Modification of Constraint Induced Movement Therapy in the Home Health Setting for a Subject with Chronic Hemiparesis after Stroke Christine M. Hicks, DPT; Patricia Kluding, PT PhD“ Graduate, Postprofessional DPT Program, Department of Physical Therapy and Rehabilitation Sciences, University of Kansas Medical Center Assistant Professor, Department of Physical Therapy and Rehabilitation Sciences, University of Kansas Medical Center, Kansas City, KS ABSTRACT Purpose: Constraint induced movement therapy (CIMT) has been found to be beneficial in upper extremity recovery of patients fol- lowing a stroke. However, its feasibility has not been assessed. This prospective case study describes changes in upper extremity function with a modification of CIMT adminis- tered in the home health setting. y in the home health setting Case Description: The participant was an 83-year-old man 6 months post-stroke with left sided hemiparesis resulting from a right ischemic stroke. The residual left-sided weakness wa complicated by pre-existing left shoulder pain due to osteoarthritis. He had not been able to return to many of his household chores and hobbies following the stroke. The intervention consisted of | hour function- al task practice sessions in the participant's home 3 days each week for 5 weeks. A restraint of the less-affected arm was used for 5 hours each day during the intervention period. Activities that required use of the left upper extremity alone and activities that required the use of both upper extremities were included. Primary outcome measures used before and after the intervention included the Motor Activity Log (MAL) and the Wolf Motor Function Test (MFT). Outcome: Improvements were noted in both the MAL and WMFT following the intervention. The participant increased his ability to perform functional activities and household chores. Discussion: The supervised practice of functional tasks in the par- ticipant’s home provides a clinically-relevant option for home-based physical therapy of the geriatric patient with stroke. This case study showed that the modified CIMT was feasible in the home setting for our participant. Further research on CIMT interventions in the home setting should include repeated baseline measurements and a larger number of subjects. Key Words: cerebrovascular accident, home care services, rehab} tion, upper extremity, exercise therapy Address all correspondence to: Patricia Kluding, PT, PhD, Department of Physical Therapy & Rehabilitation Sciences, University of Kansas Medical Center, 3901 Rainbow Blvd, Mail Stop 2002, Kansas City, KS 66160 Ph: 913-588-6918, Fax: 913-588-9428 (pkluding@kumc.edu). Journal of Geriatric Physical Therapy Vol, 31;3:08 BACKGROUND AND PURPOSE Upper-limb hemiparesis is among the most problematic impair- ments following a stroke due to its effect on the performance of ties of daily living (ADLs). Learned nonuse is a behavior ac originally recognized in non-human primates, in which a single deafferented limb is not used because of a conditioned suppression of movement.' Individuals after stroke demonstrate learned nonuse because of the difficulty associated with coordination and control- ling the movements of the hemiparetic side. However, with the emergence of constraint-induced movement therapy (CIMT) to overcome learned nonuse, patients with stroke are making motor and functional recovery gains even several years after stroke.** Constraint induced movement therapy (CIMT) consists of 3 key principles: (1) restraining the less affected upper limb, which forces the individual to use of the more affected upper limb for functional tasks, (2) training by shaping movements with the more affected limb, and (3) massed practice.° Shaping is defined as “an operant conditioning method in which a behavioral objective, in this case movement, is approached in small steps of progressively increasing difficult With shaping, feedback can be provided on small improvements in performance. Massed practice refers to multiple repetitions of a functional task that can be performed in group treatment sessions and can include bilateral movements, Most CIMT trials have incorporated some combination of shaping and massed task practice in the intervention.” Constraint induced movement therapy has been shown to advance motor recovery for patients in different stages of recov- ery,’"“and can even induce neural changes in people with chronic stroke.” A recent randomized, multisite clinical study (EXCITE trial) of people who were 3 to 9 months post-stroke found improve- ments in upper extremity function after CIMT that persisted for 1 year.’ It appears that CIMT training is most effective for individuals with mild to moderate impairments in the upper limb. Most stud- ies have focused on subjects with the ability to actively extend the metacarpophalangeal (MCP) and interphalangeal (IP) joints at least 10°, and actively extend the wrist at least 20°. The current protocol for traditional CIMT includes restraint of the less affected upper extremity in a sling for 90% of the waking hours for 14 days. Training by shaping occurs for 6 hours every day during the 14-day period.** Although traditional CIMT has been shown to be efficacious, the intense schedule may be difficult to implement. Surveys have shown that individuals (1) become tired of wearing the mitt, (2) are tempted to “cheat” with their less affected limb, and (3) would prefer a therapy protocol that required less time each day.'’ Therapists (60%) reported that they believe patients were unlikely to adhere to CIMT, many facilities did not have available resources to execute CIMT, and reimbursement for 10 weekdays for CIMT would limit patient involvement.'" Because of the difficulties implementing traditional CIMT, several modifications to this protocol have been investigated, as pre- sented in Table 1. One group of researchers compared the standard CIMT protocol (6 hours of shaping per day) with a less-intense protocol (3 hours per day) over 10 days.° Both groups improved, but the treatment effect was greater for the group who received CIMT 6 hours per day. Another study implemented 3 hours per day of shap- ing over a longer period of time (20 days).'' This case-controlled study found improvements following treatment compared to baseline, but did not compare the protocol to a control. A series of studies have investigated the modified constraint-induced move- ment therapy (mCIMT) protocol developed by Page et al.'"'*! The mCIMT protocol was designed to be performed in an ourtpa- tient setting, and combines structured, 2 hour, functional practice sessions with restriction of the less affected upper limb for 5 hours each weekday, during a 10-week period. This type of modification to the protocol has been shown to be as effective as traditional CIMT with the added practicality benefit.” This was confirmed by a recent randomized controlled trial comparing mCIMT to a group that received equivalent time of exercise and a no-treatment con- trol group.'' Further, modified CIMT was fond to improve upper extremity motor control, with greater efficiency of reaching and grasping movements found following the intervention.'? There is little information in the literature on patient satisfac- tion for CIMT interventions. A survey of 10 individuals who used a constraining mitten alone during waking hours at home reported that 90% were positive about the intervention and would recom- mend the treatment to others, although 50% were relieved to stop wearing the constraint. Many of the patients that receive home-based physical or occu- pational therapy following a stroke could benefit from CIMT to address upper extremity functional deficits. Home-based therapy is often initiated following discharge from inpatient rehabilitation for people who have had a stroke, which may allow for an earlier discharge from the hospital setting.” The intensity of home-based therapy is variable, but more intense home therapy has been found to improve social participation and health-related quality of life compared to conventional care.'* Providing rehabilitation for people in the home following a stroke has been found to improve balance, endurance, aerobic fitness, and functional mobility compared to patients who receive no care or usual care.'"'"" Home-based therapy interventions are focused on patient- centered goals, with interventions such as consultation/education, specific exercise, and functional home and community mobility activities.”'! Upper extremity rehabilitation in this setting typically focuses on compensation techniques, using the unaffected side to improve function. The use of CIMT within the home health setting might be ideal as it allows the practice of real, day-to-day functional activities that are meaningful for the patient. Patients would be able to do “therapy” and complete tasks that need to be done in the home at the same time. The purpose of this prospective case study was to describe the use of a CIMT protocol modified for application in the home health setting in an individual with chronic stroke and learned nonuse of the left upper extremity. To fit the framework of a typical home health therapy schedule, we used a 5-week CIMT protocol consist- ing of 1-hour sessions 3 days per week and restraint of the less- affected upper extremity for 5 hours each day 5 days per week. CASE DESCRIPTION Inclusion and Exclusion Criteria Potential participants were evaluated to ensure that they had the following criteria to be eligible for this study: (1) 18 years or older with a first, ischemic stroke at least 6 months previously, (2) at least 10° of active extension at the MCP and IP joints and 20° of active extension at the wrist of the more-affected arm, (3) lim- ited performance of ADLs as demonstrated by the Outcome and Assessment Information Set (OASIS), (4) qualified for home health therapy (eg, cannot leave home without assistance and only leaves for medical appointments, church services, and hair dresser), (5) perform all functional transfers independently, (6) maintain stand- ing balance for at least 2 minutes, and (7) score > 24 on the Mini Mental Status Exam (MMSE). Subjects were excluded if any of the following applied: (1) cur- rently receiving physical or occupational therapy, (2) upper extrem- ity spasticity higher than 2 on the Modified Ashworth Scale, (3) upper extremity pain higher than 4/10 on the visual analog scale, (4) previous upper extremity botulinum toxin A treatment, or (5) currently participating in other research projects. History, Diagnosis, Prognosis AD, an individual who met all the above criteria signed the informed consent form approved by the University of Kansas Medical Centers Human Subjects’ Committee, and a referral was obtained from his physician for physical therapy treatment. AD was an 83-year-old male with chronic, left-sided hemiparesis resulting from a right ischemic stroke 6 months previously. His past medical history included chronic obstructive pulmonary disease, hyperten- sion, and osteoarthritis in the left shoulder. Consistent with the diagnosis of osteoarthritis, radiographs of the left shoulder 1 year before his stroke revealed narrowing of the left glenohumeral and acromioclavicular joint space, and a large osteophyte on the humeral Table 1. Variations of Constraint-Induced Movement Therapy Protocols Reported in the Literature with the Current Protocol for Comparison Purposes Kunkel, Miltner, Wolf? 10 days over 2 weeks 90% of waking hours 10 days over 2 weeks 90% of waking hours Dettmers"' 20 days over 4 weeks 9.3 hours per day Page'” 13 50 days over 10 weeks 5 hours per day Current protocol 14 days over 5 weeks 5 hours per day 114 Journal of Geriatric Physical Therapy Vol. 31;3:08 head. After his stroke, the CT scan report identified lacunar infarcts in the right caudate nucleus. Numerous hyperintense foci of various sizes in the right and left cerebral hemispheres were also noted that may have represented degenerative changes or lacunar infarcts, according to the report. AD participated in 4 weeks of inpatient rehabilitation following his stroke, but was not referred for any additional outpatient or home health therapy on discharge. At the time of this study, AD lived in a house with 3 stairs to enter on a 10-acre farm. He was widowed and lived with his adult son. AD was interested in this study because he wanted to be able to use his arm functionally to achieve his goals of maintaining his house, caring for his horses, and tending his garden. Additionally, he was interested in home health therapy because he did not receive any therapy after discharge from the hospital. This patient may be classified in the Guide to Physical Therapist Practice Pattern 5D: Impaired Motor Function and Sensory Integrity Associated with Nonprogressive Disorders of the Central Nervous System-Acquired in Adolescence or Adulthood. Examination/Evaluation Findings The study screening process determined that AD met all the inclusion/exclusion criteria to participate in this study. He scored a 29/30 on the MMSE and had no sensory, speech, or visual deficits. Although AD was able to perform gross left upper extremity movements of shoulder flexion, elbow flexion, and wrist and finger extension against gravity, he did not frequently use the arm for functional tasks. Active range of motion (ROM) of the left hand and wrist was limited as compared to the right (see Table 2), but he did meet the inclusion criteria. No synergy patterns were observed during active movement of the left upper extremity. Using the Modified Ashworth Scale to measure tone, passive resistance was rated 0 at the wrist and 1 at the fingers and elbow indicating mini- mal hypertonicity. Using standard manual muscle strength testing techniques,” strength on the left was poor (2/5) for wrist extension, elbow flexion, and shoulder flexion, as compared to good minus (4-/5) for right wrist extension and elbow flexion, and good (4/5) shoulder flexion. He reported a pain level of 4/10 on a verbal analog scale in the left shoulder at rest, with increasing pain during flexion and abduction. AD was able to ambulate independently with an ankle-foot orthosis and quad cane. AD reported that he spent most of his day sitting in a chair; he had not cleaned, cooked, fed his horses, worked in or on the house, or tended a garden since his stroke. Table 2. Examination Findings at Baseline for Active Range of Motion of Selected Upper Extremity Joints, Movement against Gravity Journal of Geriatric Physical Therapy Vol. 31;3:08 Measures The Motor Activity Log (MAL) and Wolf Motor Function Test (WMFT) were used to quantify upper extremity behavior and use. The MAL is a semi-structured interview that has been found to be a valid and reliable instrument to assess daily use of the hemiparetic arm after stroke.5?>24 The participant rated both “how much” and “how well” he used his left arm for activities such as combing hair, pouring coffee, donning and doffing shoes, and opening an enve- lope. A rating scale of 1 to 5 was used for both the amount of use and quality of movement components, with 1 defined as “not at all” and 5 defined as “equal to the less affected arm.” This assessment was completed the week prior to beginning the intervention, weekly during the intervention, 1 week postintervention, and 1 month postintervention. The WMFT incorporates 15 upper-extremity functional tasks, and the time required for each task (up to 120 seconds) is measured. Grip strength and the amount of weight that the subject is able to move are also reported to give an indication of functional strength. Reliability and internal consistency of the WMFT has been found to be very high (ICC values above 0.9).?°*” Further, use of the WMFT in people after stroke has been found to differentiate between the more-affected upper extremity (mean 9 seconds), the less-affected upper extremity (mean 2.5 seconds), and healthy controls (mean 1.5 seconds). For this case study, the WMFT was performed 1 week prior to the intervention, 1 week postintervention, and 1 month postintervention. The WMFT sessions were videotaped, and the tapes were used to time the tasks using a stopwatch. All measures were performed by the therapist who provided the intervention, and therefore were not blinded. Intervention The 5-week intervention consisted of 1 hour therapy sessions, 3 days a week for a total of 14 home-based physical therapy sessions (one session was cancelled due to inclement weather). Additionally, AD wore an oven mitt on his less-affected hand for 5 hours per day, 5 days a week. The purpose of the oven mitt was to act as a reminder to refrain from using his less-affected hand for functional activities. However, the mitt allowed him to use that arm for gross movements and support for a loss of balance if needed. Each ses- sion consisted of functional task practice with the more-affected arm working alone and functional task practice with both hands together, as illustrated in Table 3. The actual progression of activities practiced is presented in Table 4. These activities were practiced in both sitting and standing positions, with changes in postural control demands used to vary the difficulty of the task. Table 3. Examples of Activities Practiced with the Case Participant during Modified CIMT Intervention Provided in the Home Setting er Table 4. Specific Functional Activities Practiced with the Case Participant During Modified CIMT Intervention Provided in the Home Setting Don/Doff jacket x 4; Wash pots for stew, sharpen knife, cut veggies, cut meat, prepare beef stew Session 2 Session 4 Make pot of coffee, Clean off table (stacked papers and envelopes x50) Session 6 Open/close door x 4; Tools in and out of bag; Tires off of wheels Session 8 Session 10 nl Therapy cancelled secondary to bad weather Session 15 Clean out bed of truck Don/Doff jacket x 4; Empty dishwasher; Perform upper extremity exercises "Snap buttons on shirt (6 buttons) x 3; Pick up coins (60) from table; Drive truck, Feed horses Clean off table and books stacked x 30); Paid bills ( checks, ae fe ) x (writing stuffing envelopes, Move pots in garden x 20; Spread out dirt; Open/close door x 4; Tools in and out of bag x 15 Wash pots for corn beef; Cook corn beef; Collect clothes to load and start washing machine; Empty dishwasher, Make pot of coffee, Cut potatoes to plant x 20 Clean off table (papers, books, and envelopes); Fold two loads of laundry : . Don/doff jacket x 4; Empty trash; Open/close door x 4; Clean and wash off table; Sort seeds to plant x 100; paperclip together envelopes of seeds; Turn pages of book x 35; Session 12 Fold two loads of laundry Session 13 Session 14 Empty dishwasher; Fold two loads of laundry RESULTS With the exception of the 1 session cancelled because of weather, AD participated fully in all of the sessions and reported full compli- ance with wearing the restraint 5 hours per day, 5 days per week. AD demonstrated improvements following the intervention on the MAL for both amount of use (AOU) and the quality of movement (QOM) (Figure 1). AD had an average rating of 2.13 for AOU one week prior to intervention, and this improved to 3.84 after the intervention (change of 1.17). One month following the interven- tion, AOU was 3.74. AD’s initial QOM rating was 2.25, and this improved to 3.84 after the intervention (change of 1.59), and 1 month later was 3.48. AD also showed improvements on the WMFT with both the more-affected and the less-affected extremities (Table 5, Figure 2). The average time to complete the tasks with his more-affected extremity (left) decreased from 6.22 seconds to 4.06 seconds (change of -2.16 seconds). This time increased to 19.70 seconds 1 month later, largely due to his inability to perform the two tasks on the WMFT that required the extension of the arm. Because of his inability to extend the arm, he received the maximal score of 120 seconds for each of these tests as indicated by italics in Table 5. During this session, the participant complained of tightness in his left shoulder. If these 2 tasks are excluded from analysis, the average time | month posttreatment was 4.27 seconds. The average time to complete the tasks with his less-affected extremity (right) decreased in time from 3.06 seconds to 2.32 seconds (change of 0.74 seconds). This increased to 2.39 seconds one month after the intervention. Motor Activity Log Results ~#— Quality of Movement (QOM) —e— Amount of Use(AOU) wo ~~ o @ = 1 Wk Post | 1 Mo Post Test Date Figure 1. Results of the Motor Activity Log before, during, and after the intervention. The amount of weight that AD was able to move to a box during the WMFT remained constant at 9.09 kg for the right extremity, while the left extremity increased from 3.18 kg at baseline to 4.09 kg after the intervention, and was 3.64 kg one month postinterven- tion. Improvements in grip strength are illustrated in Figure 3. On the right extremity, grip strength increased from 11.64 kg at baseline to 11.95 kg following the intervention and was 14.86 kg one month postintervention. Grip strength on the left extremity increased from 1.82 kg at baseline to 4.82 kg after the intervention, and was 5.91 kg one month postintervention. 116 Journal of Geriatric Physical Therapy Vol. 31:3:08 Table 5. Results of the Wolf Motor Function Test (WMFT) Before and After the Intervention, and at 1 Month Follow-up (values are in seconds unless otherwise indicated) Right (less-affected) Task 1A: Forearm to table 0.97 0.91 0.75 Task IB: Forearm to box 1.22 1.00 Task IIA: Extend elbow 4 | oo | 0.87 Task IIB: Extend elbow with weight 0.90 Task IIIA: Hand to table (front) 1.06 0.78 0.72 Task IIB: Hand to box (front) 1.07 1.03 0.69 Task IIIC: Weight to box 9.09kg | 9.09kg | 9.09 kg Task IV: Reach and retrieve 1.00 Task VA: Lift can 1.75 Task VB: Lift pencil 1.34 Task VC: Lift paper clip 4.16 Task VD: Stack Checkers 3.18 Task VE: Flip cards 7Al Task VF: Grip Strength 14.86 kg Task VG: Turning key in lock 3,75 Task VH: Fold Towel 5.19 Task VI: Lift Basket 3.15 Average time 3.06 2.32 2.39 (% change from initial) (-24%) (-22%) Left (more-affected) Task 1A: Forearm to table 1.65 1,12 1.28 Task IB: Forearm to box 7.84 2.16 2.13 Task IIA: Extend elbow 4.28 1.32 120.00 Task IIB: Extend elbow with weight 2.31 2.41 120.00 Task IIIA: Hand to table (front) 2.16 1.66 1.00 Task IIIB: Hand to box (front) 3.06 1.54 1.50 Task IIIC: Weight to box 3.64 kg Task IV: Reach and retrieve 2.00 Task VA: Lift can 3.57 Task VB: Lift pencil 2,78 ‘Task VC: Lift paper clip 3.15 Task VD: Stack Checkers 5.87 Task VE: Flip cards 10.7 Task VF; Grip Strength 91 kg ‘Task VG: Turning key in lock 6.56 Task VH: Fold Towel 11.4 Task VI: Lift Basket 3.47 Average time 6.22 4.06 MTN (% change from initial) (-35%) | 4.3 (-31%) Journal of Geriatric Physical Therapy Vol. 31:3:08 117 oleft, affected UE w Right, unaffected UE = E re 3 s 2 5 z Post-CIMT 1 month follow up Figure 2. Change in average Wolf Motor Function Test time before and after the intervention. “left upper extremity time at 1 month follow up excludes 2 tasks that the subject was unable to complete. Left affected UE [m Right, unaffected UE Grip strength (kg) Initial Post-CIMT 1 month follow up Figure 3. Change in grip strength before and after the intervention. DISCUSSION Following a CIMT intervention modified for use in the home health setting, this participant demonstrated improvements in both the MAL and WMFT. Both of these scales have been found to have excellent reliability, with little measurement error between testing sessions spaced 2 weeks apart in previous research.”°?” The MAL results showed improvement in both the amount of use and quality of use of the affected left upper extremity, and the weekly measure- ments showed consistent improvement throughout the 5 weeks of this intervention. The magnitude of change in these measures (1.17 AOU and 1.59 QOM) was actually larger than the average change found in the EXCITE trial using the traditional CIMT protocol (1.03 AOU and 0.87 QOM).° Achieving a 3 or higher on the MAL has been reported to be a clinically relevant change,’ and this was accomplished by the participant on both AOU and QOM measures. According to the results of the WMFT, AD showed bilateral improvement in speed of task completion and functional strength following the intervention. The baseline score for this participant's more-affected upper extremity (6.22 seconds) was slightly better than the average of 9 seconds reported previously for subjects with mild-moderate stroke.*” The improvement in both arms is not surprising, as the intervention emphasized practice of functional tasks that required both limbs to work together. This is different than traditional shaping activities used in previous CIMT studies that emphasize unilateral use of the more affected upper extremity. The average improvement in time noted by this participant (2.16 seconds) is less than that noted in the EXCITE trial (8.5 seconds),” although the baseline value for this participant would have placed him in the higher-functioning category in the EXCITE trial. Because of tightness in the left shoulder on the 1 month follow- up session, the participant was not able to complete 2 of the tasks on the WMFT that he had performed previously without difficulty. These 2 tasks required him to extend his elbow fully with and with- out a weight, and he was not able to accomplish this. This finding was unexpected, and it is unknown whether this difficulty was a result of increased arm use due to the intervention. It is possible that increased functional use primarily in the direction of flexion may have led to an exacerbation of shoulder osteoarthritis or devel- opment of an elbow flexion contracture over the ensuing month between assessments. Previous work has found that individual items on the WMFT are stable and reliable,” so we reported the follow up WMFT scores both with and without these items. Prior to this intervention, the participant was sedentary because he was unable to do many of the things that he previously did on the farm. He reported that he was very satisfied with the intervention, and often commented on how glad he was to be getting therapy since he did not receive therapy when he left the hospital. The participant was able to resume cooking and cleaning in the home as well as driving, feeding horses, and tending garden. These were all things that were meaningful for the participant, although patient satisfaction and self-efficacy were not specifically measured. Other researchers have studied the use of a constraint during daily activities at home alone,'° or more commonly in combination with outpatient sessions.'"**” The supervised practice of functional tasks in the patient’s home is unique to this case study, and provides a clinically-relevant option for home-based physical therapy. The protocol for treatment used in this case study was less intense than those previously reported. A total of 14 hours of supervised practice was provided over the 5 weeks of this study, as compared to other protocols that ranged from total practice sessions of 25 to 60 hours over 2 to 10 weeks.*'"' However, the magnitude of change noted by this participant was comparable to that reported in these other studies. Because a plateau was not reached in the weekly MAL sessions during the 5-week intervention, it is possible that further improvement may have been seen with a longer intervention. The participant in this case study was reported to have multiple lacunar strokes or degenerative changes in the caudate nucleus and bilateral cerebral hemispheres on CT scan. However, his clinical presentation was not consistent with a lesion of the caudate nucleus (chorea, dystonia, and abulia) or with the syndrome état lacunaire described by multiple bilateral lacunes (progressive dementia and pseudobulbar palsy).*° Alternatively, he seemed to demonstrate signs of a pure motor (hemiparesis) syndrome which would be consistent with a lacunar infarct in the corticospinal tract within the internal capsule. Although lesion location does seem to be relevant for motor cortex excitability and perhaps response to CIMT intervention,” *! it is difficult to speculate on whether the lesion location influenced the ability of this participant to respond to the intervention. The participant in this case was older at age 83 than many of the subjects studied previously, although a recent study reported improved motor performance and function in older adults (mean age 72) with CIMT intervention.” An analysis of individual factors that may lead to changes in response to CIMT found that age was not an important factor, although this study included individuals age 17-79.” This participant also demonstrated shoulder pain in the more-affected side that likely influenced his willingness to use chat extremity. However, in spite of advanced age and the presence of shoulder pain, he was able to demonstrate noticeable improvements with the modified CIMT intervention. 118 We did not assess changes in posture, gait, or other gross func- tional measures. However, previous researchers have recently report- ed functional improvements (eg, total Functional Independence Measure, or FIM, score including locomotion and transfer sub- scales) following modified CIMT intervention.'*?” The ability to generalize results from this case study is limited by several issues. The assessment of outcomes was not performed by an individual blinded to the intervention, and therefore is a potential source of bias. Furthermore, the functional improvements may have been due to continued natural recovery after his stroke 6 months previously, or due to a general increase in activity level promoted by the intervention rather than the specific treatment activities. The lack of a baseline period without treatment or a control group limits our ability to speculate on those issues. This case study reports on the application of a modified CIMT intervention for an individual with chronic stroke in the home health setting. The intervention consisted of real-world activities that the participant identified as meaningful in his own home setting, and included bilateral activi- ties with the traditional CIMT protocol of shaping and constraint of the less-affected upper extremity. Future research could explore this unique application with a larger number of subjects, and should include analysis of cost-effectiveness analysis for the provision of this intervention in the home. ACKNOWLEDGEMENTS We would like to acknowledge Kathleen Kinerney, PT at the Eastern Kansas Veterans Administration who assisted with subject recruitment. REFERENCES 1. Taub E, Uswatte G. Constraint-induced movement therapy: Bridging from the primate laboratory to the stroke rehabilitation laboratory. / Rehabil Med. 2003;41:34-40. Taub E, Uswatte G, Pidikiti R. Constraint-induced movement therapy: A new family of techniques with broad application to physical rehabilitation. A clinical review. / Rehabil Res Dev. 1999;36:237-251. Miltner WH, Bauder H, Sommer M, Dettmers C, Taub E. Effects of constraint-induced movement therapy on patients with chronic motor deficits after stroke: A replication. Stroke. 1999;30:586-592. Kunkel A, Kopp B, Mueller G, et al. Constraint-induced move- ment therapy for motor recovery in chronic stroke patients. Arch Phys Med Rehabil. 1999;80:624-628. Wolf SL, Winstein CJ, Miller JP, et al. Effect of constraint- induced movement therapy on upper extremity function 3 to 9 months after stroke: The EXCITE randomized clinical trial. JAMA. 2006;296:2095-2104. Sterr A, Elbert T, Berthold I, Koelbel S, Rockstroh B, Taub E. Longer versus shorter daily constraint-induced movement thera- py of chronic hemiparesis: An exploratory study. Arch Phys Med Rehabil. 2002:1374-1377. Wolf SL, Blanton S, Baer H, Breshears J, Butler AJ. Repetetive task practice: A critical review of constraint-induced movement therapy in stroke. Neurol. 2002;8:325-338. Journal of Geriatric Physical Therapy Vol. 31;3:08 8. 20. wn Dromerick AW, Edwards DF, Hahn M. Does the application of constraint-induced movement therapy during acute rehabi- litation reduce arm impairment after ischemic stroke? Stroke. 2000;31:2984-2988. Liepert J, Bauder H, Wolfgang HR, Miltner WH, Taub E Weiller C. Treatment induced cortical reorganization after stroke in humans. Stroke. 2000;31:1210-1216. Page SJ, Sisto SA, Levine P, McGrath RE. constraint-induced movement therapy in chronic stroke: A sin- gle-blinded randomized controlled trial. Arch Phys Med Rehabil. 2004;85:14-18. Efficacy of modified Taub E, Weiller movement therapy Dettmers C, Teske U, Hamzei F, Uswatte G, C. Distributed form of constraint-induced improves functional outcome and quality of life after stroke. Arch Phys Med Rehabil. 2005;86:204-209. Page SJ, Sisto SA, Levine P. Modified constraint-induced therapy in chronic stroke. Am J Phys Med Rehabil. 2002;81:870-875. Page SJ, Elovic D, Levine P, Sisto SA. Modified constraint-indu- ced therapy and botulinum toxin: A promising combination. Am ] Phys Med Rehabil. 2003;82:76-80. Page SJ, Levine P, Leonard A. Modified constraint-induced movement therapy in chronic stroke: Results of a single-blinded randomized controlled Lin KC, Wu CY, Wei TH, Gung C, Lee CY, Liu JS. Effects of modified constraint-induced movement therapy on reach-to- trial. Phys Ther. 2008; epub ahead of print. grasp movements and functional performance after chronic stro A randomized controlled study. Clin Rehabil. 2007;21:1075 -1086. Burns A, Burridge J, Pickering R. Does the use of a constraint mitten to encourage use of the hemiplegic upper limb impro- ve arm function in adults with subacute stroke? Clin Rehabil. 2007;21:895-904. Early Supported Discharge Trialists. Services for reducing dura- tion of hospital care for acute stroke patients. Cochrane Database of Systematic Reviews. 2005;CD000443(2). Ryan T, Enderby P, Rigby AS. A randomized controlled trial to evaluate intensity of community-based rehabilitation provi- sion following stroke or hip fracture in old age. Clin Rehabil. 2006;20:123-131 Legg L, Langhorne P, Outpatient Service Trialists. Rehabilitation therapy services for stroke patients living at home: Systematic review of randomised trials. Lancet. 2004;363:352-356. Duncan PW, Studenski $, Richards L, Gollub S, Lai SM, Reker D. Randomized clinical trial of therapeutic exercise in subacute stroke. Stroke. 2003;34:2173-2180. Hale LA, Piggot J. Exploring the content of physiotherapeutic home-based stroke rehabilitation in New Zealand. Arch Phys Med Rehabil. 2005;86:1933-1940. Clarkson HM. Musculoskeletal Assessment: Joint Range of Motion and Manual Muscle Strength. Philadelphia, Pa: Lippincott Williams & Wilkins; 2000. Uswatte G, Taub E, Morris D, Light KE, Thompson PA. The Motor Activity Log-28: Assessing daily use of the hemiparetic arm after stroke. Neurol. 2006;67:1189-1194. herapy Vol. 31:3:08 te a 26. 29k van der Lee JH, Beckerman H, Knol DL, de Ver HCW, Bouter LM. Clinimetric properties of the Motor Activity Log for the assessment of arm use in hemipareetic patients. Stroke 2004;35:1410-1414. Whitall ], Savin DNJ, Harris-Love M, Waller SM properties of a modified Wolf Motor Function test for people prof *sychon with mild and moderate upper-extremity hemiparesis. Arch Phy Med Rehabil. 2006;87:656-660. Wolf SL, Catlin PA, Ellis M, Archer AL, Morgan B, Piacentino A. Assessing Wolf Motor Function Test as outcome measure for research in patients after stroke. Stroke. 2001;32:1635-1639. Morris D, Uswatte G, Crago JE, Cook EW, Taub E. ty of the Wolf Motor Function Test for assessing upper extremity function after stroke. Arch Phys Med Rehabil. 2001;82:750-755. The reliabili- Pierce SR, Gallagher KG, Schaumberg SW, Gershkoff AM, Gaughan JP, Shutter L. Home forced use in an outpatient reha- bilitation program for adults with hemiplegia: A pilot study. Neurorehabil Neural Repair. 2003;17:214-219. Wu CY, Chen CL, Tsai WC, Lin KC, Chou SH. A randomized controlled trial of modified constraint-induced movement the- rapy for elderly stroke survivors: Changes in motor impairment, daily functioning, and quality of life. Arch Phys Med Rehabil. 2007;88:273-278. Kandel ER, Schwartz JH, Jessell TM. Principles of Neural Science. New York, NY: Elsevier; 1991. Liepert J, Restemeyer C, Kucinski T, Zittel $, Weiller C. Motor strokes: The lesion location determines motor excitability chan- ges. Stroke. 2005;36:2648-2653. Rijntjes M, Hobbeling V, Hamzei F, et al. Individual factors in constraint-induced movement therapy after stroke. Neurorehabil Neural Repair. 2005;19:238-249. Preconference Courses: Section on Geriatrics Geriatrics Getting Started and Doing it Well Sunday, February 8, 2009, 12:00pm — 6:30pm Mentoring the Clinician Beyond Entry-Level: Skills, Knowledge, and Behaviors for Successful Residency and Fellowship Mentoring Monday, February 9, 2009, 8:00am—4:30pm Medical Malpractice Claims: From Beginning Through Trial Monday February 9, 2009, 8:00am—4:30pm Course Space is limited Visit: www.apta.org and click events to register today!