Fictional Case Study using Constraint Induced Therapy and Visual Scanning in R MCA stroke with L hemineglect

Contributors:

Alexandra Manea, Sarah McGall, Kathryn McGuire

Abstract:

The purpose of the case is to present the effects of constraint induced therapy (CIT) in combination with visual scanning training in a 65 year old female who presented with profound visual and spatial neglect and motor and sensory deficits in the upper limb following a right (R) middle cerebral artery (MCA) stroke. This patient was referred to an inpatient rehabilitation unit 2 weeks post stroke and presented with left (L) sided neglect, hemiparesis of the L upper extremity, difficulty ambulating, impulsiveness, and mild sensory deficits.  Following a 6-week intensive task-oriented rehab program involving the above-mentioned interventions, the patient was able to return home independently, and experienced significant improvements in functional mobility, upper arm motor control and strength, and ability to implement appropriate strategies to manage her neglect.

Introduction:

The following case presents an individual with profound L visual and spatial neglect and L side motor and sensory deficits in the upper limb following stroke. The purpose of this case study is to create an effective task-oriented rehabilitation program utilizing a combination of constraint induced therapy (CIT) and visuospatial training methods to encourage optimal rehabilitation and return to independence. Individuals with spatial neglect following stroke present greater challenges in regaining motor function of the paretic limbs[1], leading to impaired motor and functional recovery, increased risk for falls, increased hospitalizations, and a lower likelihood of home discharge and community reintegration[2].

There are several methods used to treat spatial neglect such as prism training, mirror therapy, and neck muscle vibration, but a 2015 review revealed visual scanning training (VST) had the most positive impact on occupational performance[3]. Furthermore, VST has been found to improve grip strength of the paretic limb vs. controls[4]. Despite these positive findings, it is important to note that major stroke treatment guidelines conflict somewhat on the use of VST in cases of neglect. The 2015 Canadian Stroke Best Practice Guidelines (CSBPG) says that visual scanning techniques can be used in patients with neglect, although the existing evidence is not considered high quality (Evidence Level C)[5].  The Evidence-Based Stroke Rehab Clinician’s Handbook (EBSR) states that there is strong evidence for visual scanning, however the two RCTs they cite are rather dated[6]. Finally, Stroke Engine states that there is conflicting evidence on visual scanning techniques for use in the treatment of neglect[7].

As far as CIT, it is considered effective in promoting the use of the paretic limb and regaining motor function[8]. Stroke Engine recommends CIT in the hemiparetic upper limb[9], and states that there is not enough evidence on the use of CIT in neglect patients to comment either way on its effectiveness[7]. For our patient specifically, the Viatherapy App for upper extremity stroke rehabilitation recommends Modified CIT with at least 2 hours per day of intensive practice and at least 5 hours per day of unaffected limb constraint[10], although it does not take cognitive deficits into account. Both the CSPBG and the EBSR recommend the use of CIT for rehabilitation of the affected upper limb (Evidence Level A), provided the patient demonstrates at least 20 degrees of active wrist flexion and 10 degrees of active finger extension and has minimal sensory or cognitive deficits[5][11]. It should be noted that our patient does have the recommended active range of motion, however she also has marked sensory and cognitive deficits due to the hemineglect. As such, using CIT in this patient is somewhat experimental, and could potentially direct future research into its use depending on the outcomes.

Our aim with this case study is to harness the known benefits of CIT for upper extremity recovery and to examine the potential for its use in patients with a combination of upper extremity hemiparesis and hemineglect. We will also explore how CIT in combination with VST helps to improve the rehabilitation outcomes for this patient.  With this approach, we hope to maximize overall functional recovery, decrease the risk of falls, and improve the patient’s chances of returning home independently and being able to fully participate in her usual ADLs and IADLs.

Client Characteristics:

Wendy is a 65 year old retired primary school teacher who suffered a R sided MCA stroke 2 weeks ago. She was referred to an inpatient stroke rehabilitation unit at the hospital. Wendy presents with L sided neglect, L hemiparesis of the upper extremity, difficulty ambulating, impulsiveness, and L sensory deficits. She has hypertension and Gastroesophageal Reflux Disease (GERD), and is overweight. Wendy’s husband passed away 2 years ago and she lives on her own in a bungalow. She has no children.

Examination Findings:

Subjective:

In the subjective interview, Wendy reports that she has been experiencing weakness and decreased sensation in the L arm. She is oriented x 3, and understands that she experienced a major stroke recently. Prior to her admission, she had been very active (gardening, walking) and participated in many social activities such as weekly book club meetings and bingo at the community centre. She wants to return home and get back into her daily routine. She is apprehensive about standing and walking without falling and fears she will never regain her independence.

Objective:

As this case study is focused on treatment of the upper extremity as well as the patient’s hemineglect, the details listed below include observation of functional mobility such as transfers and gait with a focus on deficits associated with neglect, outcome measures such as the Chedoke-McMaster Stroke Assessment (CMSA), Berg Balance Scale (BBS), Functional Independence Measure (FIM), Behavioral Inattention Test-Conventional (BIT-C), and a more focused examination of the affected upper limb.  All details listed below were gathered in the first week of the patient’s stay.

The patient’s scores were 67/126 on the FIM, 24/42 on the CMSA Impairment Inventory (of note, Arm and Hand were both Stage 3), 44/105 on CMSA Activity Inventory, 26/56 on the BBS and 110/146 on the BIT-C.  PROM was within normal limits (WNL) in both upper extremities, while AROM on the L (affected) side was decreased in all directions. Upon quick passive movement through range, the patient exhibited a 'catch-and-release' followed by mild resistance with both elbow flexion and extension, indicating the presence of mild spasticity. Manual Muscle Testing using Kendall's modified scale revealed scores of 2+ at the shoulder, 2+ at the elbow and wrist, and 2- at the fingers. Sensation testing revealed decreased sensation and proprioception in the L upper extremity, with the greatest deficits distal to the elbow. The patient also exhibited marked tactile extinction on the L, correctly identifying “both” 0/5 times during simultaneous stimulation of L and R sides.

As far as transfers and gait, the patient was independent with bed mobility, but required occasional cueing to ensure safe positioning of the affected extremities. She required only supervision and cueing with supine <-> sit, and minimum assistance with sit <->stand and bed<-> wheelchair transfers when leading with her unaffected side, but did demonstrate impulsivity, lack of awareness of safe positioning of her L side, and inattention to details such as the brakes on the wheelchair and her seatbelt.  If leading with her affected side, patient required minimum to moderate assist with all transfers.

Patient ambulated ~15m with 2-wheeled walker (2ww) and min assist X 2 initially. Patient was able to grasp 2ww with assistance/cueing on L, and was able to maintain grasp independently during ambulation.  She utilized a mild circumduction strategy with her L lower extremity due to decreased knee flexion and ankle dorsiflexion, and due to external rotation of her L LE and the inattention to positioning she repeatedly caught it on the side of the 2ww. Patient’s trunk remained rotated to the R throughout ambulation, and she did not notice objects or people on her L while ambulating.  When given control of the 2ww, patient gradually steered to the L and would likely collide with the wall or other objects if PT and PTA had allowed her to.

Clinical Impression:

Physiotherapy Diagnosis:

Patient presents with L-side hemiparesis, with her scores on the CMSA indicating that the upper extremity is more affected than the lower extremity.  Patient exhibits decreased sensation and proprioception in L upper extremity, and tactile extinction during simultaneous stimulation of L and R sides. Overall, patient demonstrates marked L sided neglect, which is confirmed by her score on the BIT-C. She also exhibits minimal spontaneous movement of L upper or lower extremities, lack of awareness of body position/objects/obstacles on L, and gaze deviation to the R. Patient’s independence and functional mobility are significantly affected by the above deficits, and patient’s score on the BBS indicate she is at high risk of falls. Patient is currently unable to participate in her usual social roles, as she requires supervision/assistance with transfers, gait, and most ADLs.

Problem list:

  • Visual and spatial neglect of the L side of her body
  • Weakness and spasticity in L upper extremity
  • Weakness in L lower extremity
  • Decreased spontaneous use of the L upper and lower extremities due to hemineglect
  • Tactile extinction due to hemineglect
  • Impaired balance due to neglect/hemiparesis
  • Unable to transfer/ambulate independently due to neglect/hemiparesis
  • Kinesiophobia due to balance and gait deficits
  • Increased risk of injury and falls due to weakness, neglect, and impulsiveness

Intervention:

Short term goals:

  • Perform a reaching task with the L arm with minimal assistance/cueing within one week
  • Perform a sit to stand with supervision within one week
  • Independently position L upper and lower extremities appropriately during transfers with minimal cueing within one week
  • Demonstrate appropriate use of visual scanning strategies during ambulation within 2 weeks
  • Ambulate 50m with supervision using 2ww within 3 weeks
  • Improve BBS score by a minimum of 7 points within 3 weeks (MCID)
  • Improve CMSA activity and impairment scores by 7 points within 3 weeks (MCID)
  • Improve BIT-C score by 8 points within 3 weeks (unknown MCID, although scores <129 indicate the presence of spatial neglect)

Long term goals:

  • Independent with visual scanning strategies within 6 weeks
  • Independent with all transfers within 6 weeks
  • Independent with ambulation with a quad cane within 6 weeks
  • Able to return to reading, participate in book club meetings following discharge
  • Able to return to cooking her own meals following discharge

Management program:

The following is a 6 week rehab intervention created for Wendy, with a focus on improving motor activation and control of the affected upper extremity and targeting the hemineglect.  PT sessions will be focused on task-oriented activities with approximately half an hour per session devoted to the upper extremity 5 days per week, which has been demonstrated to improve hand function and activities of daily living in as little as 4 weeks[12]. The other half hour will be devoted to functional mobility including balance, gait and transfers.  We will incorporate CIT and Visual Scanning strategies in all activities in order to maximize the effects of the rehabilitation sessions.

  • Task-oriented Activities:
    • Upper extremity interventions:
      • Bingo-based reaching tasks in both standing and sitting.
      • Gardening-like activities to simulate digging with tools, transferring items from one pot to another, and watering plants using a hose or watering can.
      • Gripping and weight-bearing activities with affected arm during gait and balance training.
      • OT will also work on cooking and eating tasks and other functional activities as part of their sessions.
    • Functional mobility:
      • Transfers: practice conducted throughout day with OT/PT, nursing staff, and PSWs. The goal will be to progress to no cueing from the supervising staff member, and eventually to independence with all transfers.
      • Ambulation/Gait: Patient will ambulate 2 times per day with 2ww and assistance. The goal will be to progress ambulation as appropriate towards independence, increased distance, and a more mobile gait aid.
      • Balance: Balance training will be incorporated into the above task-oriented activities.
  • Constraint Induced Therapy:
    • Patient will engage in 2 hours per day of intensive practice with the affected arm plus an additional 3 hours per day with the unaffected limb constrained for a total of 5 hours per day of CIT, in accordance with the recommended parameters from the ViaTherapy App, as discussed above.
    • Both OT and PT will incorporate CIT into their sessions, and patient will be given tasks to complete on her own as well in order to fulfill the required number of hours per day.
  • Visual Scanning:
    • Integrated throughout PT and OT sessions. PT will initially repeatedly cue patient to scan to the L and to consciously direct her attention to that side. The goal is for the patient to begin to automatically incorporate these strategies as she goes about the various rehabilitation tasks, and PT will minimize the amount of feedback as the patient progresses in her ability to employ these strategies effectively.
    • Once patient has some comfort with visual scanning during ambulation in a stable environment, PT will progress visual scanning practice by randomizing the environment to the L of patient with inclusion of different obstacles and/or people that patient must notice and navigate around.

Outcome:

Following a 6-week stay on the intensive stroke rehab unit, the patient exhibited marked improvement on a number of outcomes. Again, as this case study is focused on treatment of the upper extremity as well as the patient’s hemineglect, the improvements listed below include those to do with functional mobility such as transfers and gait with a focus on features associated with neglect, outcome measures such as the CMSA, BBS, FIM, and BIT-C, and specific improvements associated with the affected upper limb.

Relevant outcome measures were assessed in the final week of the patient’s stay on the rehab unit.  The patient’s FIM score was 84/126 (up from 67/126 at admission), the CMSA Impairment Inventory was 32/42 (up from 24/42, and of note, Arm was up to Stage 5 while Hand was up to Stage 4), the CMSA Activity Inventory was 55/105 (up from 44/105), the BBS was 34/56 (up from 26/56), and the BIT-C was 119/146 (up from 110/146). PROM remained WNL bilaterally, while AROM on the L improved in most directions.  Most notably, shoulder flexion improved to 110 degrees (from 70), and wrist extension improved to 30 degrees (from 20). Spasticity was still present on quick stretch of the elbow flexors and extensors, however there was less resistance to movement following the 'catch-and-release', indicating that spasticity was decreased compared to initial examination. MMT of L upper extremity showed significant improvements as well, with scores of 4 at the shoulder and elbow, and 3-3+ at the wrist and hand. Sensation testing revealed that patient was no longer reporting decreased sensation on the L, and that her proprioception in the L upper extremity had improved although still showed deficits.  Patient continued to exhibit tactile extinction on the L, reporting “both”only 2/5 times with simultaneous stimulation of L and R.

The patient’s functional mobility has also shown significant improvement over the course of the her stay. Patient is independent with all transfers at this time, demonstrating appropriate use of visual scanning strategies, safe positioning of her L extremities, and proper sequencing with brakes and seatbelt on the wheelchair. It is not recommended at this time that she engage in transfers leading with the affected side due to the continued evidence of neglect. Patient ambulates ~50m independently with 2ww, and demonstrates appropriate visual scanning strategies to maintain position in centre of ward hallway, and to avoid people/obstacles on her L. She maintains her trunk and head in a neutral position during ambulation, grasps the 2ww with both hands, and maintains control of 2ww throughout ambulation independently.

Discussion:

This case study presented an individual with R MCA stroke that resulted in L side hemiparesis of the upper extremity and L sided neglect. In an effort to address the L side motor impairments and the challenges of neglect, we employed a 6 week intervention that involved CIT and VST. CIT focused on constraining the unaffected limb for the duration of 5 hours per day with task-oriented activities such as bingo, gripping, and reaching activities performed during PT sessions for a minimum of 1 hour of the proposed 2 hours of daily intensive practice. VST involved the therapist directing the patient’s attention to their L as they participated in task-oriented activities such as bingo, ambulation, and transfers. The two therapies complement each other well in a a patient with both upper limb hemiparesis and visual and spatial neglect, as CIT encourages the patient to use the affected limb to complete a task and VST is an important technique for the patient to master in order to compensate for the reduced automaticity of attention to the neglected side.

Following the 6-week rehabilitation program, we noted improvements in several outcomes including visual and spatial attention, sensation, balance, ambulation, and transfers. The patient continues to exhibit tactile extinction, and her scores on the BIT-C at discharge indicate she iss still experiencing neglect; however, she was able to participate safely in the functional activities necessary for independent living due to the visual scanning techniques that were employed. Currently, there is a lack of research into therapeutic programs that combine the effects of CIT and VST, although past systematic reviews have alluded to the potential benefits of combining these interventions[13]. Based on the outcomes of this case study, larger-scale research into the combined use of CIT and VST when working with patients experiencing both hemiparesis and hemineglect should be considered.

Self-study questions:

1) Which of the following are treatment options for hemispatial neglect?

  1. Prism training
  2. Neck vibration training
  3. Visual scanning
  4. All of the above

2) Which outcome measures were included in Wendy’s case?

  1. CMSA
  2. Grip strength
  3. Alpha-FIM
  4. 6min walk test

3) What was the key intervention used in this Case Study

  1. Visual scanning combined with neck-vibration therapy
  2. Constraint induced therapy combine with prism training
  3. Constraint induced therapy combine with visual scanning
  4. Functional activity rehabilitation combine with neck vibration therapy

References:

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  2. Chen P, Hreha K, Kong Y, Barrett A. Impact of Spatial Neglect on Stroke Rehabilitation: Evidence From the Setting of an Inpatient Rehabilitation Facility. Archives of Physical Medicine and Rehabilitation. 2015;96(8):1458-1466. [2]
  3. Gillen G, Nilsen D, Attridge J, Banakos E, Morgan M, Winterbottom L et al. Effectiveness of Interventions to Improve Occupational Performance of People With Cognitive Impairments After Stroke: An Evidence-Based Review. American Journal of Occupational Therapy. 2014;69(1):6901180040p1. [3]
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  9. Canadian Partnership for Stroke Recovery. Constraint-induced movement therapy: Upper extremity. Available from [9] (Accessed 07/05/2019)
  10. Toronto Rehabilitation Institute, University Health Network. ViaTherapy: Best practice and evidence-based recovery interventions for upper extremity stroke rehabilitation. 2018. Available from [10] (Accessed 07/05/2019)
  11. Teasell R, Hussein N. Rehab of hemiplegic upper extremity post stroke. In: Stroke Rehabilitation Clinician Handbook. London, Ontario: Canadian Stroke Network, 2016.  Available from [11] (Accessed 07/07/2019)
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  13. Vahlberg B, Hellström K. Treatment and assessment of neglect after stroke – from a physiotherapy perspective: A systematic review. Advances in Physiotherapy. 2008;10(4):178-187.[13]