Implementation and sustainability of upper limb constraint-induced movement therapy programs for adults with neurological conditions : an international qualitative study

Purpose
Constraint-induced movement therapy (CIMT) is an effective intervention for arm recovery following acquired brain injury; however, there is an evidence-practice gap between research and CIMT use in practice. The aim of this study was to identify individual, organisational and social factors enabling implementation and sustained delivery of CIMT programs internationally.

Design/methodology/approach
Descriptive qualitative design. Purposive sampling was used to recruit occupational therapists and physiotherapists with previous experience delivering CIMT. Semi- structured interviews were conducted, using an interview schedule informed by the Theoretical Domains Framework (TDF) to explore individual factors (such as knowledge, skills and beliefs), organisational factors (such as organisational culture and resources) and social factors (such as leadership) influencing CIMT implementation. Interviews were audio-recorded, transcribed and managed using NVivo. The TDF guided data analysis and identification of key influences on CIMT implementation and sustainability.

Findings
Eleven participants (n = 7 [63.6%] occupational therapists and n = 4 [36.4%] physiotherapists) were interviewed from six countries, working across public (n = 6, 54.6%) and private health (n = 5, 45.5%). Six key domains influenced CIMT implementation and sustainability. Clinicians needed knowledge and opportunities to apply their skills, and confidence in their ability to implement CIMT. Within their workplace, supportive social influences (including broader team support), the environmental context (including organisational culture and resources) and reinforcement from seeing positive outcomes contributed to implementation and sustainability. Other important influences included community demand and tailoring of programs to meet individual needs.

Originality/value
This is the first study to examine therapists' experiences of CIMT implementation and sustainability across multiple countries. Factors related to capacity building, social and organisational support and resources enabled CIMT program implementation and ongoing sustainability. These findings can be used to design behaviour change interventions to support CIMT use in practice.

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