Ashan Weerakkody

Knowledge that we need training and education, but it's actually not as hard or impossible to deliver in public health systems or in clinical practice in general. So it's more effective. We need to be creative instead of assuming that it can't be done.

Mark Elkins

We would like to acknowledge the Turrbal and Jagera peoples of the Meanjin as the traditional owners and custodians of the land on which we're recoding this podcast, we acknowledge the elders past, present and emerging. The topic of this podcast is constraint induced movement therapy in stroke. My name is Mark Elkins. I'm the editor of Journal of Physiotherapy and I'm joined by Ashan Weerakkody and I'll get him to introduce himself.

Ashan 

Thanks, Mark. My name's Ashan Weerakkody and I'm an APA neurological physiotherapist from Perth. I'm also an Ph.D. candidate with Edith Cowan University in Perth, researching implementation, Science and Stroke Rehab.

Mark 

Thanks for joining us, Ashan. Can you start maybe by telling us what constraint induced movement therapy is and traditionally how it's delivered?

Ashan 

Yeah, constraint induced movement therapy is a therapy intervention for people after stroke, an upper limb therapy intervention. So we know people who have strokes often have an impairment of that upper limb function, which impacts their ability to carry out activities of daily living. So constraint induced movement therapy is a package of interventions comprising three main components. So what most people think of concern and movement therapy is about a restraint or a mitts or something restraining the upper limb.

But that's only a very small component. The primary components of CIMT are intensive practice using the more affected upper limb after stroke. So that's through repetitive task practice and also a series of impairment based exercises. But the most important part is what's called the transfer package. So that's a behavioural package used to increase the stroke survivors. I guess motivation and adherence to using their stroke affected arm more through the day.

So the main aims of the CIMT are to get a person using their stroke affected arm as much as possible throughout the day outside of clinic, and that will facilitate neuroplasticity and more use of their upper limb, but also to overcome learned non-use. So when you have an upper limb that doesn't work as well after stroke, there's a tendency to not use it, which then can become an ingrained habit. So this this therapy is designed to overcome that.

Mark 

So what sort of practical things would be in the behavioural package?

Ashan 

Yeah. So the first thing that's probably and is a big deviation from physio routine physio practice is called a behavioural contract. So that's essentially a negotiation between a stroke survivor and their treating clinicians where they will negotiate, what tasks they will use their stroke affected arm during the programme, what tasks they can use both hands and what tasks they can use.

They're less affected or unaffected on. And the main reason for that is we want to try to drive more use of the stroke affected arm, but acknowledging that people have an upper limb impairment. So there's going to be tasks that they can't do without their I suppose, good arm. So with that, that would be mapped throughout the day.

So you would look at a daily pattern of when they can use their good hand, their bad hand or both. Along with that there's a questionnaire called the motor activity log, which gets stroke survivor thinking about how much and how well they use your arm with a range of certain tasks. This is not only an outcome measure, but it's also part of the therapy.

So it's trying to get a stroke survivor thinking and internalising the affected arm use. Along with that, we have things like a training diary where stroke survivors are documenting what they do each day, but also the most important thing. And what we found in my own clinical practice is problem solving with clinicians, because this program can be quite difficult and clinicians that have an integral role in, I guess, problem solving, giving ideas, advice on modifying the program through the day.

Mark 

Why did you decide to undertake the systematic review on this topic?

Ashan 

So my background, my research background has been in implementation science. So it's looking at evidence based interventions that we provide in rehab and understanding how we get clinicians to adopt that into real world clinical practice. So CIMT is by far the most researched upper limb rehab intervention we have in stroke. I think the first systematic review was published in 2005 and it might have been in the Australian Journal of Physio from memory, demonstrating that it was superior to most other upper limb interventions at that time.

And since then the literature has gone far greater than that. But even if we're looking at 2005 to now, that's eighteen years and it's still not routine practice for eligible patients. There's been several systematic reviews demonstrating efficacy, and I know there have been some studies that have looked at perceptions and experiences around some stakeholder perceptions, but we thought, let's bring a systematic review together to look at what people actually think about this intervention, because it's one thing for therapy to be effective, but if we don't know if it's acceptable, then it's never going to be adopted into routine practice.

Mark 

So how many qualitative and quantitative studies were you able to include in the review?

Ashan 

Overall? We had 14 studies, of which seven were purely qualitative using focus groups in interviews. We had one mixed method study which interviewed two patients, but also surveyed clinicians. And then we had six quantitative studies that use surveys as their main data collection tool.

Mark 

So let's start with qualitative data, and you came up with four themes out of that. And the first one was that CIMT is challenging, but support at all levels helps. Can you tell us a bit more about that theme?

Ashan 

Yeah, so this theme came out because several of the stakeholders that were involved in the qualitative studies acknowledged lots of challenges associated with either undertaking or delivering the program or supporting the program. And these included things like managing the fatigue associated with the intensity of the program as well as things like frustration, particularly having to use an arm that doesn't work as well as the other clinicians reported challenges such as managing time constraints with other workloads.

But then interestingly, these participants who had undertaken and acknowledged these problems, identified several enablers that made CIMT achievable and acceptable. Some of those included therapies, support for patients. So being able to identify challenges and modify the program to make it easier and therapists identified things like interdisciplinary collaboration. So physiotherapists and occupational therapists working together to share the workload as well as institutional support and organisational support.

So managers being able to reallocate resources or have increased flexibility with scheduling to be able to facilitate a CIMT program.

Mark 

Okay. So the next theme was that therapists need a know how and the resources and the staffing if they're going to implement. CIMT Tell us a bit more about that.

Ashan 

Yeah, so overwhelming early for clinicians. The number one barrier was the knowledge, skills and confidence to deliver CIMT programs. So a CIMT program wouldn't go ahead if the therapist didn't know how to do it, how to adapt it into their own clinical setting, and then build confidence in learning how to develop those skills over time. Not only was it being able to access education and training to learn how to do CIMT, but then the institution that they worked for needed to facilitate ongoing peer mentoring and support.

So this needed to be through establishing sustainable education structures and support from senior clinicians, but also health services, providing sufficient resources such as available space and sufficient staffing to be able to run a senior program.

Mark 

So it's quite different to other rehab interventions in that there's this behavioural package. It's a big sort of sustained investment in time and money and so on. That kind of was reflected in your third, theme that it is quite a different intervention to others.

Ashan 

Yeah, absolutely. All participants acknowledged that it was different to anything they had received in prior rehabilitation. So often there are multiple components and both patients and clinicians described that the individual components and the pros and cons to that an example would be shaping, which is a an impairment based task. So you're targeting particular movement impairments, but those tasks are timed or counted and feedback is given immediately.

So stroke survivors get immediate knowledge of their results and they can track that over time. So actually the majority of people that was motivating and they saw hugely positive. However, there were some who identified this was a negative because they felt that the focus on speed and time came at the detriment of movement quality. Another thing was clinicians also compared functional outcomes for CIMT to other interventions that they delivered.

And we were seeing in the qualitative data that clinicians were almost amazed that the outcomes that they were receiving with CIMT compared to others. And this was a motivating factor to continue delivering programs because they thought that this was superior to other therapies.

Mark 

It's wonderful that some patients get really marked benefits from it, but your last theme identified that you don't always get the functional outcomes that you might hope for from CIMT.

Ashan 

Absolutely. So overwhelmingly, the main motivation people chose to do CIMT was to get better, and almost a common quote was that they wanted to return back to normal or have substantial results, or to be able to impress other people with how much, how far they'd come after completing the program. So it's almost an expectation that doing a two weeks CIMT program or however long that would be, would go from someone having a fairly impaired arm to then being almost fully independent and close to normal.

In reality, that's very rarely the case. If a two week program did that for everyone with a who had a stroke, it's almost negligent that we aren't doing that. So what we saw in the literature was stroke survivors had noticed that they were improving, but these were less than the expectations that they had, and it almost was a shifting of their understanding of the rehab process.

So it was more then this is CIMT, you do this and you'll be better. It's more, this is CIMT and it's part of your journey towards your overall rehabilitation path. And this is one thing that's going to get you going and to keep you going and to build self-efficacy and motivation to continue on progressing once scheduled therapy is over.

Mark 

So quite a bit of diversity in there in those four themes. Yes, which is good. I mean, it's nice that we're getting all these viewpoints on the therapy and all of that. It's giving us insights into maybe how we can get better. Translation Is it possible to summarise those four things into what it all means for clinicians?

Ashan 

Yeah, so for clinicians, I think the key factor we've seen is that stroke survivors overwhelmingly have seen that this is a positive intervention. Whether it's met their expectations or not, they've generally seen positive results but also found it as a good pathway for long term rehabilitation or long term life after stroke. And clinicians who are delivering CMT are identifying ways of overcoming the challenges associated with delivering it.

So they acknowledge that we need training and education, but we need to then embed educational structures into place. But it's actually not as hard or impossible to deliver in public health systems or in clinical practice in general. So it's more effective. We need to be creative instead of assuming that it can't be done. So that's kind of the overall overarching themes that have come from the four the qualitative themes that we developed from this semantic synthesis.

Mark 

And so bravely took on not just the qualitative evidence but also the quantitative and so in those quantitative studies that you included in the review, did they just reinforce those themes that you've already talked about, or did you identify other issues.

Ashan 

Whether it was silly to take on the quantitative as well as the qualitative? I'm not sure, but there was such a breadth of qualitative survey data that was out there that we thought if we didn't include it, it would would really miss a big hole in answering this research question. What we found is that the majority of the survey data included therapists and stroke survivors who had no experience with CIMT, and that was quite good because it gave us an opportunity to look at the differences between perception and actual experience.

So one thing theme was consistent between both the qualitative and quantitative data was the need for clinicians to develop the knowledge, skills and confidence that was consistent with both people who were comfortable delivering CIMT as well as those who had no experience, because they all acknowledge that if you don't know how to do this and do this well, you can't provide the program.

What was different was when we looked at the patient factors and the institutional factors, there was a gap between perception and experience. So in the patient factors, in the quantitative data, the assumption was that stroke survivors wouldn't be able to tolerate the intensity of the program. It would be too demanding of them and therefore not feasible, which was very different to what we saw in the qualitative data of stroke survivors who had actually participated in the program.

Similarly with the institutional factors, those with CIMT Experience identified that organisational leaders and their managers and the overall interdisciplinary team as enablers to providing CIMT where as those with no experience saw that the organisation as a barrier. So there's lack of resources, lack of funding, the lack of staffing, which we didn't see with people who had experience and primarily in the qualitative data.

Mark 

I liked that idea that you mentioned right back at the start about maybe the physios are not sharing the clinical burden of having to deliver a consistent course of therapy over such long hours and so on. And yeah, so I can totally say that getting the whole institution behind it is kind of necessary to make it work.

Ashan 

And it's certainly something I've seen in clinical practice. But it was also I presented this study yesterday here at the Ignite Conference and one of the comments made was often we delineate the upper limb and separate it based on discipline. So the assumption that as a physio, our job is more focusing on mobility and assuming that the upper limb is left to the right and then the O.T. has so many other domains to work on, whether it's cognition, AIDS awareness, insight, all those things.

And they don't have the ability to exclusively focus on the upper limb. And we know from the research that the dose required for upper limb recovery after stroke is enormous, far greater than mobility in our outcomes for upper limb, far poorer than they are for outcomes with mobility. So the only way people are going to get the adequate dose that they require is if we're sharing that workload and we're both taking ownership over that.

Mark 

I think there's heaps of rich insights in both sets of data for helping us think about how we might do better with translating this into practice. But with what you've found in the review, where do you think research needs to go to now?

Ashan 

I don't think we need any more efficacy studies that's been well established and even trying to understand what the protocol for CIMT we use. So there's the original CIMT protocol, which was 6 hours a day, but then we're finding that modified programs are just as effective. So I don't think there's any role for that in stroke Rehab at this stage.

So I think research really needs to shift towards implementation studies and looking at different contexts. So public private, acute, subacute, chronic, developed nations, low and middle income countries, and saying how that we can implement CIMT across all of these different domains because at the moment for upper limb rehab, it's the best thing we've got. So we just need to see how we can develop programs to be able to get that, to have more stroke survivors be able to access it in the first place.

So I see implementation science is probably the way forward, not just with CIMT, but probably with all Stroke Rehab, but for us looking at giving clear examples in a range of settings because that will hopefully provide blueprints for other services, being able to then pick up a program or a protocol and then implement it in their setting. So that's probably where I see it going.

Mark 

Great. Well, look, thank you so much for your time. It's been wonderful to get your insights into the research.

Ashan 

Thanks very much for the opportunity.