Despite the fact that constraint induced therapy (CIT), a stroke-specific recovery option, was shown to be effective in Phase III clinical trials at the beginning of this decade, only a handful of clinics have a structured CIT program. Part of the reason there is a relatively small clinical footprint for CIT is that many clinicians are not clear about what CIT actually is. When asked if they do CIT, many therapists who work with stroke survivors will answer in the affirmative. When asked how they implement CIT, they may say something like "I do unilateral training" or, "I have them wear a sling and/or mitt during treatment." But this "soft" approach for CIT may be no more effective than drinking a shot of whiskey for a cough because alcohol is an ingredient in cough medicine. CIT involves many specific elements that are interdependent. Cutting or changing one element affects them all.

The best way to fully realize the potential of CIT is to have one or more therapists trained in CIT by researchers that have a proven track record of clinical efficacy. A good place to start would be the Taub clinic, University of Alabama, Birmingham. They have a five-day workshop called Constraint Induced (CI) Therapy Training Program for Health Professionals: Pediatric and Adult Applications. The next workshop will be held November 1-5, 2010. Any rehabilitation facility could continue a CIT program in perpetuity in the same way any novel therapeutic option perpetuates. Usually, one or more therapist is trained in the treatment option. That therapist then trains others. As therapists leave the facility to pursue other professional endeavors there is always a group of trained therapist to take their place.

Implementing Research

While it is important for clinicians to lean on the available research in order to be evidence-based, the opposite is true as well; research relies on clinicians to confirm clinical efficacy. We need therapists to take what's done in research and implement it in real-world clinical settings. Drug companies do this through Phase IV trialing. This is the level of trial in which the drug has received permission to be sold, but surveillance for safety and clinical efficacy continues.

Therapeutic options for stroke rehabilitation will benefit from the same level of clinical trialing. Look at it this way: while it is essential to learn from quality research done in multisite trials that are well controlled and have hundreds of participants, it is just as important to learn from the "real-world" trialing done among thousands of therapists with tens of thousands of stroke survivors. Clinicians may actually improve the existing structure for CIT. But in order to improve it, they have to understand it, implement it and then tweak it.

The right mix of elements that make up CIT, done at the right time, with the correct dosage and with adequate focus on the details has been shown to be clinically efficacious in clinical trials. The elements that make up CIT, from dosage to the proper type operant conditioning, are beyond the scope of this article. However, one aspect of CIT that is often lost on rehabilitation clinicians attempting to self-initiate a CIT program is worth a quick mention: paperwork.

Part of the essence of CIT is its ability to transfer what is done clinically into everyday life. Let's consider an unrelated example. Imagine that you have a patient with vertigo. In the clinic you tell him to steady himself once he's gone from lying down to sitting. You also tell him that, once he is sitting, to allow for a few seconds allow for vestibular, proprioceptive and visual orientation to an upright posture. You tell him not to attempt to stand until this orientation has taken place.

All this advice is good, and all of it is an attempt to keep the patient with balance problems safe. But since you only know what the patient is doing when he is in front of you, there's no way of telling if he's following your good advice elsewhere. CIT includes documents that are designed to make sure that there is transfer of what is learned clinically to the patient's everyday life. These questionnaires, contracts, charts and other paperwork are collectively called the "transfer package."

The paperwork that makes up the transfer package accomplishes many goals including:

·         Assuring compliance;

·         Helping pick relevant tasks to work on clinically and at home;

·         Informing the stroke survivor and caregivers about every aspect of the program;

·         Extending the amount of time in which the patient is focusing their practice on their affected side;

·         Promoting a self initiated "upward spiral of recovery" and designed to continue after the person has been discharged from the CIT program.

Allowing stroke survivors to drive their own nervous system toward recovery by using the survivor's own real-world involvement of the affected extremities is the best post-stroke rehabilitation available. Encouraging this requires extra paperwork at the beginning, but it can drive a higher level of recovery for the rest of their life.

Peter G. Levine is co-director of the Neuromotor Recovery and Rehabilitation Laboratory (rehablab.org) and the author of Stronger After Stroke (Demos Health, 2008). He also conducts seminars teaching research-based, neuroplasticity-producing stroke recovery strategies. E-mail him at StrongerAfterStroke@yahoo.com.