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

2. Background Information n 730,000 strokes/yr n 50% patients have motor deficits n 30-66% of patients are unable to use affected UE for ADLS following stroke

3. What is Constraint-Induced Movement Therapy? n 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 n 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 n “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. n Shortened rehab LOS forces therapists to focus on teaching compensatory techniques in order to maximize fxn for safe return to home n Areas of the cortex controlling movements of the affected limb shrink following stroke due to a combination of direct insult and learned nonuse n Preliminary studies show that repeated forced use of impaired limb results in improved mvmt and enlargement of these areas.

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

7. Blanton and Wolf (1999) Literature Review n 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

8. Blanton and Wolf (1999) Literature Review n Measures –Taken before, after, 3 mo f/u –Wolf Motor Function Test (14 timed, 2 strength) –Motor Activity Log (30 ADLS) n 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

9. Taub et al (1999) Literature Review n 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

10. Taub et al. (1999) Literature Review n Measures: WMFT, MAL, Arm Motor Ability Test n 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.

11. Liepert et al. (2000) Literature Review n Purpose: to use CIMT as a model to assess therapy-induced plasticity in stroke patients n 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

12. Liepert et al. (2000) Literature Review n Measures: MAL, transcranial magnetic stimulation mapping of motor output, motor threshold, and amplitude weighted center of activation sites (CoG) n 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

13. Conclusions n CIMT has been proven effective in subacute and chronic stroke for all but the 25% of pts with most severely impaired extremity fxn n CIMT may reverse the “learned nonuse” behavior by making pts more willing to use the affected extremity in functional ADLs n 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 n Can compensatory skills be taught without jeopardizing spontaneous recovery of the affected side? n How can resources best be allotted to promote recovery of hemiplegic limbs? n How can we best bridge the gap b/t therapeutic gains in the clinic and fxnl (I) in the real world?

15. Questions?