1 Running head: EFFECTIVENESS

Effectiveness of Robotic Therapy, Conventional Treatment, and Constraint Induced Movement Therapy at Improving Upper Extremity Motor Function for Patients Post-CVA: A Systematic Review Touro University Nevada Jennifer Chang, Kelly Garcia, William McCombs, & Jermaine Varian

2 EFFECTIVENESS Effectiveness of Robotic Therapy, Conventional Treatment, and Constraint Induced Movement Therapy at Improving Upper Extremity Motor Function for Patients Post-CVA: A Systematic Review Introduction Stroke, also known as a cerebrovascular accident (CVA), is a condition that affects millions of people in the United States. According to the National Stroke Association (NSA), there are currently more than 7 million stroke survivors in the United States (NSA, 2012). Individuals who have survived a stroke are often faced with a myriad of neurological deficits ranging from impairments in cognitive functioning to impairments in motor functioning. It is imperative that these individuals receive the appropriate therapy services from occupational therapists, physical therapists, and/or speech therapists to improve overall functioning and independence. Common intervention approaches used by therapists in the rehabilitation of stroke patients include conventional treatment methods and newly developed treatment interventions, such as constraint induced movement therapy (CIMT) and robotic therapy (RT). RT is a treatment intervention that can be used for the rehabilitation of the hemiparetic or hemiplegic UE after stroke. It consists of a high tech robotic device that provides different modes of movement to a patients affected UE. It also provides visual feedback to a patient through a computer screen and consists of a sophisticated computer program that monitors a patients progress and training (Hayward, Barker, & Barauer, 2010). Another alternative to conventional treatment is CIMT. CIMT is used to restrain the functional hand by using a sling or mitt in order to increase performance of the paretic limb and decrease learned non-use (Wolf, Winstein, Miller, Taub, Uswatte, Morris, Nichols-Larsen, 2006). This may include a regimented protocol that may last

3 EFFECTIVENESS up to two weeks or more. In order for clients to participate in this type of treatment they must have 20 degrees of wrist extension and 10 degrees of finger extension (Bonifer, Anderson, Arciniegas, 2005). Once clients meet these criteria they may be considered for CIMT. Although there is a large body of evidence demonstrating the effectiveness of these treatment approaches with individuals who are within the first six months of their stroke, there is limited evidence that analyzes and compares the effectiveness of these three treatment approaches on clients with chronic stroke. Individuals with chronic stroke are those who are at least 6 months post-stroke and continue to experience the neurological symptoms associated with their stroke. Theoretical Framework RT, CIMT, and conventional treatment for stroke patients are based on different theoretical models. RT and CIMT rely on the principles of motor learning (Finley et al., 2005). These principles suggest that learning occurs in three stages: skill acquisition, skill retention, and skill transfer. Skill acquisition focuses on acquiring a new skill, skill retention focuses on refining the skill, and skill transfer refers to generalizing the skill to different settings. Motor learning principles also suggest that the attainment of skill occurs through blocked and random practice. Blocked practice refers to practicing a skill repeatedly, and random practice refers to practicing a variety of different skills (Flinn & Radomski, 2008). Random practice is considered to be more effective than block practice, at skill retention and skill transfer (Flinn & Radomski, 2008). Furthermore, RT and CIMT follow the dynamic systems approach of motor control. It is hierarchical model that emphasizes that movement develops from the interaction of many systems within the body and environment (Mathiowetz & Bass-Haugen, 2008). CIMT and RT

4 EFFECTIVENESS utilize repetitive task practice (RTP). This focuses on improving a clients performance of functional tasks through goal-directed practice and repetition (Hubbard et al., 2009, p. 176). RTP is the clinical application of the task-oriented approach, which derives from the dynamic systems theory of motor control (Mathiowetz & Bass-Haugen, 2008). Additionally, RT utilizes the motor learning principle that movement practice improves motor function (Giuffrida &Rice, 2009, p. 709). Conventional treatment interventions use the Neuro-Developmental Theory (NDT) or Bobath approach. This is a treatment approach for individuals with motor dysfunction resulting from central nervous system (CNS) pathophysiology. Clients with hemiplegia or clients with loss of muscular control on one side of the body are often good candidates for this treatment approach. An NDT therapist will use handing techniques to provide specific tactile, proprioceptive, and kinesthetic messages that help organize the quality of the patients movement and influence the status of relevant impairments, such as spasticity and flaccidity (Levit, 2008, p. 646). Bobath and Bobath developed this treatment approach based on their belief that hemiplegia is associated with two categories of motor problems: the loss of normal movement responses and the development of abnormal tone and movement (Levit, 2008, p.644). They hypothesize that these sensory and motor functions directly cause the abnormal patterns of coordination and functional limitations commonly found in clients with CVA. When these sensorimotor problems are addressed, specifically with NDT, it is predicted that clients with hemiplegia will significantly increase their occupational performance. Bobath and Bobath consider NDT as a living concept because they expected it to change and develop over time through the development of scientific research and clinical experience. The Neuro-

5 EFFECTIVENESS Developmental Treatment Association (NDTA) has continuously been working on keeping the theoretical basis for NDT up-to-date (Levit, 2008, p.644). Operational Definitions: UE Motor Function UE motor function can be operationalized in different ways. First, it can be categorized into one of the VI stages of upper extremity and hand recovery identified by Brunnstrom. The stages of recovery for the arm range from Stage I, Flaccidity: no voluntary movement or stretch reflexes to Stage VI, Isolated joint movements freely performed with near normal coordination; spasticity minimal (Latham, 2008, p. 672). Function according to Brunnstroms stages of recovery of the proximal UE and hand for clients with stroke can be assessed through the use of the upper-limb portion of the Fugl-Meyer Assessment (FMA). It specifically examines the presence of synergistic and isolated movement patterns and grasp (Fasoli et al., 2004). The FMA was used in 8 out of the 10 research studies that were reviewed making it the most commonly used UE motor function assessment in this systematic review. UE motor function can be determined by how successful clients can use their UEs to perform their activities of daily living (ADLs). The Motor Activity Log (MAL) was used in 6 of the research studies reviewed. The MAL is a structured interview used to measure how often and how well clients with strokes are able to perform a variety of daily activities (Flinn et al., 2009). One other ADL assessment may include the Canadian occupational performance measure (COPM). The COPM is also an interview, but it tends to be a more client-centered assessment used to identify and track how well a client is able to perform his or her most important ADLs.

6 EFFECTIVENESS UE motor function can also be measured by using different constructs such as strength, reach, and ROM. Assessments that can be used to assess biomechanical measures include the Modified Ashworth Scale (MAS) and the Motor Power Assessment (MPA). Purpose The purpose of this review is to investigate how effective three common therapeutic interventionsRT, CIMT, and conventional treatmentare at improving the upper extremity (UE) motor function of individuals with chronic stroke. Another objective of this review is to identify the advantages and disadvantages of utilizing the therapeutic interventions in current practice. The results of this study are expected to help clinicians in the rehabilitation setting to determine the best possible treatment options for clients with chronic stroke. Hypotheses We hypothesize that each of the treatment interventions mentioned above will have significantly positive effects at improving the UE motor functioning of individuals who have suffered a stroke. However, due to the different theoretical frameworks and treatment implementations of the interventions, the degree of effectiveness is anticipated to have variable outcomes for each treatment approach. With regards to advantages and disadvantages of the interventions, RT is expected to be the most difficult to implement in current practice due to the amount of technology it requires, and conventional treatment is expected to be the most cost effective but the least successful at improving UE motor functioning of individuals with chronic stroke. Methodology Search Strategy

7 EFFECTIVENESS To obtain articles for this review, the following electronic databases were searched: (a) Google Scholar, (b) American Journal of Occupational Therapy (AJOT), (c) PubMed, and (d) EBSCO Multi-search. In order to acquire the most recent literature available on the subject matter, these databases were searched from January 2001 until the present month and year of this review. The search was limited to only scholarly, peer-reviewed journal articles, and full text articles. These limits were chosen in an attempt to find reputable studies and the best possible research evidence. The keywords used to yield results for each treatment intervention were stroke, CVA, chronic stroke, robotic therapy, constraint induced therapy, conventional treatment, occupational therapy, and upper extremity. The keywords were used separately and in Boolean/Phrase combinations (e.g. robotic therapy and chronic stroke). Literature Selection From the hundreds of articles that the initial search results yielded, a total of 19 articles were selected for review based on the preliminary information provided in the abstracts. After further review, only 10 of the 19 articles were selected to be in this study based on the eligibility criteria established. Studies were included in this review if participants were adults who had suffered a stroke, the interventions studied were RT, CIMT, and/or conventional treatment, and if the interventions focused on improving the upper extremity motor function of participants. Studies were excluded if participants were less than three months post stroke; if the primary purpose of the study was not to promote upper extremity motor function; and if the article was a preliminary study to another study conducted by the same authors using the same intervention protocol and a greater sample size. Results General Findings

8 EFFECTIVENESS The studies that were selected based on the inclusion and exclusion criteria were grouped into one of three intervention categories: RT, CIMT, and conventional treatment. For the purposes of this review, when a study included elements of both (e.g. compared RT and conventional treatment) they were classified into two intervention categories. A total of five articles investigated robotic therapy, another five investigated CIMT, and four articles investigated conventional treatment. The majority of CIMT and conventional treatment studies provided the highest levels of evidence utilizing a randomized control trial design (RCT). RT studies mostly used a pre and posttest design with the exception of one single case study design and one RCT design (see appendix A for summary of articles). The following paragraphs will provide a synthesis of the evidence found for each intervention category and an overview of the interventions used. Robotic Therapy (RT) Within the five RT articles of this review, only two robotic devices were used. Lum, Burgar, Shor, Majmundar, and Van der Loos (2002) used the mirror image movement enabler (MIME) while the InMotion2 was utilized by all other researchers in the remaining studies (Fasoli et al., 2004; Finley et al., 2005; Flinn, Smith, Tripp, & White, 2009; MacClellan, et al., 2005). Both the MIME and InMotion2 focus on improving shoulder and elbow function through repetitive task movements. The InMotion 2 is a commercial version of another robotic device developed by the Massachusetts Institute of Technology, called the MIT-Manus (MacClellan, et al., 2005). It is more popularly used and provides sensorimotor and progressive exercises that can provide either passive movement or resistance to a patients UE. The MIME has many similarities with the InMotion2; however, it has a bimanual mode that allows patients to practice bilateral movements with their arms (Lum, et al., 2002).

9 EFFECTIVENESS The results of these studies support the most recent research in stroke recovery that states that individuals who are six to 12 months post stroke can experience significant gains in motor functioning. Statistically significant gains on UE motor function outcome measures were noted with participants who were considered to have mild to severe impairments on the FMA and participated in a six week RT protocol (Fasoli et al., 2004; Flinn et al., 2009; Lum et al., 2002). Smaller statistically significant results were demonstrated with the studies that provided a shorter duration intervention (e.g. three weeks) and mostly included participants who were considered to have severe impairments on the FMA (Finley et al., 2005; MacClellan et al., 2005). The duration and the severity of the impairments were hypothesized to be the cause of the smaller significant results. Furthermore, the evidence demonstrated that individuals with chronic stroke and mild to severe impairments are able to tolerate an intensive RT treatment regimen (MacClellan et al., 2005). During evaluations at follow-up, no statistically significant gains were made from the post treatment measurements (Fasoli et al., 2004; Finley et al., 2005; Flinn et al, 2009; Lum et al., 2002). Some studies even showed a decline in UE motor functioning at follow-up measurements. MacClellan et al. (2005) noted statistically significant declines during follow up in the motor functioning of participants who had moderate impairments. The authors explained that this could be due to the small sample size of the individuals who had moderate impairments. Additionally, Fasoli et al. (2004), found a decline in effect size from discharge to the four month follow-up. The researchers claimed that the diminished performance on the FMA and motor power tests at follow-up may be attributed to the lack of ongoing exercise for the paretic arm after discharge from robotic therapy (Fasoli et al., 2004, p. 1110). The studies further demonstrated that UE motor functioning gains are limited to the limbs exercised by the robotic

10 EFFECTIVENESS device (Fasoli et al., 2004; Lum et al., 2002). In other words, there is limited evidence that RT improves the motor functioning of the distal UE (e.g. wrist, hand, and fingers) or that the improvements translate to increased functional performance (Lum et al., 2002). Constraint Induced Therapy (CIMT) Most of the studies on CIMT that were gathered for this review included patients who were post stroke two months or greater. All of the studies revealed that clients who were involved in CIMT for approximately six hours per day for two to three weeks experienced significant gains in upper extremity recovery. One study explained, patients who had experienced a first stroke between 3 and 9 months prior, administration of CIMT resulted in statistically significant and clinically relevant improvements in paretic arm motor ability and use compared with participants receiving usual and customary care (Wolf, et al., 2006, p. 2103). It was also said that Improvements were...not influenced by age, sex, or initial level of paretic arm function (Wolf, et al., 2006, p. 2103). A magnetic resonance Imaging study also showed improvements with the CIMT intervention. Results from this intervention showed that patients that received CIMT intervention had increased activation in bilateral hemispheres while clients who did not receive treatment had decreased activation in the sensorimotor cortex (Lin et al., 2010). One study found that a modified protocol that used a distributed practice schedule was found to be effective and discourage learned non-use (Page, et al., 2001). The same study also found that CIMT was to be most beneficial treatment when the affected extremity was used to perform activities of daily living (Page, et al., 2001). Conventional Treatment Only comparative CT articles were reviewed in this systematic review. Three articles compared CIMT and CT, and one article compared RT and CT. The CT interventions used in the

11 EFFECTIVENESS articles included a variety of treatment techniques, such as NDT, activities of daily living (ADLs) skills training, and strength and range of motion (ROM) training. In all the CT articles reviewed, both RT and CIMT treatment proved to be more beneficial for improving FMA and MAL scores in the short-term, but this is not always the case long term. In Lum et al. (2002), it was found at the six month follow-up that no differences existed, in terms of UE improvement, between clients who received CT and RT. It was suggested that conventional techniques may have a larger impact on individual home-based exercise programs (Lum et al., 2002, p.958). The client-centered component of CT makes the UE gains from treatment more transferable to home situations in comparison to other treatment approaches. Discussion The purpose of this systematic review is to critically examine the efficacy of common treatments; specifically CIMT, RT, and CT for improving upper extremity function for clients post CVA. Clients post CVA have usually exhibit UE deficits that significantly affect performance of their ADLs. Finding out effective treatment options for clients with stroke will be of interest not only for the clients themselves but healthcare professionals as well. The studies in this review reveal that there are benefits and limitations of each treatment approach for improving UE motor function. RT is shown to be beneficial for improving biomechanical components of the shoulder and elbow but not the wrist and hand. According to Flinn et al. (2009), some form of functional control of the hand and fingers is needed in order to promote significant changes in lifestyle after stroke (p. 241). In addition, RT has not been shown to have long-term effects on UE function and may not be generalizable to the home. Although CIMT is shown to be beneficial for improving UE function, there are many limitations that make its implementation difficult. First of all, clients who do not have the 45

12 EFFECTIVENESS degrees of shoulder abduction or flexion, and 10 degrees of elbow extension required for success in CIMT, nor did they have the wrist or hand functioncould not participate in this form of treatment (Flinn et al., 2009, p. 233). Even when clients meet the criteria, they may not participate in CIMT protocol due to a number of reasons. Clients may find it difficult to restrain their unaffected extremity for 90% of their waking hours. This will impede their performance on their ADLs while they adhere to CIMT protocol. In addition, clients are expected to engage in six hours of training each day. Therapists have also noted that the practice schedule and restraint schedule in CIMT could make patient adherence and motivation, as well as ability to engage the patient over 6 hours, problematic (Page et al., 2001, p.589). CT is the treatment approach that can be more client-centered and customizable, but its benefits are not backed up by sufficient research. Also, when compared to RT and CIMT, CT is the least effective treatment intervention at improving UE motor function. However, CT has substantial benefits over the other two treatment approaches, because treatment interventions specifically focus on improving functional use of the UE. Possible recommendations for improving treatment outcomes for UE recovery have been proposed in the articles reviewed. In Flinn et al.(2009), previous research has shown that to make lasting changes in functional use, functional use has to be incorporated into treatment and daily routines (241). In Bonifer et al. (2005), it was suggested that an additional instructional video for UE home exercises be provided to supplement CIMT. Fasoli et al. (2004) also found that when repetitive, daily exercises were performed for more than 1 year (e.g., moving pencils from 1 container to another), motor recovery continued and did not reach a plateau (p. 1110). All of these findings and recommendations may help clients better maintain the UE gains they received in therapy and furthermore generalize them into home situations.

13 EFFECTIVENESS Relevance to OT It is important to note that while improvement in motor function is a prerequisite for improvement in functional use of the involved arm after stroke, improvement in motor function does not necessarily translate to functional use (Flinn et al., 2009, p. 242). Both RT and CIMT are shown to have better results on FMA and MAL assessments in comparison to CT, but these results do not imply that these UE gains may translate to functional use of UE at home. As OTs, the primary objective is to help clients regain function of their arm in everyday tasks (Lum et al., 2002). For the clients themselves, it is also more important for them to show progress in performing their valued everyday activities rather than strictly increasing ROM and strength of their arm in non-occupational exercises (Flinn et al., 2009, p.234). Conclusion As explained earlier, we hypothesized that each of the treatment interventions mentioned above will have significantly positive effects at improving the UE motor functioning of individuals who have suffered a CVA. Our findings do in fact support our hypothesis. No one treatment approach was more effective, because they were all beneficial for UE motor function in different ways. We propose that more studies be conducted on capitalizing the benefits of each and employing the use of these different treatment approaches in cohort rather than individually. For example, a study can investigate the efficacy of using RT to improve shoulder and elbow function in combination with using CT to improve distal extremity function. In this systematic review, studies that were not random controlled trials as well as studies with small sample sizes were included. Both of these may be limitations that can be addressed in future systematic reviews. This review also sought to determine the effectiveness of the treatment interventions on individuals with chronic stroke, but some studies with participants who were at least two months

14 EFFECTIVENESS post stroke were used. This could have influenced the effectiveness of the treatment interventions. In conclusion, we recommend more research to be conducted on combining treatment approaches in order to investigate the long-term effects for improving UE motor function for clients post CVA.

15 EFFECTIVENESS References Bonifer, N. M., Anderson, K. M., & Arciniegas, D. B. (2005). Constraint-induced movement therapy after stroke: Efficacy for patients with minimal upper-extremity motor ability. Archives of Physical Medicine and Rehabilitation, 86(9), 1867-1873. Fasoli, S. E., Kerbs, H. L., Stein, J., Frontera, W. R., Hughes, R., & Hogan, N. (2004). Robotic therapy for chronic motor impairments after stroke: Follow-up results. Archives of Physical Medicine and Rehabilitation, 85(7), 1106-1111. Flinn, N. A., Smith, J. L., Tripp, C. J., & White, M. W. (2009). Effects of robotic-aided rehabilitation on recovery of upper extremity function in chronic stroke: A single case study. Occupational Therapy International, 16(3), 232-243. Flinn, N. A., & Radomski, M. V. (2008). Learning. In M. V. Radomski & C. A. Trombly Latham (Eds.), Occupational Therapy for Physical Dysfunction (6th ed., pp. 1106-1130). Baltimore, MD: Lippincott Williams & Wilkins. Finley, M. A., Fasoli, S. E., Dipietro, L., Ohlhoff, J., MacClellan, L., Meister, C.,Hogan, N. (2005). Short-duration robotic therapy in stroke patients with severe upper-limb motor impairment. Journal of Rehabilitation Research and Development, 42(5), 683-692. Giuffrida, C. L., & Rice, M. S. (2009). Motor skills and occupational performance: Assessments and interventions. In E. B. Crepeau, E. S. Cohn, & B. A. Boyt-Schell (Eds.), Willard & Spackmans Occupational Therapy (11th ed., pp. 681-714). Philadelphia, PA: Lippincott Williams & Wilkins. Hayward, K., Barker, R., & Brauer, S. (2010). Interventions to promote upper limb recovery in stroke survivors with severe paresis: A systematic review. Disability and Rehabilitation, 32(24), 1973-1986.

16 EFFECTIVENESS Hubbard, I.J., Parsons, M.W., Neilson, C., & Carey, L.M. (2009). Task-specific training: Evidence for and translation to clinical practice. Occupational Therapy International, 16(3-4), 175-189. Latham, N. (2008). Optimizing motor behavior using the Brunnstrom movement therapy approach. In M. V. Radomski & C. A. Trombly Latham (Eds.), Occupational Therapy for Physical Dysfunction (6th ed., pp. 1106-1130). Baltimore, MD: Lippincott Williams & Wilkins. Leavit, K. (2008). Optimizing motor behavior using the Bobath approach. In M. V. Radomski & C. A. Trombly Latham (Eds.), Occupational Therapy for Physical Dysfunction (6th ed., pp. 1106-1130). Baltimore, MD: Lippincott Williams & Wilkins. Lin, K., Chung, H., Wu, C., Liu, H., Hsieh, Y., Chen, I.,Wai, Y. (2010). Constraint-induced therapy versus control intervention in patients with stroke. American Journal of Physical Medicine and Rehabilitation, 89(3), 177-185. Lum, P. S., Burgar, C. G., Shor, P. C., Majmundar, M., & Van der Loos, M. (2002). Robot assisted movement training compared with conventional therapy techniques for the rehabilitation of upper-limb motor function after stroke. Archives of Physical Medicine and Rehabilitation, 83(7), 952-959. MacClellan, L. R., Brandham, D. D., Whitall, J., Volpe, B., Wilson, P. D., Ohloff, J.,Bever, C. T. (2005). Robotic upper-limb neurorehabilitation in chronic stroke patients. Journal of Rehabilitation Research and Development, 42(6), 717-722. Mathiowetz, V., & Bass-Haugen, J. (2008). Assessing abilities and capacities: Motor behavior. In M.V. Radomski & C.A. Trombly Latham (Eds.), Occupational therapy for physical dysfunction (6th ed., pp. 599-617). Baltimore, MD: Lippincott Williams & Wilkins.

17 EFFECTIVENESS NSA. (2012). Stroke survivors. Retrieved from http://www.stroke.org/site/PageServer?pagename=surv Page, S. J., Sisto, S., Levine, P., Johnston, M. V., & Hughes, M. (2001). Modified constraint induced therapy: A randomized feasibility and efficacy study. Journal of Rehabilitation Research and Development, 38(5), 583-590. Taub, E., Uswatte, G., King, D. K., Morris, D., Crago, J. E., & Chatterjee, A. (2006). A placebo controlled trial of constraint-induced movement therapy for upper extremity after stroke. Journal of The American Heart Association, 37, 1045-1049. Wolf, S. L., Winstein, C. J., Miller, J. P., Taub, E., Uswatte, G., Morris, D.,Nichols-Larsen, D. (2006). Effect of constraint-induced movement therapy on upper extremity function 3 to 9 months after stroke. Journal of the American Medical Association, 296(17), 2095-2104.