Occupational Therapy News OTnews November 2019 | Page 43

REHABILITATION FEATURE
the mitten is one patient use, therefore several were bought.
Influence on practice
After completing a CIMT course last year, I was keen to reflect on
how it has influenced my working practice and obtain feedback
on patient experiences of the CIMT programme.
I have applied the CIMT programme to several of my patients’
rehabilitation, with mainly positive outcomes.
On a few occasions the CIMT programme was not as
successful as I had hoped. I attributed this to being associated
with other factors such as anxiety, mood and fatigue factors.
On reflection I believe it was my failure to recognise how these
factors would inhibit engagement in the programme, rather than
the programme failing itself. I came to realise how important
it is to consider whether a patient is at the right stage in their
recovery.
Many patients described the experience as similar to being
at a boot camp. Being psychologically at the right stage in their
recovery, well informed and educated as to what they were due
to undertake, is of paramount importance.
Measuring outcomes
The CIMT programme has encouraged me to correlate, explore
and record a range of outcome measures, from traditional
standardised assessments such as Action Research Arm Test
(ARAT), to narrative tools such as Motor Activity Log, and video
recording sessions to help keep a diary of changes occurring.
These methods allowed all parties to reflect on changes that
occurred over the 14 days.
Reviewing video footage from days one to 14 together had
the most powerful impact on the patient’s recovery. One patient
commented on how reviewing footage at the halfway point helped
him re-focus and push on with the rest of the programme.
All of the outcome measures were discussed, but it was
always the video footage that had the most powerful outcome. It
Christie et al (2019) conducted a cross-sectional
survey to investigate clinicians’ knowledge and
experience of delivering Constraint Induced
Movement Therapy (CIMT) in adult neurorehabilitation.
The survey was distributed through occupational
therapy and physiotherapy associations and
neurological interest groups/list serves in 11 countries,
including the UK. 169 completed surveys were
analysed using descriptive and inferential statistics.
Occupational therapists comprised the largest group
of respondents (64.5 per cent). Findings included: 79.3
per cent of respondents delivered CIMT to individuals,
rather than groups; and a modified version was used
most often (74.6 per cent). Whilst 88.8 per cent of
respondents used intensive graded practice, only
43.2 per cent reported use of a mitt restraint for most
waking hours. The authors identify that programmes
are not always being delivered with fidelity, and
suggest the need for further research to identify
strategies to support CIMT implementation.
I had read about CIMT in the literature and felt that our
community stroke team could provide an effective delivery of
home-based CIMT programme.
The CIMT programme involves wearing a mitten on the non-
affected hand for 90 per cent of waking hours for 14 days, only
taking it off for short periods of time to complete bilateral tasks or
activities that would create risk if only completed with one hand.
This will encourage the use of the affected arm in functional
everyday tasks. A patient who has 20 degrees of active wrist
extension and 10 degrees of active finger extension in the
affected hand should be considered for CIMT, according to the
Royal College of Physicians’ stroke guidelines (RCP 2016).
The context of the CIMT programme should comprise of both
repetitive everyday activities and adaptive task practice, also
known as shaping tasks.
There is an official CIMT mitten, however presently I do not
have access to funds to buy one, therefore I decided to use the
disposal mitten (see photographs). For infection control reasons
Christie LJ, McCluskey A, Lovarini M (2019)
Constraint-induced movement therapy for upper limb
recovery in adult neurorehabilitation: an international
survey of current knowledge and experience.
Australian Occupational Therapy Journal, 66(3),
401–412.
made me realise how important it is to embrace technology when
measuring a patient’s recovery.
Most patients said how liberated they felt taking the mitten off
at the end. They also commented on how the CIMT programme
had shown them how much repetitive use was needed to make
changes in their affected arm and that they needed to keep up the
momentum even when the mitten was removed.
Several patients asked if they could continue with CIMT
programme on their own without wearing the mitten, I think this
shows self-ownership and beginning to develop skills to improve
self-management.
One patient reported he found completing the CIMT programme
gave him ‘a lot of direction’ as he could pick what activities he
wanted to complete and it also gave him variety, which kept it
interesting for him.
Incorporating patient preference provides effective conditions
for neuroplastic changes. A young stroke patient who enjoyed rock
climbing and competitive sports reported the shaping activities gave
him the opportunity to be competitive with himself, as he wanted
to keep beating his times on shaping tasks, and it gave him the
motivation to keep pushing himself to keep practising.
One aspect I had not anticipated was how much of a role it gave
to the supporting family members. They reported that they enjoyed
the opportunity to be involved in the rehabilitation process by being
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