Implementation of a complex therapy within Rehabilitation in the Home for patients receiving upper limb therapy after stroke.

This study seeks to evaluate the implementation of modified constraint-induced movement therapy (mCIMT) within RITH. Modified constraint-induced movement therapy is a rehabilitation therapy for upper limb impairment after stroke. Rehabilitation in the Home (RITH) has developed it's own program, fit for purpose within an early-supported discharge setting. Patients will receive RITH and mCIMT regardless of whether they are involved in this study. The decision to receive mCIMT will be based on therapist and patient collaboration during goal setting and treatment planning. This study seeks to determine whether the RITH mCIMT implementation program has led to more eligible patients receiving mCIMT as part of their rehabilitation with RITH. This program consists of the described components of constraint-induced movement therapy (CIMT): - Transfer package which is a set of behavioural strategies to facilitate patient use of their stroke-affected arm outside of scheduled therapy time (Behavioural Contract, regular administration of the Motor Activity Log, training diary and home skills assignment). - Intensive practice (shaping tasks and repetitive task practice) - Constraint of the less-affected upper limb (such as a mitt, oven mitt, glove or sling) Definitions: Functional task practice- repetitive practice of tasks that are encountered on a day to day basis. These tasks are completed repetitively over a period of time (ie: 10min). Examples include using the more-affected arm to button shirts, using a spoon to feed self, drink from a cup, using a key to lock/unlock doors, and write with a pen. Shaping- a series of graduated upper limb tasks which target particular movement deficits that the therapist feels has the greatest potential to improve and fit with patient preferences for exercise. Shaping looks to improve motor skills at an impairment level, whereas functional task practice looks to improve function at the activity/participation level. Shaping tasks are generally timed or measured, to provide immediate feedback on performance to the patient which can be motivating but also highlight deficiencies. An example of a shaping task is measuring how many playing cards a patient can turn over in a 30 second period. This task targets pincer/lateral prehension grip, wrist and finger movement, forearm supination and pronation and elbow extension. As a patient improves, their speed and quality of movement increases to allow for more cards to be flipped. Shaping tasks are identified from observation of functional task performance and determination of what movement deficits may be contributing to impaired performance. Shaping tasks can also include components of a full functional task (part-practice). Adherence to program- mCIMT requires engagement and accountability from the patient. During the program, the patient (or carer if required) completes a training diary daily which documents the time spent wearing a constraint and a log of the functional task practice completed. This is reviewed on each RITH therapist visit (3 times per week) and the patient is questioned if there are deviations from the program agreed upon. The Behavioural Contract and Motor Activity Log (MAL) are completed prior to commencing the program. The RITH program is 2 weeks in duration, with 3 therapist visits per week during this period. Each RITH visit is 1 hour in duration and comprises completion of the MAL, provision and review of a training diary/home skills assignment, and completion of shaping tasks- generally 4-5 separate shaping tasks targeted at particular movement deficits. Participants are expected to complete at least 2 hours of independent functional task practice daily during this period, and encouraged to wear a constraint on their less-affected upper limb for up to 6 hours a day. The amount of practice a participant performs each day is reviewed by the visiting therapist on each visit. Carers are encouraged to support patients in completing this program. Outcome measures are completed at the completion of the 2 week program.