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

1. Constraint-Induced Movement Therapy and its Application to Physical and Occupational Therapy Nicole M. Boyko, PT/s

2. 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

3. 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)

4. 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.

5. 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

6. 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

7. 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 Blanton and Wolf (1999)

8. 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 Blanton and Wolf (1999)

9. Literature Review • Subjects/Methods • 4 patients in CIMT grp, 5 in placebo group • Inclusion criteria: 20º wrist ext, 10º finger ext • Exp grp:CIMT 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 Taub et al (1999)

10. 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. Taub et al. (1999)

11. 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 Liepert et al. (2000)

12. 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 Liepert et al. (2000)

13. 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

14. 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?

15. Questions?