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Vol. 24 •Issue 7 • Page 24

Which is more effective in improving functional outcomes in stroke patients?

Does constraint-induced movement therapy (CIMT) generate more independence in self-care outcomes in stroke patients with upper extremity spasticity, compared to self-care outcomes achieved using a neurodevelopmental treatment (NDT) approach?

Discovering the research supporting each of these approaches will help occupational therapy practitioners make sound judgments regarding the treatment protocols they implement with stroke patients.

An Overview of NDT

Neurodevelopmental treatment (NDT), or the Bobath approach to stroke rehabilitation, emphasizes normalizing muscle tone, improving posture and facilitating "automatic" movement through physical handling. (Luke, Dodd, & Brock, 2004) "The main principle of NDT is to reduce muscle spasticity and promote normal patterns of movement." (Seneviratne & Reimer, 2004, p. 13)

Controversy surrounds the theoretical foundations of NDT. Some researchers question whether treatment protocols used in studies were reflective of the theory, and had concerns about the "transparency" of methods used in many studies to allow replication. (Seneviratne & Reimer, 2004; Hafsteindottir, Algra, Kappelle, & Grypdonck, 2005; Paci, 2003) However, Paci (2003) stated that theories have been "modernized, incorporating new knowledge from neurophysiological research and motor development into the concept." (p. 2) Debates aside, this approach is used by many countries, and researchers have tried to determine the efficacy of this approach with stroke patients.

Langhammer and Stranghelle (2000) compared NDT to a motor re-learning -programme developed by Karr and Shepherd. The investigators included 61 patients in a randomized controlled study that evaluated treatment outcomes using the Motor Assessment Scale (MAS), the Sodring Motor Evaluation Scale (SMES), the Barthel ADL Index and the Nottingham Health Profile. Results of the study indicated that there were no significant differences in ADL outcomes or in the MAS or SMES; however, improvement of motor function was statistically superior in patients who received the motor learning programme treatment.

Wang, Chen, Chen and Yang (2005) investigated the efficacy of the Bobath approach versus an orthopedic approach at different levels of stroke recovery. Bobath interventions included a 40-minute program, five sessions per week, for 20 sessions. The orthopedic group received the same treatment frequency and intensity, focusing on "passive, assistive, active and progressive resistive exercise."

Researchers found statistically superior results in patients who received Bobath treatment over those receiving orthopaedic treatment, based on results from the MAS (p= 0.007), Stroke Impact Scale scores (p= 0.006) and the Berg Balance Scale (p= 0.015). Results indicated "patients with different motor recovery stages, either with spasticity or relative recovery, benefit more from the Bobath treatment than from the orthopaedic treatment programme." (Wang, et al., p. 163)

Conversely, studies have been done that have shown NDT to be ineffective. Hafsteinsodottir, et al. (2005), used the Barthel Index and a "30-item version" of the Sickness Impact Profile to measure treatment effectiveness of 324 patients from 12 Dutch hospitals. Two hundred seventeen subjects received NDT, while the other 99 did not. Results of the study indicated poor outcomes on both quality of life and self-care abilities measured by the Barthel Index in both treatment groups six and 12 months post-stroke. These researchers argued that the Bobath approach is ineffective and other approaches need to be considered.

Paci (2003) reviewed a total of 15 trials, six of which were randomized controlled trials. While results indicated that five studies found no significant differences in treatment, the remaining "show an improvement in all or some of the measured parameters for the NDT group." (Paci, p.35)

However, these results were clouded by several methodological issues such as a lack of homogeneous samples. This confounds the ability to draw clinical conclusions about the effectiveness of NDT treatment.

Luke, Dodd and Brock (2004) completed a systematic review of 688 articles, of which six met inclusion criteria. Results indicated that the "Bobath concept was found to reduce shoulder pain better than cryotherapy, and to reduce tone compared to no intervention, and compared to proprioceptive neuromuscular facilitation."

An Overview of CIMT

"CIMT forces the individual to use the affected upper extremity by immobilizing the unaffected upper extremity." (Roberts, Vegher, Gilewski, Bender, & Riggs, 2005, p. 115) The patient undergoes a rigorous therapy regimen, using the affected extremity for hours each day for several weeks.

There has been criticism of the approach "about the demand of clinical resources necessary to carry out constraint-induced therapy according to the original model of Taub." (Brogardh & Sjolund, 2006) Further, studies have not supported the use of CIMT with stroke patients in a chronic stage to increase the use in the home.

Brogardh and Sjolund (2006) completed a combined case control and randomized controlled trial to determine the effectiveness of CIMT. The researchers included a six-hour group-treatment protocol using CIMT and then assessed extended wear of the mitt post-treatment to determine if the mitt itself would improve patient outcomes. Seventeen stroke patients wore the mitt 90 percent of waking hours for 12 days. During this time patients received treatment by occupational and physical therapists in groups of two to three, six hours daily.

Following the treatment regimen, some patients were instructed to continue wearing the mitt without therapy. Results of the study indicated that the CIMT intervention significantly improved arm and hand function (Sollerman Hand Function Test p= 0.037) and overall quality of movement of stroke patients (Motor Assessment Scale p= <0.001). However researchers also found that wearing the mitt post-treatment alone did not improve functional outcomes. (Brogardh & Sjolund)

Roberts, Vegler, Gilewski, Bender and Riggs (2005) conducted a study pairing constraint-induced movement therapy with meaningful activities. Nine stroke survivors of more than a year participated in an activity-based home program, and six hours of occupational therapy service in group (three times per week) and individualized (two times per week) settings.

Patients made significant gains in upper extremity motor skills as detected by the Wolf Motor Function Test (p= .013), but their level of satisfaction on the Canadian Occupational Performance Measure declined (although these findings were not significant). The researchers hypothesized that the participants were "wanting or expecting their affected upper extremity to function better despite deficits." (Roberts, et al., p. 115) Further, the authors felt that patients may have expected post-treatment improvement to continue at the same rate as during treatment.

Mennemeyer, Taub, Uswatte and Pearson (2006) investigated the economic and social implications of stroke survivors (one year post-stroke) who had received CIMT. Results from a survey of 121 respondents indicated that half of stroke patients did not return to work, and a caregiver stopped working in one-quarter of the cases. Following CI therapy, however, 60 percent of those caregivers who stopped working could return (p< 0.001).

Comparison of the Two Approaches

Wu, Chen, Tsai, Lin and Chou (2007) completed a study to determine if constraint-induced movement therapy improved the movement, daily function and quality of life in 26 stroke survivors. Patients were randomly selected to receive either CIMT or NDT for two-hour sessions, five times per week for three weeks. The stroke patients receiving CI therapy wore mitts on the unaffected hand six hours per day.

Investigators found that patients who received CI therapy significantly exceeded outcomes in motor function on the Motor Activity Log in both reported use (p= .008) and quality of movement of the affected upper extremity (<.001). Statistical significance was also reached in ADL on the Functional Independence Measure (p= 0.018), and on the Fugl-Meyer Assessment (p= .008); statistical significance was not reached among those receiving NDT. The authors stated that the study may be biased, as patients in the CI therapy group wore the mitt extensively beyond their scheduled treatment interventions.

Wu, Lin, Chen, Chen and Hong (2007) compared modified constraint-induced movement therapy (mCIMT) to NDT with 30 stroke survivors, one to three years post-stroke. Each group received two hours of therapy five days per week for three weeks. Patients in the mCIMT therapy group wore mitts six hours per day. In addition, upper- extremity movement in bimanual and unilateral tasks was analyzed using a six-camera motion analysis system.

Findings indicated patients in the mCIMT therapy group "showed more temporally and spatially efficient movement and more preplanned movement control during the bimanual task." (Wu, et al., p. 1) However, there were no significant differences between the groups with regard to unilateral task performance or on the Functional Independence Measure. Motor Activity Log scores were reportedly significantly better in the mCIMT therapy group (p<.0001).

CIMT and NDT Together

Interestingly, CIMT and NDT have been used together in research. Pierce, Gallagher, Schaumburg, Gershkoff, Gaughan and Shutter (2003) investigated the use of constraint-induced movement therapy as an extension of traditional outpatient therapy (NDT). Seventeen patients completed a two- to three-week therapy regimen that included one-hour sessions of both occupational and physical therapy. Each patient was instructed to wear the mitt forcing use of his affected hand during activities outside of therapy. Results of the testing indicated significant improvements in 12 of the 17 subtests as measured by the Wolf Motor Function test.

In another study, Pollock, Baer, Langhorne and Pomeroy (2007) compared many known treatment approaches in a systematic review of the literature concerned with postural control and lower-limb function following stroke. These researchers compared 20 trials, which included 1,087 patients. They searched Cochrane databases and found that a mixed approach (which includes a conglomeration of approaches) "is more effective in promoting recovery of disability than any other approach." (Pollock, et al., p. 214)

This is a unique finding since most research compares different treatment approaches. These researchers offer a unique perspective on researching varying approaches. It may not be that one is better than the other. It may be the case of learning which approach is most appropriate for different levels of stroke recovery.

The Review

Summarizing the results of the findings in this clinical review was difficult. When CIMT and NDT were compared in the research, there was a great discrepancy between the lengths of time each intervention took place. Many of the studies did not describe comparison interventions with enough detail to determine what "conventional" occupational therapy intervention or physiotherapy intervention included. Many of the studies did not describe standardized treatment procedures. (Paci, 2003; Page, et al., 2002)

Further, many of the studies had enough heterogeneity between the groups that it made it difficult to determine whether the results were due to the intervention, or variability between the treatment groups. Finally, investigators' individual theoretical understandings of various approaches may or may not include new understandings and interventions of given approaches, especially NDT.

All of these variables make it impossible to accurately determine which intervention is superior. CIMT has more studies supporting its use consistently in the research literature at this point. However, because of the cloudy interpretation of the theory behind NDT, it should not be discounted as a viable approach.

Both approaches appear to have therapeutic benefits, but CIMT has more evidence documenting increased movement and functional abilities. However, with the questionable methodologies used to date, these results must be interpreted with caution.

The task for occupational therapy practitioners and researchers is to further evaluate the benefit of these approaches using stronger methodologies. It is imperative to improve functional outcomes for stroke survivors. Their quality of life depends on it!

References available at or upon request.

Heather Panczykowski, MS, OTR, is Director of the occupational therapy assistant program at Jamestown Community College in Jamestown, New York.


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