Feasibility of a home constraint-induced movement therapy for hand weakness after stroke.

Constraint-induced movement therapy (CIMT) is an efficacious treatment for chronic arm and hand impairment after stroke. A recent meta-analysis concluded that CIMT is more effective than alternative therapies or no treatment at all (1). Despite this evidence, CIMT is under-utilized. A difficult protocol and extraordinary demands on therapists' time are often cited (2). In the EXCITE trial of CIMT, an additional obstacle was the expense of travel incurred by families transporting patients to and from the treatment center (3). A CIMT with a simpler protocol, less demand on therapist's time, and reduced cost to families would offer broader accessibility. If efficacy is preserved, this treatment can improve quality of life after a stroke. We report here the results of a pilot study of CIMT for mild hand weakness after stroke that was modified to be less intensive with no therapist-guided treatment, for use in a home program (HCIMT). The goals of this study were to evaluate feasibility and to guide the design of larger studies of this method. Nine subjects were recruited who were ≥ 6 months post-stroke. Seven patients had cortical-subcortical strokes; 2 had purely sub-cortical strokes. Six patients had mild dominant hand weakness; 3 had non-dominant hand weakness. All patients had completed a traditional outpatient hand therapy program but had persistent impairments in hand use. Inclusion required active finger and wrist extension > 20° from the neutral position. After initial assessment , subjects were instructed in 12 standardized dexterity tasks. Each participant also identified 4 additional tasks, with the guidance of an occupational therapist, which were chosen to be specifically relevant to the subject's preferred activities, e.g. computer typing exercises. The unaffected arm was restricted using a splinted restraint for 90% of the day for the duration of the treatment. Subjects performed the individualized functional activities and the standard dexterity exercises at home with the affected arm for 4 h on 20 consecutive weekdays. Motor hand function changes were analyzed pre-and post-treatment using the following parameters: (i) power: grip and pinch dy-namometries; 3-jaw chuck; and (ii) dexterity: tapping speed; 9-hole peg test. Improvement was defined as > 25% change on 3 or more tasks. Feasibility was defined as compliance > 90%. Compliance was measured by monitoring motor activity logs as well as through interviews with family members. In addition we investigated the influence of the following variables: (i) dominant vs non-dominant hand; (ii) sensory loss; (iii) motor deficit …