were able to describe ‘restraint’ (68%) as a key element of the treatment protocol but few identified ‘massed practice’ (21%) or ‘shaping’ (2%) as other key elements. Only 26% frequently/regularly used CIMT/mCIMT and only 31% adopted use as the first choice for clients who met the inclusion criteria.
A barrier to the adoption of CIMT/mCIMT was perceived relative advantage; only 38% perceived the approaches as superior to traditional methods. Multiple regression analyses revealed perceived effectiveness versus knowledge predicted 16% of the frequency of use of CIMT/mCIMT. Less than half (47%) perceived CIMT/mCIMT to be easy to use with compatibility factors (available time, eligible clients, and clients able/willing to comply) as well as ability to trial and observe CIMT/mCIMT (available time, eligible clients) seen as additional barriers.
The results of this study reveal that despite strong evidence, CIMT and mCIMT are still not routinely used in practice, even for clients who meet the inclusion criteria. Limited ability to trial and observe CIMT/mCIMT, both in entry level education and practice, may contribute to perceived barriers. Experiential learning opportunities in entry level education and professional development, as well as group or self-administered strategies to overcome time barriers may promote increased consumer access to evidence-based practice and improve occupational outcomes, especially in an era where value over volume is prioritized.
Barker, R.N., Gill, T. J., & Brauer, S. G. (2007). Factors contributing to upper limb recovery after stroke: A survey of stroke survivors in Queensland Australia. Disability and Rehabilitation, 29(13), 981-989. https://doi.org/10.1080/09638280500243570
Latham, N. K., Jette, D. U., Coster, W., Richards, L., Smout, R. J., James, R. A., Gassaway, J., & Horn, S. D. (2006). Occupational therapy activities and intervention techniques for clients with stroke in six rehabilitation hospitals. American Journal of Occupational Therapy, 60, 369-37 https://doi.org/10.5014/ajot.60.4.369
Natarajan P., Oelschlager, A., Agah, A., Pohl P. S., Ahmad, S. O., & Liu, W. (2008). Current clinical practices in stroke rehabilitation: Regional pilot survey. Journal of Rehabilitation Research & Development, 45(6), 841–849. doi: 10.1682/JRRD.2007.04.0057
Nilsen, D. M., Gillen, G., Geller, D., Hreha, K., Osei, E., & Saleem, G. T. (2015). Effectiveness of interventions to improve occupational performance of people with motor impairments after stroke: An evidence-based review. American Journal of Occupational Therapy, 69, 6901180030. http://dx.doi.org/10.5014/ajot.2015.011965