672276

research-article2016
CRE0010.1177/0269215516672276Clinical RehabilitationRostami et al.

CLINICAL
Article REHABILITATION

Clinical Rehabilitation

Occupation-based intervention 2017, Vol. 31(8) 1087­–1097

© The Author(s) 2016
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DOI: 10.1177/0269215516672276

constraint-induced movement journals.sagepub.com/home/cre

therapy for patients with median

and ulnar nerve injuries:
a randomized controlled trial

Hamid Reza Rostami1,2, Malahat Akbarfahimi1,

Afsoon Hassani Mehraban1, Ali Reza Akbarinia3
and Susan Samani4

Abstract
Objective: To investigate effect of practice type during modified constraint-induced movement therapy
on hand function in patients with chronic median and ulnar nerve injuries.
Design: A prospective, single-blinded, randomized controlled clinical trial.
Setting: Participants’ private home.
Subjects: A convenience sample of 36 outpatient participants allocated randomly to three equal groups.
Interventions: Intervention groups underwent 3-hour intensive training of affected hand each day, 3-day
a week, 4-week in association with immobilisation of healthy hand: occupation-based group practiced
meaningful occupations while rote exercise-based group performed rote exercises during constraint-
induced movement therapy. Control group performed different activities with affected hand for 1.5-hour
each day during 4-week without restriction of healthy hand.
Main measures: A blinded assessor tested Canadian occupational performance measure, box and block,
Static two-point discrimination, disabilities of arm, shoulder, hand questionnaire, and self-assessment
manikin in a random order across sessions 3-time as baseline (pre-test), after 4-week intervention (post-
test), and 1-month after intervention period (follow up).
Results: Scores significantly changed in intervention groups compared to control. Despite significantly
more improvement in occupation-based than rote exercise-based group in subjective measures at post-
test and follow up (Canadian occupational performance measure: mean change 4.7 vs. 2.1 for performance,

1Department of Occupational Therapy, School of 4Cognitive

Rehabilitation Sciences, Iran University of Medical Sciences,
Tehran, Iran
2Department of Occupational Therapy, School of
Rehabilitation Sciences, Esfahan University of Medical
Sciences, Esfahan, Iran
3Department of Hand Microsurgery and Plastic Surgery, Laleh
Hospital, Tehran, Iran
Research Centre, Shahid Beheshti University,
Tehran, Iran
Corresponding author:
Malahat Akbarfahimi, School of Rehabilitation Sciences, Shah
Nazari St., Mirdamad blvd., Tehran, Iran.
Email: akbarfahimi.m@iums.ac.ir
1088 Clinical Rehabilitation 31(8)

P< 0.001 and mean change 5.3 vs. 2.6 for satisfaction, P< 0.001), it was significant just at follow up for box
and block and static two-point discrimination.
Conclusions: Practice content of constraint-induced movement therapy is a critical part of its effectiveness
on improving outcomes following peripheral nerve repair in favour of occupation-based intervention in
present study.

Keywords
Constraint-induced movement therapy, median nerve, ulnar nerve, occupation-based intervention, rote
exercise

Received: 24 May 2016; accepted: 6 September 2016

Introduction
Traumatic upper extremity nerve injuries may
affect and intrude all aspects of daily living activi-
ties as well as different life domains in patients.1
Functional recovery following peripheral nerve
injuries is often poor2-5 because of different fac-
tors especially bilateral cortical reorganization
due to the lack of input from the injured nerve.2,6,7
Recent research has shown the central nervous
system factors more effective than peripheral fac-
tors in functional outcomes following nerve
repair.7,8 Different cortical reorganization tech-
niques have been introduced during recent years
such as local skin anaesthesia9 and tourniquet-
induced anaesthesia10 which by temporary deaf-
ferentation try to increase afferent inputs from the
injured part to the CNS.11
Another technique that works with intensive
and repetitive training of the affected hand (6-hour
a day, 5-day a week for two weeks) in association
with temporary deafferentation of the healthy hand
(immobilisation during most of waking hours) is
constraint-induced movement therapy.12 It has
shown good results in improving upper limb func-
tion in different population of patients such as
stroke or cerebral palsy.13 Changing the conditions
of the classic constraint-induced movement ther-
apy is entitled Modified form of it. Rostami et al.
applied modified constraint-induced movement
therapy on three patients with chronic median and
ulnar nerve injuries and based on their results,
introduced this technique as a feasible intervention
for improving hand function in these patients.14
One of the important aspects of constraint-
induced movement therapy is intensive practice with
the affected hand. A blending of different practice
types are implemented in constraint-induced move-
ment therapy from rote exercises (simple, repetitive
movement patterns in which the exerciser’s focus is
on the movement per se)15 to occupations (activities
of everyday life, named, organized, and given value
and meaning by individual and a culture).16 Earley
et al. implemented occupation-based intervention,
engaging in meaningful client-centred occupations
that match client’s occupational goals,17 in a con-
straint-induced movement therapy program for a 52
years old violinist woman with a history of 4-year
prior ischemic stroke. After intervention period, she
was able to achieve self-identified, personally mean-
ingful goal of playing violin.18
Considering the probable positive benefits of
constraint-induced movement therapy in patients
with chronic median and ulnar nerve repair,14
capacity of implementing occupation-based inter-
vention during constraint-induced movement ther-
apy,18 and better outcomes following purposeful
activities than rote exercises,19-21 we designed the
present prospective randomized controlled trial to
answer two main questions. First, whether con-
straint-induced movement therapy is an effective
intervention for improving hand function in
patients with chronic median and ulnar nerve injury
and repair? Second, if the type of the practice,
occupation-based vs. rote exercise, is effective on
results of constraint-induced movement therapy?
Rostami et al. 1089
Methods
Design
The present study was designed as a single-blinded
prospective randomized controlled trial and the local
ethics committee approved the study design.
Participants were informed about participating in a
non-invasive experimental study for improving their
hand function. Despite knowing existence of three
groups, they knew nothing about the content of the
intervention in different groups. With this information
and knowing whatever needed about their own group,
written informed consent was obtained from all par-
ticipants. The present trial is registered as a RCT, no.
IRCT2016011710806N4 in http://www.irct.ir/.
Participants
After searching the documentaries of different hos-
pitals and finding name and addresses of candidate
patients, they were called by the principal investiga-
tor for assurance about the demographic variables
and their desire to take part in the study. Then, the
inclusion and exclusion criteria were checked on the
candidate patients in a meeting at participants’ pri-
vate home. Patients meeting the following criteria
were recruited to participate in the study: (1) a first
unilateral median, ulnar, or combined nerve injury
and repair at forearm or lower levels, (2) time since
injury and repair at least six months, (3) functional
passive range of motion in the affected hand (15–20
degrees extension and 5–10 degrees flexion at wrist
joint, 30–45 degrees flexion at metacarpophalangeal
and interphalangeal joints) and (4) age between
18–60 years old. Patients with bilateral injury, bra-
chial plexus lesion, shoulder or elbow problems,
rheumatologic diseases, complex regional pain syn-
drome, any surgery during the study period, burned
hands, unhealed bone fractures and tendon ruptures,
or neurological diseases were excluded.
In the day before starting intervention, a blinded
assessor evaluated different aspects of hand func-
tion for all of the participants. Following baseline
assessment, principal investigator allocated partici-
pants to one of the three groups of the study (two
experimental intervention groups including occupa-
tion-based and rote exercise-based, and one control
group) randomly by selecting consecutively opaque
envelopes. Randomisation was stratified based on:
(a) affected nerve (median, ulnar, or combined), and
(b) affected hand (dominant or non-dominant).
These strata were randomised together and we did
not use them in data analysis.
Intervention
Considering the necessity of generalisation of the
learned issues to the real life situations and signifi-
cant effects of treatment environment on functional
outcomes following constraint-induced movement
therapy,22 the evaluation and intervention sessions
for all the three groups took place in the partici-
pants’ private home. An occupational therapist was
responsible of implementing intervention pro-
grams for all the participants.
- Occupation-based group: The intervention pro-
tocol consisted of three hours of intensive hand train-
ing on even days of the week for four weeks, in
association with the immobilisation of the healthy
hand during therapy and during the 6 hours of top
hand use at home by a resting splint which restricted
wrist and fingers movements. The occupational ther-
apist that implemented intervention programs for all
participants was informed just about the top occupa-
tional priorities in this group based on Canadian
occupational performance measure. Occupational
therapist and participants together, in a client-centred
perspective, collaboratively determined the thera-
peutic occupations and activities consistent with the
occupational priorities and present abilities and capa-
bilities of the participants. Goal meaningful occupa-
tions especially those related to participants’ jobs
were different among individuals. Generally, training
program included two integrated parts including sen-
sory (discriminative touch, touch localization, stere-
ognosis, and etc. according to the usual procedures)23
and motor re-education simultaneously and com-
pletely based on meaningful occupations. All pre-
paratory treatment techniques such as stretching or
strengthening, if required, were integrated into the
therapeutic occupations.
- Rote exercise-based group: The training hours
and immobilisation period were same as occupa-
tion-based group except performing intervention in
1090 Clinical Rehabilitation 31(8)
odd days of the week. Occupational therapist knew
nothing about the interests and occupational priori-
ties of this group; so, sensory and motor re-education
programs were determined considering the present
abilities, capabilities, and impairments of the partici-
pants by the occupational therapist. Some of the
practices included repetitive active, active-assistive
and passive movements of the upper extremity joints
especially hand; tendon gliding exercises, progres-
sive-resistive exercises, and displacing pegboards
with different sizes, identifying location of the dif-
ferent objects on skin and etc.
- Control group: Participants tried to use the
affected hand in different activities for one and half an
hour each day during four weeks without any restric-
tion on the healthy hand. Occupational therapist knew
nothing about the interests and occupational priorities
of this group; then in a counselling session, he
explained the present abilities and disabilities to par-
ticipants and instructed them to practice different
movements and activities. Same as the other two
groups, training program included two integrated
parts, sensory and motor re-education simultaneously,
without the presence of the therapist.
Outcome measures
Assessment of outcome measures took place upon
entry to the study as pre-test, the day after the end of
the four weeks intervention as post-test, and one
month after finishing the intervention period as fol-
low-up. An assessor blinded to the groups’ assign-
ment performed all assessments in a random order
across sessions. Evaluation process included follow-
ing measures: Canadian occupational performance
measure as the primary outcome is an individual-
ized, client-centred, semi-structured interview that
was used for understanding occupational priorities
from participants’ perspective. During interviews,
participants were encouraged to identify any daily
activity they would like or need to do but found dif-
ficult to complete because of their injury. Then, they
identified the top five important daily activities and
rated, first, their current level of performance, and
then, how satisfied they were with this current level
of performance on a 1-10 point scale, with
higher scores indicating better performance and
satisfaction. A change of two points is reported as a
clinically significant change;24 static two-point dis-
crimination is an objective measure for the tactile
gnosis at the volar tip of the second or fifth finger
representing true median or ulnar-innervated areas.
It was applied in a descending order starting with
15mm down to 2mm to assess the limits of tactile
discrimination. Normal two-point discrimination is
considered less than 6 millimeter, fair is 6 to 10 mm,
poor is 11 to 15 mm, and absent is higher than 16
mm;25 disabilities of the arm, shoulder, and hand
questionnaire is a validated 30-item, self-reported
questionnaire for evaluating disability rate of the
upper limb in daily activities with a five responses
option for each item, on a 100-point scale. Higher
score represents higher disability.26 A decrease of
20.9 points is reported to be a clinically important
change;27 box and block test is an objective hand
dexterity measure that involves moving 1-inch
square wooden blocks from one side of an 8-inch
square box to the other one. The critical measure is
the number of blocks transported within one minute.
The average score of three tests in each session is
recorded;28 and self-assessment manikin scale is a
subjective non-verbal pictorial assessment for self-
reported emotion associated with a person’s affec-
tive reaction to a situation. It ranges from a smiling
and happy figure to a frowning and unhappy figure
for pleasure dimension, ranges from an excited and
wide-eyed figure to a relaxed and sleepy figure for
arousal dimension, and ranges from a large figure to
a small figure for dominance dimension. Each part
is rated by on a 1-9 point scale.29
Statistical analysis
Statistical analysis was performed using SPSS ver.
16.0 for Windows. The significance level was set at
0.05. The variables were tested for normal distribu-
tion using the Kolmogorov-Smirnov test. To com-
pare the baseline demographic characteristics and
outcome measures among the groups, we performed
the Kruskal-Wallis test and one-way analysis of
variance (ANOVA). To test the study’s hypotheses,
we used ANOVA with repeated measures with the
between-subject factor set at 3 levels (3 groups) and
the within-subject factor set at 3 levels (Time: pre,
Rostami et al. 1091
Figure 1.  CONSORT flowchart of the Study Process.
post-test, and follow-up). Additional post-hoc anal-
yses with Bonferroni adjustment for multiple test-
ing were performed when a significant time, group,
or group × time interaction was observed to identify
sources of differences between and within groups.
Results
Allocation of participants at each time of data col-
lection is shown in a flow chart (Figure 1). Etiologies
of nerve injury included bone fractures, motor vehi-
cle accidents, laceration by sharp tools such as knife
and etc. The mean time since injury and repair to
the enrolment in the present study was 13 months
(range 8–23 months). Thirty six participants (25
men and 11 women; mean age: 35 years and range:
22–55 years, Table 1) were enrolled into the study
and final analyses were performed on 34 partici-
pants (occupation-based = 12, rote exercise-based =
12, control group= 10). There were no statistically
significant differences in the age, gender, level of
injury, type of nerve affected, affected hand, and
any of the outcome measures at baseline among the
groups (P > 0.05) (Table 1). The means and means
changes of the outcome measures over time are
shown in Table 2. As it is observed in table 2, mean
1092 Clinical Rehabilitation 31(8)
Table 1.  Baseline characteristics of study participants.
Characteristics Groups
Occupation-based
CIMT
Age (year) 31 ± 8
Gender (Male:Female) 8:4
Injured Nerve (Median:Ulnar:Combined) 4:2:6
Level of Injury (UpForearm: Mid 2:3:7
Forearm:Wrist)
Time Since repair (Month) 14
Injured Hand (Right:Left) 9:3
Injured Hand (Dominant:Non-Dom) 10:2
CIMT: Constraint-induced movement therapy.
change scores in occupation-based constraint-
induced movement therapy group exceeded the
clinically important change values for both parts of
the Canadian occupational performance measure
(performance: 4.7, satisfaction: 5.3), box and block
test (8.2), and disabilities of arm, shoulder and hand
questionnaire (50.8). Also, static two-point discrim-
ination score reached to the normal limit in the fol-
low up session (5.9 mm). For rote exercise-based
constraint-induced movement therapy group, mean
change scores exceeded the clinically important
change values for both parts of the Canadian occu-
pational performance measure (performance: 2.1,
satisfaction: 2.6) and disabilities of arm, shoulder
and hand questionnaire (26.1). Static two-point dis-
crimination score reached to the fair limit in the fol-
low up session (9.3 mm). In the control group, mean
changes in no one of outcome measures exceeded
the minimal clinically important change.
Repeated measures ANOVA showed a signifi-
cant effect for time, group, and group × time inter-
action (Table 3). Post-hoc analyses revealed
significant difference among all three groups with
most increased mean change for occupation-based
group (Table 2). One-way ANOVA on each testing
session showed a significantly between groups dif-
ference in both the post-test and follow up sessions
for outcome measures except box and block test
and static two-point discrimination; there was not
any significant difference in these two measures
between two intervention groups in post-test
P-value
Rote exercise-based Control
CIMT
39 ± 10 34 ± 6 0.07
9:3 8:2 0.70
4:3:5 3:2:5 0.21
2:4:6 1:4:5 0.33
12 13 0.40
7:5 7:3 0.12
9:3 8:2 0.26
session despite a significant difference in follow up
session. Post-hoc analyses within each group on all
outcome measures showed significantly increased
scores between post- and pre-test as well as between
follow up and post-test sessions for occupation-
based group while it was significant just between
post- and pre-test sessions in rote exercise-based
group and not significant at all for the control group.
These findings indicate that all outcome meas-
ures including subjective and objective measures
significantly improved in both the intervention
groups compared to the control group. Despite sig-
nificantly more improvement for occupation-based
group than rote exercise-based group in all subjec-
tive measures at both post-test and follow up ses-
sions, for objective measures it was significant just
in the follow up sessions.
Discussion
Findings in our study showed that constraint-induced
movement therapy is an effective method in improv-
ing hand function during chronic stages of median
and ulnar nerve injury and repair. Improvement in
both the intervention groups maintained in the follow
up session indicating retention of improvement. A
critical finding in follow up session was significantly
continued improvement in the occupation-based
constraint-induced movement therapy group com-
pared to rote exercise-based constraint-induced
movement therapy group indicating of better
Rostami et al. 1093

Table 2.  Mean and mean changes of outcome measures.

Measures Mean scores Mean changes

Pre [95%CI] Post [95%CI] Follow [95%CI]

Canadian occupational performance measure-Performance (1–10)
O-CIMT 2.4 [1.8–3.0] 5.6 [5.0–6.2] 7.2 [6.6–7.7] 4.7
R-CIMT 2.8 [2.2–3.4] 4.3 [3.7–4.8] 4.9 [4.4–5.5] 2.1
Control 2.7 [2.0–3.4] 3.2 [2.6–3.8] 3.6 [3.0–4.2] 0.9
Canadian occupational performance measure-Satisfaction (1–10)
O-CIMT 1.7 [1.2–2.1] 4.6 [3.8–4.6] 6.9 [6.5–7.3] 5.3
R-CIMT 1.9 [1.5–2.3] 3.6 [3.2–3.9] 4.5 [4.1–4.9] 2.6
Control 2.0 [1.5–2.5] 2.9 [2.5–3.3] 3.2 [2.7–3.7] 1.2
Box & Block test
O-CIMT 1.9 [1.0–2.8] 5.1 [4.1–6.2] 10.1 [9.2–11.0] 8.2
R-CIMT 2.1 [1.2–3.0] 4.7 [3.7–5.8] 5.2 [4.2–6.1] 3.1
Control 2.1 [1.1–3.1] 2.7 [1.5–3.8] 3.2 [2.2–4.2] 1.1
Disabilities of arm, shoulder, and hand questionnaire (0–100)
O-CIMT 70.4 [64.8–76.1] 36.3 [32.2–40.3] 19.6 [15.8–23.3] 50.8
R-CIMT 63.6 [57.9–69.2] 44.2 [40.1–48.2] 37.4 [33.6–41.2] 26.1
Control 65.9 [59.7–72.1] 58 [53.6–62.4] 53.9 [49.8–58] 12
Static Two-Point Discrimination (millimetre)
O-CIMT 14.2 [13.2–15.1] 10.8 [9.6–12.1] 5.9 [5.0–6.8] 8.3
R-CIMT 12.9 [12–13.8] 10.1 [8.8–11.3] 9.3 [8.4–10.2] 3.6
Control 14.1 [13.1–15.1] 13.5 [12.1–14.8] 13.0 [12.0–14.0] 1.1
Self-Assessment Manikin – Pleasure (1–9)
O-CIMT 2.1 [1.3–2.8] 6.6 [5.7–7.5] 7.8 [7.1–8.6] 5.7
R-CIMT 2.2 [1.6–2.7] 3.4 [2.5–4.3] 4.4 [3.7–5.2] 2.3
Control 2.3 [1.7–2.9] 2.5 [1.6–3.4] 2.9 [2.1–3.7] 0.6
Self-Assessment Manikin – Arousal (1–9)
O-CIMT 1.8 [1.3–2.3] 5.8 [5.4–6.3] 7.7 [7.2–8.0] 5.8
R-CIMT 1.7 [1.2–2.2] 2.7 [2.2–3.2] 2.2 [2.7–3.5] 0.5
Control 1.7 [1.1–2.3] 2.0 [1.5–2.5] 2.2 [1.8–2.6] 0.5
Self-Assessment Manikin – Dominance (1–9)
O-CIMT 1.6 [1.2–2.0] 6.8 [6.5–7.2] 8.3 [7.9–8.8] 6.7
R-CIMT 1.8 [1.5–2.2] 2.8 [2.5–3.2] 3.1 [3.7–5.2] 1.3
Control 1.8 [1.4–2.2] 2.2 [1.8–2.6] 3.4 [1.9–2.8] 0.6

O-CIMT: Occupation-based constraint-induced movement therapy group; R-CIMT: Rote exercise-based constraint-induced move-
ment therapy group.

generalisation and transfer of learning. Participants
in the occupation-based group had significantly bet-
ter scores for their own perception from level of per-
formance and satisfaction (Canadian occupational
performance measure), upper limb functional ability
in activities of daily living (Disabilities of arm,
shoulder, and hand questionnaire), as well as motiva-
tion (self-assessment manikin) than the rote
exercise-based group in post-test session; despite
lack of any significant difference between two inter-
vention groups in objective hand function measures
(two-point discrimination and box and block tests).
At last, there was a significantly better performance
in all the objective and subjective measures in the
occupation-based than rote exercise-based group in
the follow up session.
1094 Clinical Rehabilitation 31(8)

Table 3.  Repeated measures ANOVA results (3 group × 3 sessions).

Measures Repeated measures ANOVA

  Time Group Time*Group Interaction

(P value – effect size) (P value – effect size) (P value – effect size)
COPM-P F(2,62) = 61.90 F (2,31) = 12.63 F (4,62) = 31.68
(<0.001 – 0.89) (< 0.001 - ES = 0.45) (< 0.001 - ES = 0.77)
COPM-S F(2,62) = 63.01 F (2,31) = 18.65 F(4,62) = 42.39
(<0.001 – 0.93) (< 0.001 - ES= 0.55) (< 0.001 - ES = 0.82)
BBT F(2,62) = 53.33 F (2,31) = 14.57 F (4,62) = 22.12
(<0.001 – 0.78) (< 0.001 - ES = 0.48) (< 0.001 - ES = 0.67)
DASH F(2,62) = 71.66 F(2,31) = 17.21 F(4,62) = 38.60
(<0.001 – 0.93) (< 0.001 - ES = 0.53) (< 0.001 - ES = 0.79)
Static 2PD F(2,62) = 48.43 F(2,31) = 14.56 F(4,62) = 20.32
(<0.001 – 0.79) (< 0.001 - ES = 0.48) (< 0.001 - ES = 0.66)
SAM-P F(2,62) = 45.18 F (2,31) = 17.78 F (4,62) = 18.20
(<0.001 – 0.70) (< 0.001 - ES = 0.65) (< 0.001 - ES = 0.60)
SAM-A F(2,62) = 65.40 F(2,31) = 18.42 F(4,62) = 45.65
(<0.001 – 0.89) (< 0.001 - ES = 0.84) (< 0.001 - ES = 0.91)
SAM-D F(2,62) = 56.62 F(2,31) = 21.76 F(4,62) = 48.80
(<0.001 – 0.90) (< 0.001 - ES = 0.91) (< 0.001 - ES = 0.90)

COPM-P: Canadian occupational performance measure-Performance; COPM-S: Canadian occupational performance measure-
Satisfaction; BBT: Box & Block test; DASH: Disabilities of arm, shoulder, and hand questionnaire; Static 2PD: Static Two-Point
Discrimination; SAM-P: Self-Assessment Manikin – Pleasure; SAM-A: Self-Assessment Manikin – Arousal; SAM-D: Self-Assessment
Manikin – Dominance.

Merzenich and Jenkins mentioned the differen-
tially training of the dysfunctional skin zone,
behavioural state and strength of behavioural rein-
forcement, positive influence of meaningful stim-
uli, and different stimulus patterns as important
factors for cortical plasticity.30 Other factors such
as involving injured limb in performing meaning-
ful activities, increasing focus and attention to the
affected limb, and increasing inputs from the
affected limb to the brain are important for improv-
ing function.14,31 In the literature, lack of correla-
tion between the hand function and perception of
touch at fingertips level, age, or time elapsed since
repair is reported in patients with PNI, given a min-
imum of regeneration and reinnervation10,32 and
instead, factors such as cognitive capacity, motiva-
tion, and environmental factors have been known
more important for optimal motor learning33 and
improving functional outcomes in these patients.
10,32,34,35 All the mentioned points for helping corti-
cal reorganization and improving hand function
are highly consistent with conditions of the
constraint-induced movement therapy program
especially occupation-based protocol in our study.
Constraint-induced movement therapy provides
negative experience of using the healthy hand
simultaneously with intensive, repetitive, and
structured training of the affected hand; so, inte-
grating these aspects together could lead to
observed improvement of hand function in both
intervention groups in our study.
An important point happened in the occupation-
based group that benefited from natural context
including real and familiar environment, objects,
people, and meaningful occupations; it was sig-
nificantly continued improvement in the follow
up session. Natural context provides structured,
meaningful, and enriched source of informational
support for eliciting optimal performance, in addi-
tion to better motor skill retention and transfer.33
This significant continued improvement in occupa-
tion-based group and producing significant differ-
ence between intervention groups in all outcome
measures in follow up session despite lack of
Rostami et al. 1095
significant difference in hand objective measures
between intervention groups in post-test session
may be consistent with the effect of contextual
interference; that is, greater retention and generali-
sation of learning through random and variable
practice of different tasks within a training session
despite better performance acquisition during
repetitive and intensive practice of just one move-
ment or a task in that training session.36 Also, it is
suggested that focus on functional activities leads
to greatest gains in function and minimal gains in
impairment whereas focus on impairment causes
reductions in impairment level with minimum
effect on function.36 Thus, content of an interven-
tion is a vital issue in improving performance and
not necessarily the intensity of practice; effective
skill acquisition occurs when the content of inter-
vention is according to the patient’s goal, priorities,
and interests in an individualized manner.21
Participants in the occupation-based group were
motivated for using their affected hand more and
more during different activities of daily living and
reported the transfer of new abilities to the new
occupations. It is reported that active participation
of patients in a client-centred program completely
according to their meaningful occupational priori-
ties, needs, and interests may lead to physical, cog-
nitive, and social health in addition to a sense of
mastery and decency in life situations, more satis-
faction and motivation, sense of autonomy and
control on own life, increased adherence and
engagement in treatment process and as a result,
improved functional outcomes.18,37,38 During occu-
pations people focuses on the multidimensional and
meaningful goals, whereas in rote exercises people
focus on individual movements, stretching, or
strengthening exercises. This knowledge of results
is a strong variable affecting motor learning.33
Multimodal capacity of the brain39 makes it a neces-
sary issue to use as many senses as possible simul-
taneously especially for those with an impaired
sense to regain the impaired sense of touch;34,40
stimulating different sensory perceptual systems as
well as different motivational and affective systems
is inherent in meaningful occupations.
Sensory re-education, based on the principle of
remodelling cortical maps by experience, is a
crucial part of rehabilitation in patients with PNI
for relearning how to interpret the new patterns of
sensory input from injured hand;23 however, motor
functions are often emphasized in these patients
and sensory re-education is often neglected.3,41
Using different types of sensory stimuli for chal-
lenging the learning situation simultaneously with
use of familiar shapes, textures, and objects as
stimuli for taking the advantages of memory will
improve functional sensibility more rapidly and to
a greater extent.21 An important issue in the pre-
sent study was emphasizing on both sensory and
motor re-education simultaneously in both inter-
vention groups. However, meaningful and famil-
iar occupations and objects were provided for
occupation-based CIMT group while sensory-
motor re-education program in rote exercise-based
CIMT group was implemented using activities and
tools irrelevant to patients’ occupational priorities.
Our study highlights interesting perspectives for
the future rehabilitation programs following upper
limb peripheral nerve injury and repair especially for
the chronic stages when cortical reorganization pro-
cesses are happened and patients is living with differ-
ent levels of disability because of inability to
participate in different life domains. However, there
was some limitations in our study that need to be con-
sidered in the future studies such as our small and
convenient sample, inability to blind the therapist
responsible for implementing interventions because
of nature of rehabilitation techniques, and lack of
laboratory tests to investigate probable neuroplastic
changes in peripheral and central nervous systems for
more clear describing the observed improvement.
Clinical Messages
•• Modified constraint-induced movement
therapy improves hand function in patients
with chronic median and ulnar nerve injury.
•• Occupation-based intervention leads to
more satisfaction, motivation, and sense
of autonomy and control on life than rote
exercise.
•• Occupation-based intervention produces
more generalisation and better learning
transfer than rote exercise.
1096 Clinical Rehabilitation 31(8)
Acknowledgements
We warmly thank the participants for their patiently par-
ticipation and cooperation.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest
with respect to the research, authorship, and/or publica-
tion of this article.
Funding
The authors received no financial support for the
research, authorship, and/or publication of this article.
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