Constraint-Induced Movement Therapy and its Application to Physical and Occupational Therapy

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Constraint-Induced Movement Therapy and its
Application to Physical and Occupational Therapy

• Nicole M. Boyko, PT/s

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Background Information

• 730,000 strokes/yr
• 50 patients have motor deficits
• 30-66 of patients are unable to use affected UE
  for ADLS following stroke

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What is Constraint-Induced Movement Therapy?

• A technique in which the patient uses
  concentrated, repeated practice of the affected
  extremity in order to facilitate movement
• Shaping a behavioral technique in which quality
  of movement is improved progressively in small
  steps
• Family of techniques includes
• Restraining of less affected UE in hand splint
  and/or sling while subsequently shaping the
  hemiplegic UE
• Wearing glove/mitt on less affected hand while
  shaping hemiplegic hand
• Shaping of hemiplegic UE or LE without restraint
  of unaffected side
• Intense PT of hemiplegic side 5 hrs/day x 10 week
  days without restraint of unaffected side (pts
  asked not to use unaffected side)

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Rationale

• Learned nonuse a conditioned suppression of
  mvmt that occurs when pt is initially
  unsuccessful at using affected extremity
  immediately post-injury and is reinforced by
  successful compensation with unaffected
  extremity.
• Shortened rehab LOS forces therapists to focus on
  teaching compensatory techniques in order to
  maximize fxn for safe return to home
• Areas of the cortex controlling movements of the
  affected limb shrink following stroke due to a
  combination of direct insult and learned nonuse
• Preliminary studies show that repeated forced use
  of impaired limb results in improved mvmt and
  enlargement of these areas.

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Current Research

• EXCITE (Extremity Constraint Induced Therapy
  Evaluation)
• 5 yr NIH supported trial
• Sites U of Alabama at Birmingham, Emory U,
  UNC/Wake Forest School of Medicine, UCLA, UFL at
  Gainesville, Ohio State
• Protocol less affected UE restrained in sling
  for 90 of waking hours x 2 wks training of most
  affected UE 6 hrs/day with 1 hr rest x 10
  weekdays
• Diagnoses for which CI is being researched CVA
  (UE and LE), SCI (LE only), hip fx/replacement,
  focal hand dystonia in musicians, cerebral palsy
  in children

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Availability of CIMT

• Taub training clinic opened at UAB in Aug 2001
• Provides 2-3 wks CIMT for UE primarily for
  patients post stroke
• Medicare does not cover
• Private pay 2 wks 6700, 3 wks 12, 700
• CI therapy research labs offer CIMT for strokes,
  SCI, hip Fx, CP and hand dystonia for free to
  qualifying pts at select locations

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Literature Review

• Subjects/Methods
• 61 y/o African-American female 4 mo s/p ischemic
  lacunar infarct of (L) post limb of internal
  capsule
• Fxnl status (I) ADLs, amb ? device, no voluntary
  use of (R) UE
• Received CIMT using mitt on (L) UE for 90 waking
  hrs x 14 days
• Practice performing ADLS with (R) UE in clinic 6
  hrs/day x 10 days with 1-2 hrs/day rest

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Literature Review

• Measures
• Taken before, after, 3 mo f/u
• Wolf Motor Function Test (14 timed, 2 strength)
• Motor Activity Log (30 ADLS)
• Results
• Improved on all items on WMFT
• Prior to Rx, using (R) UE for 1/30 tasks on MAL
• After Rx, using (R) UE 50 as much on 25/30
• Upon 3 mo f/u, using (R) UE for 30/30 tasks

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Literature Review

• Subjects/Methods
• 4 patients in CIMT grp, 5 in placebo group
• Inclusion criteria 20º wrist ext, 10º finger ext
• Exp grpCIMT with unaffected UE in resting hand
  splint for 90 of waking hrs x 14 days
• Sling also used during 6 hrs/day of Rx x 10 days
  in performing activities such as eating, throwing
  a ball, playing board games, writing, sweeping
• Placebo told they had greater capacity to use
  affected UE and instructed in passive ex

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Literature Review

• Measures WMFT, MAL, Arm Motor Ability Test
• Results
• Experimental grp showed significant increases on
  WMFT and AMAT while controls showed no change or
  a decline
• Experimental grp showed a very large significant
  increase in real-world affected extremity use as
  measured by MAL which persisted at 2 yr f/u.
  Controls showed no change or a decline.

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Literature Review

• Purpose to use CIMT as a model to assess
  therapy-induced plasticity in stroke patients
• Subjects/Methods
• 10 men and 3 women with chronic hemiplegia post
  stroke
• Inclusion criteria same as previous Taub study
• CIMT with unaffected UE in resting hand splint
  for 90 waking hrs x 12 days
• Sling also applied to unaffected UE in clinic for
  6 hrs/day of Rx for 8 days to increase quality of
  mvmt and use of affected UE

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Literature Review

• Measures MAL, transcranial magnetic stimulation
  mapping of motor output, motor threshold, and
  amplitude weighted center of activation sites
  (CoG)
• Results
• 1 day post Rx, 37.5 more activity in affected
  hemisphere was noted
• Increased cortical representation area in
  affected hemisphere
• Increase in ADLs persisting at 6 mo f/u

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Conclusions

• CIMT has been proven effective in subacute and
  chronic stroke for all but the 25 of pts with
  most severely impaired extremity fxn
• CIMT may reverse the learned nonuse behavior by
  making pts more willing to use the affected
  extremity in functional ADLs
• CIMT seems to result in cortical reorganization
  which represents the pts actual potential for
  recovery of fxn in the affected extremities

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Questions for Acute Care Practitioners to Ponder

• Can compensatory skills be taught without
  jeopardizing spontaneous recovery of the affected
  side?
• How can resources best be allotted to promote
  recovery of hemiplegic limbs?
• How can we best bridge the gap b/t therapeutic
  gains in the clinic and fxnl (I) in the real
  world?

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Questions?