After a whirlwind two days the conference was almost over. This was the last session I would attend before the closing plenary and my mind was already buzzing with thoughts from other sessions I had seen. I wondered if I had made a mistake signing myself up to cover a session so close to the end of the conference. However, when Kathryn Jarvis sprung into life on stage I knew it was going to be an engaging and thought provoking session…
Implementing constraint induced movement therapy: a mixed methods study
Kathryn provided a simple outline of constraint induced movement therapy (CIMT);
A complex intervention to increase upper limb function, usually post stroke, made up of two components:
- Constraint of the less affected upper limb with a mitt or sling.
- Intense training of the affected limb.
She then relayed a story of a “bouncy” consultant who had heard about CIMT and with enthusiasm had asked – why aren’t we doing it? This question has stayed with Kathryn and prompted her to think critically about the evidence base for CIMT, and start her own research in to the area.
CIMT is not widely used in practice, and where it is practiced we are not using existing evidence based protocols. Kathryn’s mixed methods design used both quantitative outcome measures and qualitative interview to capture the impact of CIMT for four participants. For me, one of the most interesting aspects of Kathryn’s presentation of this research was her acknowledgement that where she expected to see the most gains in terms of performance (and there were improvements in performance for all four participants, some more marked than others), the biggest observable benefits of the CIMT protocols were in areas of volition and habituation. Kathryn thinks that “mixed methods ROCK” because had they not been using qualitative methods alongside the quantitative outcome measures, this aspect would not have been captured in the research.
What Kathryn’s research reveals is that evidence based protocols for CIMT are feasible for patients, with patient’s benefiting from a protocol that involves 3 hours training and 3 hours constraint. Feasibility in practice is not necessarily the same, the intensity of the training requires huge investment of time from staff and the trust where this research was carried out are still not implementing this protocol. Kathryn also highlighted that we still do not know what the active ingredients of CIMT are – we know the core components are training, constraint, routine, hope and the role of the therapist, but which elements are producing the outcomes? Complex interventions require a complex web of research.
Application of a conceptual framework to facilitate return to paid work following a brain injury
Karen Beaulieu has over thirty years experience as an occupational therapist working with patients who have had a brain injury. Both her own experience and the existing literature highlighted to her that returning to work is often a high priority for those who have experienced a brain injury, however a return to sustained paid employment is very difficult. Karen has conducted qualitative phenomenological research with 16 brain injury patients who have returned to work, and 11 employers who have been involved in this process, to explore how we as occupational therapists can begin to better facilitate this priority goal for our patients.
Karen acknowledged the short window of time she had to discuss this complex piece of research, and discussed her plans to take this research project forward. In the mean time, though she wants to be sharing the conceptual framework she has devised from her research and urges us to think about applying it. The four key themes of facilitating factors that came out of her research were occupational needs (including neglected areas such as drive and engagement), experiencing loss, grief and adjustment, looking at self identity (How are they different? What anchors them to their former selves?), and the importance of social inclusion and understanding in returning to work. These themes then lead to the conceptual framework below:
Karen urged all those who work with brain injury patients to be thinking about the elements outlined in the framework much earlier than usual, starting this process of managing expectations and addressing the grief from the beginning of a patient’s rehabilitation. I really look forward to seeing how this framework develops and hearing more of Karen’s findings in this area.
By Ayla Greenwood, @AylaOT