Modified Constraint-Induced Movement Therapy Evidence Based Approaches

1. Modified Constraint-Induced Movement Therapy Evidence Based Approaches S. Omar Ahmad, OTD, Ph.D.

2. Objectives Describe the basic epidemiology and incidence of stroke Describe the underlying theory of Learned Non-use and Cortical Reorganization Discuss the principles of CIMT and MCIMT Identify the appropriate population and program inclusion criteria Discuss the models strengths and weaknesses

3. Levels of Evidence: US Preventative Service Task Force Level I: Evidence obtained from at least one properly designed randomized control trial. Level II-1: Evidence obtained from well-designed controlled trials without randomization. Level II-2: Evidence obtained from well-designed cohort or case controlled analytic studies, preferably from more than one center or research group. Level II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled trials might also be regarded as this type of evidence. Level III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

4. Levels of Evidence: US Preventative Service Task Force, Recommendations Level A: Good scientific evidence suggests that the benefits of the clinical service substantially outweighs the potential risks. Clinicians should discuss the service with eligible patients. Level B: At least fair scientific evidence suggests that the benefits of the clinical service outweighs the potential risks. Clinicians should discuss the service with eligible patients. Level C: At least fair scientific evidence suggests that there are benefits provided by the clinical service, but the balance between benefits and risks are too close for making general recommendations. Clinicians need not offer it unless there are individual considerations. Level D: At least fair scientific evidence suggests that the risks of the clinical service outweighs potential benefits. Clinicians should not routinely offer the service to asymptomatic patients. Level I: Scientific evidence is lacking, of poor quality, or conflicting, such that the risk versus benefit balance cannot be assessed. Clinicians should help patients understand the uncertainty surrounding the clinical service.

5. Levels of evidence: National Health Service Level A: consistent randomized control trials, cohort, All or None, Clinical Decision Rule validated in different populations. Level B: consistent Retrospective Cohort, Exploratory Cohort, Ecological Study, Outcomes Research, Case-Control Study; or extrapolations from level A studies. Level C: Case-series Study or extrapolations from level B studies Level D: Expert opinion without explicit critical appraisal, or based on physiology, bench research or first principles

6. Neural Plasticity? Changes in nervous system induced by lived experience Functional, anatomical, cellular, molecular, & genetic changes in neurons induced by environmental demands Also changes in: Glial metabolism Neurotransmitter & receptor activity Dynamic patterns of activity!

7. Plasticity to Improve Performance Spontaneous recovery Rehabilitation techniques Conventional rehabilitation Constraint-induced movement therapy Cognitive training Plastic changes are optimized when training involves skill learning & trial repetition not unskilled (e.g., easy) motor behaviors!

8. Key Considerations Initial changes are temporary Practice makes changes permanent Repeated exposure even to small events can induce change The most substantial changes occur when the brain is engaged (attention) Motivation increases the efficiency of inducing change

9. and Cautions Positive changes support performance Active training needed to induce desired changes Massed practice needed to focus the changes Some evidence that plastic changes in one system may occur at expense of other systems Maladaptive plasticity also occurs Non-directed changes may limit performance Non-directed changes may yield additional changes Undesired changes may persist after trigger ends

10. Neuroplasticity& Cortical Maps

11. Cortical Re-mapping

12. Central Loss

13. Central Loss Ipsilateral effects ~ Decreased dendritic branching ~ Decreased spine density ~ Increased dendritic branching ~ Neuronal sprouting ~ Synaptogenesis ~ GABAa receptor downregulation ~ NMDA receptor enhancement ~ Facilitation of LTP ~ Neuronal hyperexcitability ~ Alteration of cortical maps Contralateral effects ~ Increased cortical thickness ~ Dendritic growth (short term) ~ Dendritic pruning (longer term) ~ Increased spine density (longer term) ~ Synpatogenesis (longer term) ~ GABAa receptor downregulation ~ NMDA receptor enhancement ~ Neuronal hyperexcitability

14. Plasticity & Comfort Zone Skiing in ruts vs. fresh powder Willingness to leave comfort zone enhances brain function Learning & exploration mode when young Adults tend to rely on acquired or polished skills

15. Optimal Training! Cardiovascular activity is essential Training must be active, not passive Training must begin just within reach of existing skills Training must then be incrementally and proportionally increased as skill level increases Training should be interesting & varied! (motivation & attention are key factors)

16. Epidemiology and Incidence Stroke Affects 730 000 persons per year in US Stroke is the 3rd leading cause of death About 60% to 80% survive Over 65 y.o. > under 65 y.o. African Americans > European Americans

17. Epidemiology and Incidence Stroke Leading cause of disability in adults in the United States Stroke survivors represent the largest group admitted to inpatient rehabilitation hospitals (34% of first admissions) Cost estimate is from $13 to $30 Billion

18. Epidemiology and Incidence Childhood Hemiplegia/Hemiparesis Stroke One in 4000 full-term infants �� 1.5 to 5.1 per 100,000 children per year Cerebral Palsy Two children out of every thousand born in this country have some type of cerebral palsy At least 5000 infants and toddlers and 1,200 - 1,500 preschoolers are diagnosed with cerebral palsy each year. www.CHASA.org www.kidshavestrokes.org www.NINDS.org

19. What is the problem? Many stroke survivors are left with significant deficits. Upper-limb hemipareparesis after stroke is one of the most prevalent diagnoses treated by therapists Deficits produce long-term need for assistance from caregivers and society

20. History Relatively new approach (late 70�s to early 80�s) Steven Wolf, MD began studies of �Forced Use� Therapy at Emory University Edward Taub, MD initiated research with non-human primates at the University of Alabama-Birmingham Both scientists as well as many others continue to develop this approach

21. Learned Non-use Substantial neurological injury leads to depression in motor and/or perceptual function Animal attempts to use the deafferented limb Continued attempts to use deafferented limb produces failure, pain, incoordination, falling, etc., Animal begins to function adequately with 3 limbs, reinforcing 3 limb function

22. Learned Non-use Nonuse response tendency persists, preventing monkeys from learning that after several months, the limb is potentially usable Conclusion: the animals never learned they could eventually use the limb (Learned Non-use or Learned Helplessness)

23. Learned Non-use in Humans When a person's brain is damaged by a stroke, it often becomes more difficult to move an arm. The person therefore tends to use the arm less. This leads to shrinkage of the regions of the brain that control arm movement Movement of the arm gets even more difficult.

24. Processes of Learned Non-use Decrease in size of cortical representation of limb Punishment of use of affected arm Reinforcement of use of intact arm The three processes interact to produce a cycle during which the person uses the arm less and less It is potentially reversible and can be overcome by the application of an appropriate intervention

25. Childhood VS Adult Response to CNS damage Children with early CNS damage (prenatal, perinatal, and early postnatal) differ from adults with a sudden CNS lesion. Underlying neural framework for movement with complex cortical pathways has not yet developed. Results in atypical movement patterns, which include ignoring or disregarding one body part(s). Unlike the adult who once had normal movement patterns then loses them, the child never acquired typical movement. Deluca, Echols, and Ramey, 2007

26. Constraint-Induced Therapy Also referred to as: CIMT CIT CI Therapy Forced non-use

27. Developmental Disregard Children with CNS damage use compensatory or idiosyncratic methods to accomplish desired goals. Difference between the two sides becomes more noticeable with age and functional use. Deluca, Echols, and Ramey, 2007

28. Developmental Disregard Lack of development on one side leads to increased attention (regard) to body parts that function with greater ease and yield positive outcomes. Deluca, Echols, and Ramey, 2007 Pays less and less attention to body parts that are not functioning well Lack of feedback at the sensory and motor levels for those body parts that are seldom or never used.

29. Rationale for CIMT Learning produces changes in the effectiveness of neural connections Learning can lead to structural alterations in the brain Every day events can strengthen or weaken synaptic connections (stimulation, deprivation, and learning).

30. Experience Alters Somatosensory Maps in the Cortex

31. Experience Alters Somatosensory Maps in the Cortex

32. The Process Constraining movements of the less-affected arm by placing it in a protective safety mitt 90% of waking hours Approximately 2 weeks Intensively training the correct use of the more-affected arm Shaping therapy for motor learning is provided in a supervised therapeutic setting for 6 hours per day Several hours of forced-use in daily living skills outside of the rehab setting

33. Process

34. Difference from Conventional Therapy CIMT induces concentrated, repetitive practice of more-affected limb Duration Intensity CI therapy helps a patient relearn everything from brushing their teeth to salting their food again.

35. Inclusion Criteria ADULT Some hand function Able to walk for relatively short distances without an assistive device High level of motivation and commitment Sufficient endurance, Adequate cognition PEDIATRIC Asymmetric abilities between two arms No movements requirements prior to implementation of treatment

36. Contraindications ADULT The patient must not have chronic pain that would be exacerbated by the intensity of the program The patient should not have medical complications that would prevent compliance with the length of the program PEDIATRIC Severe limitations of bilateral UE Acute or chronic serious illness Seizure disorder that disrupts daily participation Severe MR, Autism, or sensory impairment Severe behavior problem Infant younger than 8 months

37. Constraint Splint Mitt Sling Cast

38. Techniques Hand over hand Fading Modeling

39. Why It Works The treatment is thought to work because it overcomes a strong tendency not to use the weaker arm (learned non-use) that develops early after stroke. CIMT produces a large "rewiring" of the brain; that is, after treatment, more of the brain works to move the weaker arm than before therapy.

40. Cortical Reorganization After CIMT, area surrounding the infarct (usually not used for hand control) get recruited These are synapses in the brain that are previously not used for a particular function, but have the potential for activation after the usually dominant system has failed. Such neurons get utilized and, by repetition and practice, can be set into constant use

41. Mechanism of Action Changing learning contingencies Reinforces use learning Blocking nonuse learning Sustained, repeated practice of functional arm movements induces expansion of contralateral cortical area controlling movement Taub attributes only 20 percent of the improvement to constraining the good arm, and 80 percent to the intensity of practice

42. Other Uses for CI Therapy Upper limb of chronic and sub acute CVA Upper limb of chronic TBI Lower limb of CVA patients The arm in young children with cerebral palsy Combined with Botox Concentrated use of a residual limb as a treatment for phantom limb pain

43. Page et al (2002) Survey  Sample: 208 stroke survivors & 85 therapists 68 % of patients said they were not interested in participating in CIT 2/3 of patients who said they would participate in CIT program said they were somewhat or extremely unlikely to adhere to the CIT protocol 80% of patients said they would participate if protocol is modified

44. Page et al (2002) Survey (cont.) 60% of therapists said that patients were extremely unlikely to adhere to such protocol Majority of therapists felt that many facilities did not have the resources needed to execute such protocol Conclusion: effective, but limited. Although it has been shown to be effective in laboratory research, CIT may have low clinical practicality in some environments.

45. Regional Trends in Rehab Natarajan, P., Oelschlager, A., Agah, A., Pohl, P., Ahmad, S., Liu, W. (2008). Current clinical practice in stroke rehabilitation: A regional survey. Journal of Rehabilitation Research and Development Out of the 106 clinicians who specified whether they treat adults or children, 75.5% worked exclusively with adults, 3.8% worked with children and the remaining 20.7% worked with both adults and children Only 12 respondents report being trained in CIMT and 25 clinicians report using this efficacious method for treatment

46. Current clinical practice in stroke rehabilitation: A regional survey.

47. Current clinical practice in stroke rehabilitation: A regional survey.

48. Strengths Better use of the previously not used involved extremity in real life, functional situations: Quality of movement Quantity of movement Speed of movement Supported by evidence based practice.

49. Limitations Motivation Adherence Reimbursement Safety Generalizability to some environments?

50. Possible Solution Modifying the protocol. It is not so much the nature of the techniques that require revision but rather the intensity with which they are delivered.

51. References Azab, M., Al-Jarrah, M, Nazzal, M., Maayah, M., Sammour, M, & Jamous, M. (2009) Effectivemness of constraint induced movement therapy as home-based therapy on the Barthel-index in patients with chronic stroke. Topics in Stroke Rehabilitation 16(3):207-211 Brady, K., Garcia, T. (2009). Constraint induced movement therapy: Pediatric applications. Developmental Disabilities Research Reviews 15:102-111 Desmurget, M., Jordan, M., Prablanc, C., Jeannerod, M. (1997). Constrained and unconstrained movements involve different control strategies. Journal Neurophysiolgy, 77: 1644-1650 Dombovy, M. (2004). Understanding stroke recovery and rehabilitation: current and emerging approaches. Current Neurology and Neuroscience Reports, 4: 31-35 Dromerick, A., Edwards, D., & Hahn, M. (2000). Does the application of constraint-induced movement therapy during acute rehabilitation reduce arm impairment after ischemic stroke? Stroke, 31:2984-2988 Geno, K., Nicolai, N., Earley, D., Herlache, E. (2009). Improving participation in CIMT. OT Practice, 14(11)9-12.

52. References Levy, C., Nichols, D., Schmalbrock, P., Keller, P., Chakeres, D. (2001). Functional MRI evidence of cortical reorganization in upper-limb stroke hemiplegia treated with constraint induced movement therapy. American Journal of Physical Medicine and Rehabilitation, 80: 8-12 Liepert, J. Uhde, I., Graf, S., Leidner, O., Weiller, C. (2001). Motor cortex plasticity during forced-sue therapy in stroke patients: a preliminary study. Journal of neurology, 248: 315-321 Page, S., Elovic, E., Levine, P., Sisto. S (2003). Modified constraint induced therapy and botulinum toxin A: a promising combination. American Journal of Physical Medicine & Rehabilitation, 82: 76-80

53. References Page, S., Levine, P., Sisto, S., Bond, Q., Johnston, M., (2002). Stroke patients' and therapists' opinions of constraint-induced movement therapy. Clinical Rehabilitation, 16 :55-60. Page, S., Sisto, S., Levine, P. & Johnston, M. (2001). Modified constraint induced therapy: a randomized feasibility and efficacy study. Journal of Rehabilitation Research and Development, 38: 583-590 Sun, S., Hsu, C., Sun, H., Hwang, C., Yang, C., & Wang, J. (2009). Combined Botulinium Toxin type A with modified constraint induced therapy for chronic stroke patients with upper extremity spasticity: A randomized control study. Nurorehabil Nural Repair, online. Taub, E., Uswatte, G., (2003). Constraint induced movement therapy: bridging grom the primate laboratory to the stroke rehabilitation laboratory. Journal of Rehabilitation Medicine, 41: 34-40 Wu, C., Chem, C., Tang, S., Lin, K., &Huang, C. (2007). Kinematic and clinical analyses of upper-extremity movements after constraint-induced movement therapy in patients with stroke: A randomized clinical controlled trial. Arch Phys Med Rehabil, vol 88: 964-970 Xerri, C., Coq, J., Merzenich, M., Jenkins, W. (1996). Experience-induced plasticity of cutaneous maps in the primary somatosensory cortex of adult monkeys and rats. J Physiol Paris, 90:277-87.