Neuro-Intervention Essentials, CIMT & Inpatient Rehab—Comprehensive Study Notes

Opening Prayer & Mindset

• Session began with a student-led prayer asking for:
  • Comfort from God and the capacity to comfort future clients.
  • Gratitude for opportunities to grow closer to God, classmates, and the OT field.
  • Guidance for instructors and classmates to focus on “today” and not worry about tomorrow.

Warm-up Mentimeter Activity

• Prompt: “According to your media, neuro-interventions should be four different things. What are they?”
• Correct answers (highlighted by Dr. Lane):
  • Highly repetitive.
  • Adequately challenging (the “just-right challenge”).
  • Motivating / salient to the client.
  • Goal-oriented.
• Common but incorrect Mentimeter entries:
  • Merely naming interventions (mirror therapy, video games) without mapping to the four criteria.
• Clinical nuance:
  • Salience varies by client (e.g., older adult vs. teenager and video games).
  • If task is too easy → no neuroplastic change; too hard → frustration & abandonment.

Telerehab Example from Assigned Media

• Scenario: Client & spouse prepare breakfast together via telehealth.
• Task elements creating repetition:
  • Reaching into cabinet for items (repeated shoulder flexion).
  • Cutting bananas (repeated wrist/elbow motions).
  • Bringing food to mouth (self-feeding reps).
• OT take-away: Functional repetition that is meaningful leads to greater neuro recovery than rote exercise putty (especially post-stroke).

Using Key Form Maps & Transition Zones

• Key form map visually plots ADL components as:
  • 2 = consistent mastery
  • 1 = emerging/inconsistent
  • 0 = absent skill
• Planning logic:
  • Emerging skills (mix of 1’s & few 2’s) → Short-term goals.
  • Largely absent skills (mostly 0’s, occasional 1) → Long-term goals.
• Benefits cited by students:
  • Concrete road-map, links assessment → goal → treatment.
  • Enables clear re-evaluation checkpoints.

Real-World Numbers & Logistics

• Kate (inpatient OT) spends ≈ 20 min daily on chart review: clock-in, email, lunch drop, quick scan of vitals/orders.
• Typical inpatient rehab caseload: 6–7 clients seen ≥ 1 hr per day each (vs. 15+ in acute care).

COPM in Inpatient Rehab?

• Consensus: No time for full COPM interview.
• Rationale:
  • Inpatient length of stay driven by ADL metrics for reimbursement.
  • OT time better spent in ADL-focused treatment; brief occupational profile suffices.
  • Cognitive / aphasia issues & limited family presence reduce COPM reliability.

“Higher-Level” Functional Activities in Rehab

• Examples Kate provided:
  • Ordering unprepared food from hospital kitchen and cooking a full meal.
  • Community re-entry task: going to hospital gift shop/store.
  • Using a simulated in-house grocery store (community partnership with Lowe’s Foods) featuring weighted replicas, ATM, checkout.
• Purpose: Address IADLs beyond basic dressing/bathing/toileting.

Assignment Clarifications (SimU-Case Group Project)

1. SimU-Case MVPT-4 Report
   • Each student submits individually; must score ≥ 90 % for group rubric credit.
2. Group Treatment Paper
   • One combined submission.
   • Bullet lists acceptable; no formal APA title page needed but APA citations required.
3. Distinction between Rubric Items
   • “List of evidence-based remediation/compensation treatments” = demonstrate breadth & literature support.
   • “Plan for next 1-hr session” = sequence chosen activities, justify order, link to safety & goals.
   • You may reuse treatments, but do not copy-paste; explain why each fits that single hour.
4. Scope
   • OK to address deficits found anywhere in OT eval and SimU observation; start with most documented evidence (SimU video).

Manual Muscle Testing (MMT) Documentation Caveat

• SimU evaluation listed scores by joint (e.g., “Elbow 3/5”) → clinically vague.
• Best practice: document specific motions (e.g., elbow flexion brachioradialis vs. biceps) because:
  • Guides nerve, antagonist/agonist reasoning.
  • Determines adaptive positioning (supinated vs. neutral).
• Example discrepancy: Client described with 3/5 but difficulty in shoulder flexion—still plausible if compensating with abduction/scaption.

Constraint-Induced Movement Therapy (CIMT)

• Origin: University of Alabama animal research → human protocol.
• Original protocol:
  • 6 hr/day task practice.
  • Unaffected UE restrained 90 % of waking hours.
  • 2-week program.
  • Not for < 1-month-post CVA (too intense).
• Modified/“mCIMT” common in rehab:
  • 3 hr/day structured practice.
  • Same 2-week duration; still wear mitt majority of day.
• Inclusion criteria often cited:
  • ≥ 25^{\circ} wrist extension.
  • ≥ 10^{\circ} MCP & IP extension.
• Mechanisms:
  • Drives neuroplasticity by forcing use of affected limb.
  • Prevents disuse atrophy.
  • Improves cortical representation; combats learned non-use.
• Safety & interdisciplinary considerations:
  • Restraint may compromise balance reactions → coordinate with PT.
  • Avoid hot liquids or cooking without supervision.
• Video case (Mary Free Bed Hospital):
  • Client Nana: wrote legibly after 2 wks; resumed ukulele strumming.
  • Wore mitt 90 % waking hours; 3-hr therapy blocks.

Tele-Lab: Simulated CIMT via Zoom

Materials list (per student handout):

• Oven mitt on dominant hand (constraint).
• Nondominant UE simulated impairment:
  • Buddy-tape ring & little fingers.
  • Tape thumb CMC in opposition.
  • Lightly wrap elbow in ~30^{\circ} flexion.
    Activities suggested (must be repetitive & salient):
• Flip playing cards.
• Stack checkers / blocks.
• Self-feed finger foods or use utensils.
• Group brainstorm other tasks (e.g., pill-bottle opening, phone dialing).
  Discussion prompts posted to LMS board:
• Role taken (therapist, patient, or both).
• Experience highlights—what worked, what was hard.
• Telehealth feasibility vs. in-person advantages.

Observations shared live:

• Patients instinctively try compensatory strategies (e.g., using mouth, body).
• Hardest task remotely: opening child-proof pill bottle (requires 2-hand force coupling).
• Therapist challenge via Zoom: ensuring client not compensating off-camera.
• Joint insight: co-performing activity with patient enhances instruction clarity.

Practical Teaching Nuggets

• “You never get a second chance to make a first impression”—arrive organized; client/family perceive competence immediately.
• Always have a Plan B: patients may be on bed rest or orders change last minute.
• Community partnerships (e.g., grocery‐store mock-ups) expand occupation-based treatment possibilities.

Numerical & Statistical References Recap

• 4 key neuro-intervention qualities: repetition, challenge, motivation, goals.
• 20\text{ min} daily chart review in rehab.
• CIMT original dosage 6\;\text{h day}^{-1} vs. modified 3\;\text{h day}^{-1}.
• Restraint wear target 90\% of waking hours for 2\,\text{weeks}.
• Typical inpatient OT caseload 6\text{–}7 clients/day at \ge1\,\text{h} each.
• Grading of emerging skills → short-term vs. long-term goals based on key-form map ratios (1’s vs. 0’s).

Ethical, Philosophical & Safety Implications

• CIMT animal-study controversies: ensure humane foundations & informed consent.
• Weigh client autonomy vs. therapeutic benefit when restricting unaffected limb.
• Telehealth risk management: verify environment (sharp objects, liquids) when client’s protective UE reactions are constrained.

Connections to Prior Coursework

• Neuroplasticity principles from Neuroscience course underpin CIMT effectiveness.
• “Just-right challenge” ties to Motor Learning & Activity Analysis courses.
• Key form maps leverage previous instruction on standardized assessments and goal-writing.

Take-Home Checklist for Exam & Clinicals

• Memorize the 4 pillars of effective neuro-interventions.
• Be able to justify why a task is adequately challenging & salient.
• Translate key-form map data → SMART goals.
• Know CIMT dosage variants, inclusion criteria, safety red flags.
• Differentiate settings: acute care vs. inpatient rehab vs. home health in terms of time, tools (e.g., COPM feasibility).
• Document MMT by specific motion & position, not generic joint score.