330: Working With The "Excluded" Patient: A Case Study Using Modified CIMT After Stroke With Briana Elson, MS, OTR/L, BCPR, CBIS

Summary

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Podcast Summary: I Love Neuro – Episode 330

Title: Working With the "Excluded" Patient: A Case Study Using Modified CIMT After Stroke with Briana Elson, MS, OTR/L, BCPR, CBIS
Hosts: Erin Gallardo & Claire McLean
Guest: Briana “Bri” Elson, MS, OTR/L, BCPR, CBIS
Date: August 10, 2026

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Episode Overview

This episode dives into the practical application and boundaries of Constraint-Induced Movement Therapy (CIMT) for stroke patients—specifically focusing on using a modified version in a patient with severe cognitive impairment, a group usually excluded from standard CIMT protocols. Briana Elson shares her innovative case study, challenging textbook exclusion criteria and exploring how therapy can be individualized to maximize patient outcomes in real-life clinical settings.

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Key Discussion Points and Insights

Background: CIMT and Its Traditional Exclusion Criteria

• CIMT Overview:
  The therapy forces use of an affected limb by restraining the unaffected side, aiding neuroplasticity and counteracting “learned nonuse” post-stroke.

  • "[CIMT is] to force the use of the affected extremity... for more movement or more purposeful activity, whether that's opening the refrigerator door or a knob." (Briana, 04:36)

• Standard CIMT Parameters:

  • Requires 10–20° active wrist/finger extension
  • 6 hours/day restraint
  • No cognitive impairments allowed
  • Typically prescribed for mild-moderate hemiparesis, post-1 year chronic stroke
  • “Anybody who works with people who have survived a stroke… a lot of them have cognitive impairments… But then half of my caseload… I can’t apply it to.” (Briana, 02:10)

• Evolution of Protocol:
  The protocol has become more flexible over time, with “modified CIMT” seeking to include a broader spectrum of patients.

  • “Originally, it was like six weeks… For the modified version, it’s a little less, which is a lot easier for people to implement.” (Briana, 06:03)

Addressing Real-World Barriers

• Challenge of Translating Research to Practice:
  Studies exclude cognitive impairment, but these are common in real patients. Clinicians must adapt.
  • “All interventions start by saying excluding people who have cognitive impairment… but then it’s… trying to take what that research says, implementing it in the real world.” (Claire, 09:22)

The Case Study: Patient Profile and Rationale

• Patient Details:

  • Left-handed male, severe cognitive impairment (orientation log 12/30), underlying dementia, acute stroke recovery
  • Good physical baseline: 2–2+ out of 5 strength, some finger extension
  • “He had cognitive impairments, but he was left-handed and that was his affected side... it should be natural for me to just force him to use that hand.” (Briana, 06:43)

• Why Attempt CIMT?

  • “[I thought:] If we can't use [CIMT] with half the people we work with, but it has the strongest level of evidence, how can we do this?” (Briana, 06:43)
  • Leveraged procedural memory and dominance for salience

Protocol Modifications and Safeguards (14:00–17:05)

• Setting:
  Inpatient rehab with constant supervision, family and care team highly involved

• Adjusted Protocol:

  • Wore mitt 3–6 hr/day, focus on meaningful tasks (e.g., eating, grooming)
  • Careful exclusion from bilateral hand tasks and during times of sundowning/agitation
  • Supervision by caregivers/therapists; consent and order from physician necessary

• Family Education:
  Comprehensive training for wife and care team, daily huddle reminders

  • “I had to educate his family on it too... signs everywhere on the door, in his room, 'please do not throw away this mitt'...” (Briana, 19:53)

• Team Engagement:
  “I definitely could not have done it without a team that was supportive and on the same page… his caregiver… was another huge asset to our team.” (Briana, 19:53)

Challenges and Practicalities (21:35–22:52)

• Team members mistaking mitt for a restraint, disposing of it
• Patient agitation, attempts to remove mitt when tired or confused
• Unplanned interruptions: medical emergencies, variable discharge timing
• “Just knowing that it can’t be perfect like how it looks on paper... In real life, nothing is perfect like that.” (Briana, 22:52)

Outcome Measures and Results (23:00–25:31)

• Nine-Hole Peg Test (Fine Motor):
  0 → 4 pegs in 14 days

• Box and Blocks Test (Gross Dexterity):
  3 → 12 blocks; meets minimum detectable change (MDC)

• FIM (Function):
  Moderate → minimal/setup assist in grooming and feeding

• Motor Evaluation Scale for Upper Extremity:
  MDC met in ROM and functional gains

• “Out of the three standardized scores that I did, he met the MDC for two out of three, which is pretty awesome. In a small period of time.” (Briana, 25:31)

• Cognitive Status:
  No improvement throughout

  • “His cognition never got better, even in the entire time frame that I worked with him.” (Briana, 26:05)

Implications for Clinical Practice

• Adapting Evidence to Individuals:

  • Standard recommendations (mirror therapy, mental imagery) often unsuitable for cognitive-impaired patients.
  • “There are so many things that are recommended, but when you throw the cognition into it, they don’t have the sustained attention or capacity…” (Briana, 27:26)

• Use of Technology:

  • Simple, salient robotic games potentially useful; complexity must be minimized.
  • “I was able to get him to do robotics, but I had to choose the games that captured his attention…” (Briana, 27:41)
  • VR too demanding for this profile of cognitive impairment.

• Family/Caregiver Engagement:
  Key to protocol adherence and maximizing active use outside therapy sessions.

• Therapy Dosage & Scheduling:

  • 3–6 hours daily, broken into segments
  • 2–4 weeks recommended
  • “It doesn’t have to be three consecutive hours… breaking it up is a really good strategy as well.” (Briana, 32:37)

• Practical Tools:

  • Motor Activity Log helpful for generating home/practical tasks
  • Any soft mitt (even a sock) can be used as a constraint, as long as it’s safe

• Advice:

  • “Just try it… You just never know what’s going to happen. And if it’s not good, just don’t do it anymore.” (Briana, 34:25)
  • “It's a great home program too… just doing everyday things with the hand that they're supposed to be using.” (Briana, 34:29)

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Notable Quotes & Memorable Moments

• On Research vs. Practice:
  "The study is not exactly what I see in practice. So, how do I do this? Is that translation to what I see in my day to day..." (Briana, 13:20)

• On Patient Selection:
  "Of course I have to go for the most complex person ever. He had... severe, moderate to severe [cognitive impairment]. He also had underlying dementia on top of it." (Briana, 08:00)

• On Therapy Structure:
  “Structured schedule works usually best for severe cognitive impairments...” (Briana, 17:05)

• On Breaking Rules:
  “Everybody thought I was crazy. I think it made sense...” (Briana, 10:47)

• On Family Involvement:
  “Educating the family was huge for us and making sure they have a family that will be engaged… Because an outpatient, you really have to rely on them and the family more than anything.” (Briana, 30:57)

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Timestamps for Key Segments

• 00:30: Introduction to Briana Elson and context for the case study
• 02:10: Standard CIMT exclusion criteria explained
• 05:25: Functional outcomes and benefits of CIMT
• 06:23: Rationale for using CIMT on a cognitively impaired patient
• 14:00: Adapting the protocol for inpatient setting and family/team involvement
• 17:13: Detailed daily structure of therapy and constraint use
• 19:35: Strategies for team buy-in and practical reminders
• 21:35: Practical challenges encountered
• 23:00: Pre- and post-treatment functional outcomes
• 27:26: Limitations of other interventions for cognitive impairment
• 27:41: Role and pitfalls of robotics/technology
• 30:57: Recommendations for clinicians: family education, simplifying activities, adapting schedule
• 32:31: Emphasis on flexible dosing and therapy duration
• 34:25: Takeaway advice—try, adapt, and communicate outcomes

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Summary Takeaways

• Briana Elson demonstrates that with creativity, supervision, and caregiver engagement, modified CIMT can be implemented even in patients previously considered unfit due to cognitive impairment.
• The success of her approach depended on individualized, flexible therapy, team coordination, and clear communication—focusing always on patient safety and real-world function.
• Clinicians are encouraged to challenge rigid research limitations when patient safety and context allow, adapt interventions pragmatically, and share their own case stories to expand the evidence base.

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Transcript

[A]

Welcome to the I Love Neuro podcast.

[B]

We're your hosts. I'm Claire McLean.

[A]

And I'm Erin Gallardo. And we help those who love neurologic rehab and wellness think outside the box, deliver care with passion, and improve the lives of those with neurologic conditions without burnout and overwhelm.

[B]

Join us on the quest to figure all of that out. Hi everyone.

[C]

Welcome back to I Love Neuro Sterile podcast. I am one of your hosts today. Erin and Claire will be joining us shortly. We are back for a discussion with our OT instructor, Inside neurospark, Bri Elson. She does OT office hour, OT pt, office hours. She's the OT component as well as teaching inside neurospark and our OT consultant on all things that we need. And not too long ago, you represented a case in the NeuroSpark content, a case of a person who you modified constraint induced movement therapy on. And we thought, wow, this would be a great story for the podcast because I think people could learn from it. So welcome back to the show.

[D]

Thank you for having me. It's good to be back. It's been a while, so thanks. I'm ready to chat about our case, which was pretty interesting, I think too,

[C]

and I'm glad you thought it was interesting. So it was your, your presentations are always so interesting. You have a lot of videos, a lot of examples. You get real functional with it. You have definitely different takeaways and resources and images that we get to learn about and then you apply it into a case. And so I know that we always love making YouTube clips and social media clips and things like that out of your content, so. Oh, awesome. When you were presenting this one, Danielle and I were messaging back and forth on Slack. We need to schedule. Bri, I want to talk about this case on the podcast because just the intro around it, like constraint induced movement therapy is very popular. Been around a long time, super evidence based. However, there's a lot of exclusions.

[D]

A lot, a lot of exclusions. And the majority of the exclusions are because people have cognitive impairments. And anybody who works with people who have suffered a stroke or survived a stroke, I should say a lot of them have cognitive impairments. How can we say that this is such robust evidence? It's highly effective. Use this. But then half of my caseload, maybe even 3/4 of my caseload, I can't apply it to.

[C]

So what is the, what are the parameters around doing constraint induced movement therapy typically?

[D]

So typically you have to have anywhere from 10 to 20 degrees of finger Extension and wrist extension. Movement wise, anybody who's completely flaccid, it's not really meant for. And like anybody who has proximal activation but doesn't really have any distal movement, it's not necessarily meant for either. There were some slides that I showed for like a modified version where you could get them started. But as it was created, it was intended for people who have some aspect of finger, active finger and wrist extension. So it's really meant for mild to moderate hemiparesis. And you have to be able to tolerate six hours a day in the restraint. And you couldn't have any cognitive impairments because they needed to be in the restraint for that long. They didn't want people who had cognitive impairments to participate because they were using a sort of restraint system, the restraint

[C]

on the functional arm so that you to use your affected arm to do tasks of six hours a day of doing that. And then essentially people could take the restraint off if they really wanted to, right?

[D]

Yeah, yeah, they can if they needed to. And if they really wanted to, they could as. So when the protocol was originally created, it was created like about 20 years ago. It wasn't modified. It was just this is what constraint induced movement therapy is. And you have to be restrained six hours. You can't have cognitive impairments. You have to have active finger and wrist extension. You have to be chronic one year post stroke. They had all of these very rigid criteria. And then it has evolved over time to be more modified and more flexible so that more people could benefit from the protocol.

[C]

And what are some of the benefits that have been documented?

[D]

Definitely more use. So like the. That principle of neuroplasticity that we talk about learned nonuse, where people just don't use their affected arm. It's to force the use of the affected extremity, like you said, for more movement or more purposeful activity, whether that's opening the refrigerator door or a knob. Hey, Claire. And those are some of the benefits. It's even shown to be beneficial for some people who may have some kind of body neglect, because if you restrain the side that they're paying attention to, it forces them to look to the other side a little bit. It wasn't intended to be studied that way. But those are some of the kind of spillover effects that you may see.

[C]

And significant improvements in those things too.

[A]

Right?

[C]

That's why it's been one. So there's significant improvements in outcome measures after how many weeks did you say?

[D]

So the research is varied. I'm trying to Go back to see there's a clinical practice guideline and OT for stroke that kind of put together all of the, all of the literature that's out there. And so what they recommend for the dosage is one to two hour sessions, five times a week, anywhere from two to four weeks at a time. Oh, okay.

[C]

Okay.

[D]

I think originally for constraint and the movement, originally it was like six weeks or something like that.

[C]

Gotcha.

[D]

But for the modified version, it's a little bit less, which is a lot easier for people to implement.

[C]

So normally, since the person has to have cognitive awareness, you haven't been able to use it on people. But why did you feel like you wanted to try it on a recent patient?

[D]

So the person that I. Yeah, so every research paper that you ever read will say that the person has to have a mini mental score greater than 24, which is basically like they can't have dementia, they can't have any mild. They can't even have mild cognitive impairment. Like no cognitive impairment whatsoever.

[C]

Why is just so they know what's going on or they could if they wanted to.

[D]

Yeah, exactly. Could they use a restraint, consent to it, all those things to keep people safe, which. Very understandable. However, in real life, that's not most of the people that we work with. And it's supposed to be one of the things in our, like in occupational therapy practice that is the strongest level of evidence in terms of the different type of therapeutic interventions that we even have to pull from. It is one of, if not the most evidence based of all things. So I'm like, okay, if we can't use it with half the people we work with, but it has the strongest level of evidence, like, how can we do this? So the patient that I had cognitive impairments, but he was left handed and that was his affected side. And so I figured, I thought to myself, like, if his dominant extremity is the left hand, then it should be natural for me to just force him to use that hand. Because he brushed. He's going to remember that he brushes his teeth with that hand. If he's going to pull a doorknob open, like that's the natural hand that he would go for. So I kept thinking like, okay, besides for the cognitive impairment, what is the reason why I couldn't do this with this person.

[B]

Person.

[D]

He's like the perfect person.

[C]

How much cognitive impairment did he have? Did you test him beforehand?

[D]

Yes, it was significant.

[C]

Just mild?

[D]

No, was not mild. Of course not me. I wouldn't pick anybody with mild. Right. Of course I have to go for the most complex person ever. He had. We used the orientation logs. So out of 30 he had a 12 out of 30, which is severe, moderate to severe. He also had underlying dementia on top of it.

[C]

Okay. No, this is helpful just to paint the picture of who you're talking about.

[D]

Yeah.

[C]

He was left handed, so it seemed like this would be salient for him to use his left hand. He had very significant cognitive impairment on testing.

[D]

Exactly. And he also had a lot of movement. He was like the perfect candidate for it because he had two to two plus out of five strength in all his joints, a little bit of finger extension, a little bit of everything. So he was like the perfect person to use this for. And we couldn't really get him to pay attention much because of his cognitive impairments to some of the other things. So I'm like, okay, all of the things are aligning. So really the only thing that is in my way is the fact that he has a cognitive impairment. So I kept thinking to myself, what can we do to work around this? If this is supposed to be the best intervention for me to use with a person who has these impairments minus the cognitive deficits, like, how can I just make this safe for this person to participate?

[C]

Yeah. Oh, go, Cliff.

[D]

That's how I decided.

[C]

Jump on in the conversation.

[B]

And I was just going to say for. I feel like almost all interventions start by saying excluding people who have cognitive impairment. A. Yeah. Consent and outcome benefit. You want to really have. Show that a treatment is beneficial, but then it's. Yeah. Trying to take what that research says, implementing it in the real world. And just like you would with any other intervention you would do with someone like that, you're looking to see how much they can communicate or if there are other cues that they're not consenting or that whenever you work with someone with dementia, you have to be looking at a lot more than just what they're able to say about the treatment. Because we have to work with people who have cognitive changes. No matter what the intervention is. Those are things that we're going to have to pay attention to. Yeah. But yeah, I think it was so smart that you started with someone where it was his. His dominant side was the more affected by the stroke. So that it is going to be more natural. And have. Have any studies happened in CMT or modified with people with any level of cognitive impairment or. That's always.

[D]

Not that I found. Everything that I've seen was that it was a severe contraindication to use or to implement with somebody who had cognitive impairment. But also, like, such a rule, like studies. I am for sure. But all the studies are done in very sterile clinical trial type of setting.

[B]

Yeah.

[D]

The exclusion criteria is yay long. And I just kept thinking, like, well, if this is supposed to be so great, what does the cognition have to do with it? If we're thinking about motor function and salience, he should be driven by the. The task that he wants to do. That's his dominant extremity. Like, all of these things would make sense to him if we're tapping into, like, procedural memory. So those are all the things that were going through my head. Everybody thought I was crazy. I think it made sense if it

[B]

was the original C I M T where they're going home and having one hand unavailable for five hours. That's a whole different thing than modified. Where you're working with someone for one to two hours. You are there. If they get frustrated, upset, if they're confused, you can remove it and talk about it and take a break. I mean, just a completely different intervention to be sending somebody home with a restriction than being with them with the restriction, but especially with your. What I'm expecting that you got out that the outcomes that he had. Hopefully that is something that's being looked at, is expanding it to obviously, people with mild cognitive impairment first as the towards. But it seems like, yeah, Doing things with supervision and assistance where it could be stopped at any point if they seemed uncomfortable in any way. That's very different than when you're sending people off at home and you have no idea what's happening with them at home.

[D]

Yeah.

[B]

If they're tolerating it or not.

[D]

I think that's a good point, Claire, because we did it. Or I ran the study. Study, quote, unquote, my study of one. But I did it with this person in inpatient rehab where there's always someone there with him at any point, whether that's me, whether that's my other therapy counterparts, nursing supervision. His wife was very involved as well. She was always there with him when he was in the room. So we always had eyes on him. And that's also another reason why I fel. It could work because I think if we didn't have that kind of support, it would be a different story. But since we had a lot of those positive pieces, I felt compelled to give it a try. The worst thing that could happen is that it just doesn't work.

[C]

I love that you tried it too, because I'm sure you're there Evaluating him and trying to figure out what do we do? We want to send this person to the next step with the best chance of continuing recovery possible. And if he's having trouble understanding some of these interventions or the things that could be done, like I can imagine this gave you and probably the team a little boost of excitement of, ooh, we're gonna try something different and base it off research. But let's see what happens. Let's experiment a little bit. And sometimes we need these little peps in our steps to get things going.

[D]

Yeah, definitely. And because I think a lot of what I hear from clinicians too is like taking the research and then putting it into practice. Can there's such a barrier? Because it's like this study is not exactly what I see in practice. So how do I do this? Is that that translation to what I see in my day to day? How do I take that and apply it? Because the research is never what, in your true practice area? Yep, yep.

[C]

Okay. So the setup was you're an inpatient rehab. Give us more of the parameters that you put around it and your details.

[D]

So we had, we were in inpatient rehab, so we had three hours of therapy per day, one hour of ot, one hour of speech, one hour of pt. And so I had to get permission from the physician, the attending physician, because I had to use a mitt as our constraint and we technically used those as restraints. So I had to get an order for it to make sure that we could use it. I educated his family on it too. So what we tried to do is make sure that we had him in 30 minute therapy sessions throughout the day to increase the supervision that he was with somebody and dispersed across at daytime. His wife was with him during the day if he was not in therapy to make sure that he was supervised. When the restraint was on, he also sundown because he has concurrent dementia. So he would sundown around 3 o'. Clock. So we would make sure that we removed the mitt by 3 o', clock, if not before then, to make sure there wasn't any extra agitation or behavioral issues. Just to be proactive if, because we knew that was what was to come, we would just be proactive. And so his schedule ended up being like 8am to 2pm he would wear the mitt during therapy. If he could tolerate it outside of therapy with his wife, we would also let him wear it with her. And we tried to put him in groups that forced the use of the left hand. So we would do fine motor group. He would do breakfast Group where he would, because he had some swallowing issues as well, some swallowing considerations from the strokes, he needed to be supervised at meals. But that was really helpful for us because he is left handed. So somebody's supervising him while he's trying to eat three meals a day. So that's another perfect opportunity for him to do something salient, something that makes sense and something that's well, works well with the CIMT protocol. So those were.

[C]

Set him up for six hours a day?

[D]

We tried.

[C]

Yeah, that was our plan. That was the plan. And how long was he gonna be there?

[D]

He ended up being, when I first initially started it out, we had about three weeks with him, but he had a early discharge. One, he had an acute discharge and then he came back to our team maybe after two days, and then he had an early discharge to the snp. So I think we ended up doing the protocol for about 13 days. So about two weeks instead of the three. But yeah, I would say about 10 to 13 days, give or take weekends and discharge and that kind of stuff.

[C]

Okay, so how many hours a day did it end up being, do you think? For the 13 days?

[D]

I think anywhere from three to six given the day. It definitely varied. It was not a consistent six hours per day at all? No, depending on his mood. Did he sleep? Is he tired? Is he sundowning earlier? Is he in PT using the walker with two hands? Is he in the parallel bars, that kind of stuff. So I would say anywhere from three to six hours. But with modified cmt, three hours is the minimum for it to be successful still.

[B]

And what would an actual day look like for him? Can you walk us through like how that would get started, what it would look like at different time frames?

[D]

Yeah, so in the morning I would, we would try to keep his schedule really consistent. So I would get him in the morning to do his morning routine. He would not be in the mitt for things that required bilateral hand tasks, putting on his shirt or any traditional dressing task. For clothes I wouldn't have him in the restraint because he needed two hands for that. But once we were done with that and we would get to grooming tasks, brushing his teeth, combing his hair. I would put the mitt on so that he would be forced to use his left hand to do some of those single handed tasks. But that makes sense task specific. That makes sense for, for that grooming task. And then after that he would do breakfast and he would be again forced to use his left hand for breakfast group to eat. And after that he would have either Speech or pt and they may or may not take the mitt off depending on what their tasks look like for the day. I mentioned sometimes they would put him in the parallel bars to practice standing or whatnot. And they would need both hands. So they'd take the mitt off in PT for those reasons. And depending on what speech was doing with him, they may or may not take the mitt off. So that's why it's hard to say exactly how much time he had it on, because it varies. And then we also had him in. So he was in breakfast and lunch group where he would be forced to use them in. In the morning he would be forced to use it with me. He had other groups during the day, so sometimes he would be in fine motor groups. So he would work on picking up pennies and putting them in a jar like a piggy bank and using his left hand for that. Or he liked to do tinker a lot of older men, he was 86, by the way, he was an older gentleman and he liked to do tinkering. So we would get him nuts and bolts to work to screw on with the left hand and the fine motor group. And I also tried to use some robotic exoskeleton type of things that we have on hand where I work, like the armao, which is an. It's a single upper extremity device that uses feedback from a video screen. So it's non immersive virtual reality. But he would be like trying to shoot birds in the sky using the device. But it would force the use of the left hand too, because we would set it up for the left hand. So we tried to do all of those things every single day on repeat. Structured schedule works usually best for severe cognitive impairments. And so we tried to just keep him a consistent schedule each day doing the same thing day to day.

[C]

What was some of the setup you had to do for the team to everyone to be on board? And what did you tell them and how did this all get laid out? Cause I imagine you were the one who. You were the one obviously initiating it and then making sure everyone else could follow through because it needed to be everyone's effort.

[D]

Yes, definitely could not have done it without a team that was supportive and on the same page. And also I have to mention that his caregiver, which was his wife, she was another huge asset to our team. So I had to one, get the physician to agree to use the restraint. And so I had to ask about that. We had to get the order for It And I had to train his wife to know, give her the background on the evidence of why. I think this is because if they see their loved one in a restraint too, they're concerned about it. So I had to make sure I educated her. Hey, this is the evidence base I'm working with. This is why I want to do this with your husband. I think it would be beneficial for him. I had to put signs everywhere on the door, in his room, everywhere, for everyone.

[C]

What did they say?

[D]

Please do not throw away this mitt, because they think that it's a restraint, it's not a restraint. And then they see that he doesn't have orders for an actual restraint. So then he will throw the mitt away, even though we need it for our protocol. So I had to put signs literally everywhere so that people wouldn't keep throwing away our restraint. And I had to write on the mitt, please do not throw this away. And so our team meets daily in the morning for huddle, like our team huddle in the morning. So I would just gently remind people, okay, this is another day of the protocol. Please make sure that you are encouraging him to use his left hand when possible, if the task requires it or calls for it or if you can incorporate it in whatever way. So that was helpful. We met very regularly as a team, so I think that helped us a lot. And then his wife, again, was great. So when he wasn't in therapy, she would have him in the room, like, playing Uno, but he would only be able to pick the cards with his left hand, and she'd work on it with him, so she was really great, too.

[C]

Oh, that's great. So what were some of the challenges you faced besides people throwing away the mitt?

[D]

That was a big challenge, for sure. I would say his cognition at times, like towards the end of the afternoon, if he was really tired and he had a long day, he would get a little bit agitated. Sometimes you would catch him trying to take the mitt off with his mouth and pulling it off, too, if he was getting a little bit annoyed. So that could. That was a challenge sometimes. And I think just the nature of the beast of inpatient rehab, like him going out for a test, and you had no idea he was going to be gone for seven hours out of the day, or he got discharged to acute care because he had a GI bleed at one point, and he was gone for three days and lost three days off the protocol. We weren't sure if he was going to come back to our team to be able to restart it with us. And he got discharged early, earlier than we expected to go to a skilled nursing facility. And you just can't plan for those things. It's just the nature of the beast. So I think having to be flexible like most therapists are and doing what you can and just knowing that it can't be perfect like how it looks on paper in the article. Because in real life nothing is perfect like that.

[C]

So what are some of the things that you saw then after doing the protocol, did you do a little for people too?

[D]

I did. You mean like outcomes or like what did we get out of it? Okay, yeah. Yes, I did. So I did. I looked at. So this was the case study that I used for my. When I was in the. The OT neuro fellowship, we have to do case study. So he was my case study for the fellowship. So I ended up doing pre and post outcomes because I had to do it for my case report.

[B]

Perfect.

[D]

But it ended up being pretty good. So we did the nine hole peg test in the beginning initially, which is the. You use small pegs to take them in and out of this very small hole that it's supposed to fit in. In the beginning, these are all tested only on the left hand side too. In the beginning he could only do zero. He did zero, he couldn't do any. And on day 14 he could do four, which is not significant, but it shows that there was some progress in his very fine motor control, which is hard. The box and blocks test we also did in the beginning, which is like a small cube that you take across a barrier to show gross manual dexterity versus nine hole is more fine motor dexterity. So for the box and blocks his initial was three blocks and by discharge it was 12. And the minimal detectable change is five blocks for that. So we did meet the MDC for box and blocks only and within a 13 day period, which is pretty awesome. I also, he got changes in his FIM scores. So he went from moderate to minimal to setup, assist with grooming and feeding. He was able to just kind of get set up instead of needing 50% help for both of those things. So he was able to feed himself, scoop, eat, brush his own teeth, comb his own hair with the left hand with minimal to I would say super setup assistance, just depending on their other factors too, like fatigue, attention, all those kinds of things. Physically though, he could do it with not that much help. And then I also collected some data from. I don't usually use this outcome measure that much, but it's called The Motor Evaluation Scale for Upper extremity and stroke patients. And I used it because you can guide them through a movement instead of having to have them copy you. You can guide them first and then let them do it. Which was helpful because he had cognitive impairments. And we met the MDC on that scale as well for his range of motion, gains of being able to touch behind his back, touch his head, those kind of movements. So he had. He met. Out of the three standardized scores that I did, he met the MDC for two out of three, which is pretty awesome. In a small period of time.

[C]

Yeah, yeah, yeah.

[D]

And he.

[C]

He did have an acute stroke.

[A]

Right?

[C]

That's why he was in rehab.

[D]

Yes, he had an acute stroke. I think he was within. I can't remember when it was, but he was in rehab, so it was, like, maybe within a month.

[C]

Yeah.

[D]

And originally, the. The CIMT protocol was created for chronic stroke, but then research came out later on that acute stroke, it was beneficial to do in as well.

[C]

Oh, so even people with acute stroke, they felt like they made improvements beyond what would be expected just from spontaneous recovery?

[D]

Yes.

[C]

Oh, okay.

[D]

Yes. I was gonna say something else, but I forgot. It's okay. Maybe it'll come back to me. I wanted to say that. Sorry. I wanted to make a note that he. His cognition never got better, even in the entire time frame that I worked with him.

[B]

Oh, yeah.

[D]

That's good to know.

[C]

Yeah. Are there other interventions that you would do for someone with so much cognitive impairment?

[D]

It can get hard. It really can. Because for people who have hemiparesis, one of the really recommended interventions is mirror therapy. I could never get him to attend to a mirror to do mirror therapy. No way. Out of the question. So throw that one away then. Next. The next thing that's recommended is mental imagery or action observation. No, just in general for people who have hemiparesis. So if I was to look at a. A practice guideline like, okay, I have a patient with hem. Has hemiprasis. This is what I should do with them. I could never get him to do action observation and attend to a video of himself doing anything. Not gonna happen. Mental imagery. Not gonna happen. There are so many things that are recommended, but when you throw the cognition into it, they don't have the sustained attention or capacity, cognitive capacity, to do most of the things that are highly recommended for Henny Breezes.

[C]

There's so many robotic things coming out. We were at AOTA together, a bunch of them in the exhibit hall. Same thing at C. Do you Think those kind of products are going to be helpful for people with cognitive impairment?

[D]

I think yes. But I think that there is. Salience plays a big role. I was able to get him to do robotics, but I had to choose the games that captured his attention that he was engaged in. So it had to be like a fishing game or a shooting game or something like that.

[C]

Or else if I chose in a shopping cart or.

[D]

No way. Right. Would not be able to do that. It had to be really simple and straightforward and something that was like intuitive for him to do. Nothing with too much complexity. I only selected the games where he had to squeeze the handle to send off whatever in the game. Nothing where it was like, you have to do a whole movement and get. No, that would have been too hard.

[C]

VR probably would have been.

[D]

No, I think that would have been too hard for him. I didn't try it. So I don't know for sure. Okay. But I can imagine that it would have been difficult. But I do think there's an. There is definitely. There are definitely things out there, VR or robotics wise, that could really be beneficial for people with cognitive impairments if they are engaging for that specific person. Because you have to find what is that person like, what will they pay attention to, what makes sense to them. You can't pick something new. Yeah. It can't be something new that they've never seen. I can't pick if he never played tennis or pickleball. I can't pick that on my VR thing. He'd be like, what is this?

[B]

And just VR in general. Like, some people think that stuff is really cool, some people don't. When people have cognitive impairment, sometimes they don't even know what they might like or not like. And so you kind of just have to trial and error things to some degree. But then there's only so much time for that. And especially when things require a good amount of setup. These are just. There are so many barriers to using cool technology that I think when people are developing it, they don't even realize what it takes to set it up and what people's preferences are like. When you're working in tech, it's because everybody who's around you is into tech. And so you don't realize that some people aren't interested in that or don't like it.

[D]

Yeah, absolutely.

[B]

Just so many factors that there's a lot to think about.

[C]

Did you try Blaze pods with him at all? I'm just curious. It just popped into my head talking about tools.

[D]

I don't think we had them at the time because this was a couple years ago. It wasn't even that recent, but I don't think we had Blaze pods at the time when I was working with him. But I think Blaze pods would have been like an easy one because it's like the light will capture his attention. All you have to do is smack it. It's not the real high or it's not really a big put, like a big lift, I should say, for him to understand what I'm trying to get at. So I think that would have been an easy one to get to pretty quickly. I don't know how long he would have engaged with it in terms of varying. Because Blaze pots, you can do so many things in terms of random colors and whatever. I don't know if we could have done any of the higher level or like, only hit the red. Only do. I don't think I could have done those.

[C]

Yeah. Different positions and just hit the light kind of thing.

[D]

Yeah, yeah, Basic.

[C]

So if someone wants to attempt this in their clinic, in their inpatient or outpatient clinic or whatever, what are your tips and recommendations for them after having done it?

[D]

I definitely think educating the family was huge for us and making sure they have a family that will be. Especially an outpatient that will be engaged with, getting them to participate and invested in having them do it. Because an outpatient, you really have to rely on them and the family more than anything. So I think that. And also I think making it easy make it. I use something called the motor activity log. It is technically an assessment, but it gives me a lot of ideas for what I can tell the family to try to encourage them to do things like open the refrigerator door, open a drawer, wipe off the kitchen table, turn on the faucet. It just gives me ideas to tell the family. I would like you to encourage them to do X, Y, Z things at home and just have them try to do it with the left hand. Because part of the restraint is going to be at home if they're an outpatient or if they're. Even if they're an inpatient and they're with their family on the times where they're not in therapy, you have to give the family things for them to try to do or else the restraint does nothing. If they're just sitting there with. With the mid on and watching tv, it's not going to do what we want it to do. So you need to give them a list of ideas. So I use the motor activity log a lot for that and I'll go through the list and see what they can do and check off the things like, hey, try all these at home or with them in the room or whatever. So I think those are two of the big things, is getting the family involved more than anything because they spend more time with their family than they do with us as therapists.

[C]

And then three to six hours, ideally for every day of the week, or is it certain?

[D]

Every day of the week. But it doesn't, I try to emphasize, it doesn't have to be consecutive hours.

[C]

Okay.

[D]

Because if they only can tolerate one hour and then they get annoyed by it, no problem. Do one hour in the morning, take it off, they'll forget about it by the time noon comes around, put it back on, do another hour, it's okay. It doesn't have to be three consecutive hours. And I think that kind of probably one, decreases some of the stress from the family. Two, also limits the times of more heightened kind of agitation, especially if you're dealing with somebody who has cognitive impairments. You want to not get to the frustration point. So I think breaking it up is a really good strategy as well.

[C]

Yeah. So three to six hours doesn't have to be consecutive. Doing something actively with the arm, because that's the therapy part. How many weeks, ideally?

[D]

Ideally, the dosage from the literature says anywhere from two to four weeks. So I always aim high. If you're in outpatient therapy, you're there for a while. You could do four weeks. Yeah, yeah. So, but an inpatient, if you only have a two week stay, which a lot of these inpatient stays for stroke now are only about two weeks. But the good thing about CIMT is that it can travel with the person through all of the continuum of care. It could start an inpatient rehab if they go to a SNF after. I don't think they can do it in SNF though, because they can't use restraint. So we might have to skip snf. But it could do. They could do it in home and home health, they could do it in outpatient. It can travel across the continuum of care. So even if you just started it and you pass it on to the next person that will be working with that person, it's still beneficial to get it going.

[C]

Do pre testing because you want to know baseline.

[D]

Definitely. And baselines and follow. Yeah, yeah, definitely.

[C]

Recommendations or tips? Just try it. Honestly.

[D]

Because you just never know. You really don't.

[C]

Yeah. You could always ditch it if it's too.

[D]

You could always ditch it. You can Always ditch it. Just like anything else. I think you should give it. It's a great home program too. People are always trying to figure out what should they send their patients home for A home exercise program or we call them room activity program in our inpatient rehab. This is a great thing to send people to their room or to their house with. It's just doing everyday things with the hand that they're supposed to be using.

[C]

Yeah. And the mitt helps remember to not use your unaffected side and to really make yourself have to use the one that you're trying to rehab.

[D]

Exactly. Definitely the visual aid helps a lot because our brains are really smart. They're going to get the job done with what is easiest. So if you have an affected and an unaffected side, your brain is going to use the unaffected side because that's what's easiest for the brain.

[C]

And if you don't have one of those restraint mitts, you could just use

[D]

a big scheme mitt.

[C]

Yeah. Okay.

[D]

Anything can be. Yeah. A sock. People view socks before. It's a good.

[C]

Yeah. Something that's not going to hurt you too. Yeah. To don't duct tape your hand probably.

[D]

Yeah, nobody does that.

[A]

Great.

[C]

Thank you for experimenting and sharing all of that. I think this is going to motivate and inspire some people to try using it.

[D]

I hope so. And if they have any stories, I would love to hear them. But I do hope it inspires some people to just give it a try. You just never know what's going to happen. And if it again, if it's not good, just don't do it anymore and

[C]

write it up because we need more cases. Case examples. We don't have enough.

[D]

We do need to. I need to write mine up too. Now you know, you said that.

[C]

Thanks so much, Bri.

[D]

Thank you for having me.

[C]

Yes, thanks everyone. We'll talk to you next time.

[D]

Bye. Bye.

[B]

Thank you for joining the I Love Neuro podcast. If you want to connect with more like minded professionals, head to our website, www.neurocollaborative.com.

[A]

and don't forget to subscribe to the podcast so you don't miss any episodes.