A New Rehabilitation Technique for Stroke Patients
(2/16/07)- Constrained-Induced Movement Therapy:
Part II
In an article written 6 years ago, we detailed the work of Dr.
Edward Taub, a professor of psychology at the University of
Alabama in Birmingham, who developed Constrained Induced Movement
Therapy (CIMT). The underlying rationale for CIMT was that after
a stroke, a survivor tries unsuccessfully to use the affected
side.
Their initial failure discourages them from using that side.
Dr. Taub calls this “learned non-use.” Dr. Taub and his
colleagues were attempting to show that patients can
"learn" to improve the ability to move the weaker parts
of their bodies and thus cease to rely exclusively or primarily
on the stronger extremities..
At that time, we noted that the treatment protocol lacked
placebo-control verification.
Now, Dr. Taub has led a team to do exactly that. Researchers
studied survivors with mild to moderate motor impairment of an
upper limb, an average of 4.5 years after stroke.
Twenty-one survivors (average age 55) underwent
Constraint-Induced Movement Therapy: six intensive hours a day
for 10 consecutive weekdays. Twenty survivors (average age
51) had placebo therapy – a general fitness program of
strength, balance and stamina training, games to provide
cognitive challenges and relaxation exercises for
six hours a day for 10 consecutive weekdays.
CIMT patients showed “large to very large” improvements
in the functional use of their affected arm in their daily lives.
Scores on a motor activity log (MAL) in which survivors and
caregivers noted how well and how much
survivors used their impaired arm in daily living improved an
average of 1.8 points for those undergoing CIMT.
Those in the control group reported no change. In addition,
CIMT patients were able to speed their completion of
tasks in lab testing while the placebo patients were slower.
Another study compared the effects of a 2-week multisite program
of CIMT vs. usual and customary care on improvement in upper
extremity function among patients who had a first stroke within
the previous 3 to 9 months.
Two hundred twenty-two individuals with predominantly ischemic
stroke were involved in this study. The results of this research
indicated that among patients who a stroke within the previous 3
to 9 months, CIMT had had
statistically significant and clinically relevant improvements in
arm motor function that persisted for at least 1 year
With this form of therapy, Dr Taub believes he has shown that
patients can "learn" to improve the ability to move the
weaker parts of their bodies and thus cease to rely exclusively
or primarily on the stronger extremities.
These therapies have significantly improved quality of movement
and substantially increased the amount of use of the
more-affected extremities in the activities of daily living for a
large majority of patients who have received the treatment.
It is the only rehabilitation technique shown to produce a marked
change in brain organization and function. This author would
suspect that it takes a certain type of motivated person to stick
to this 2 week program of intensive therapy.
Parties interested in this form of therapy should note that Dr.
Taub’s research laboratory conducts many different CI
therapy projects. Treatment in these research studies is at no
cost. The requirements for acceptance in these studies depend on
the particular projects being carried out at any given time.
The information we have is that the current research projects
apply to CI therapy for the arm after stroke or head injury. CI
therapy for the leg has been temporarily halted in the
laboratory, but it is presently offered in the Taub Therapy
Clinic.
At this time, the following CI therapy research projects are
actively recruiting for participants:
a.. Persons who had a stroke 12 months ago or longer.
Please contact Nameeta Sarin at:
Constraint-Induced Movement Therapy Research Group
University of Alabama at Birmingham
1530 3rd Avenue South
CPM 712
Birmingham, AL 35294-0018
Phone: (205) 934-9768
Fax: (205) 975-9791
Email: citherapy@uab.edu
b... Persons with traumatic brain injury (head injury).
Please contact Staci McKay at:
CI Therapy/TBI Project
University of Alabama at Birmingham
SRC R056
1717 6th Avenue South
Birmingham, AL 35294-7201
Phone: (205) 934-7660
Fax: (205) 975-9791
Email: ci-tbi@uabmc.edu
In order to use CI therapy, survivors need to be able to extend
their wrists and move their arm and fingers. At this time,
medical insurance does not reimburse for CI therapy. It costs
about $5,000 for two weeks of treatment
at the Taub Therapy Clinic. The phone number is 866-554-TAUB.
Taub Therapy Clinic is located at the University of Alabama at
Birmingham Hospital, 1713 6th Ave. South, Birmingham, Alabama
35233.
Email address is TaubClinic@uabmc.edu.
The following statement was abstracted from their Web site:
“Taub Therapy has been proven to be over 95% successful in
helping patients in the clinic regain significant movement.
Through the one-on-one encouragement of a therapist, patients can
relearn to use their affected limb by restricting the use of the
unaffected one. By causing neurons to "rewire"
themselves, Taub Therapy not only changes the brain, it changes
lives.”
For those interested in checking primary research studies on
CIMT, we suggest you check the following literature:
1. Taub, E., Uswatte, G.,
King, D. K., Morris, D. M., Crago, J. E., & Chatterjee, A
(2006). A placebo controlled trial of Constraint-Induced Movement
therapy for upper extremity after stroke. Stroke, 37, 1045-1049.
2. Taub, E., & Uswatte,
G. (2005). Use of CI therapy for improving motor ability after
chronic CNS damage: A development prefigured by Paul
Bach-y-Rita. Journal of Integrative Neuroscience, 4,
465-477.
3. Shaw, S. E., Morris, D.
M., Uswatte, G., McKay, S., Abernathy, S., Meythaler, J. M.,
& Taub, E. (2005). Constraint-Induced Movement therapy for
recovery of upper extremity function following traumatic brain
injury.
Journal of Rehabilitation Research and Development, 42, 769-778.
4. JAMA. 2006; 296:2095-2104.
(6/10/2000)- Recent research literature is replete with isolated
articles about the brain’s regenerative powers as well as
its ability to reorganize itself after injury. Study of
regeneration of animal limbs goes back about fifty years. This
has led some researchers to propose a new approach in treating
stroke patients called constraint-induced-movement therapy.
Stroke: The Journal of the American Heart Association in its June 2000 issue reported on a study done with 13 chronic stroke patients. Patients were forced to use their paralyzed arm by simply immobilizing the good arm. They were given intense therapy on the paralyzed arm for six hours a day for at least two weeks.
The authors of the study report that this is the time needed to stimulate the brain to reorganize itself from its state of being stunned by the initial cause of the stroke. Please see footnote below.
This therapy is based on a theory of learned helplessness that has also been used to explain depression. It attributes the inability to move the arm to the idea that cells surrounding the injured area are stunned but not damaged, remaining in a state of permanent inhibition.
This discourages the individual from using his arm, which reinforces the inability to move the arm (The mind setting reinforcing the felt inability to move the limb.). Constraint-induced-movement therapy attempts to force the individual to use the arm.
The stimulation of trying to use the arm allows for the establishment of new neuropathways that disinhibits the stunned cells. This disinhibition could result in the cells being restored to their former functioning, also in the formation of new pathways bypassing the necrotic cells resulting from the stroke (Plasticity of the brain.).
While this research study has exciting possibilities, especially when it indicates restoration of limb functioning, its generalization should be approached cautiously. The number of subjects involved in the study (thirteen) is a small number.
The study did not use a double blind, experimental-control group paradigm, which would seem to reduce its reliability. However, it does hold out hope for individuals with a limb paralysis disability associated with stroke. The discipline needed to carry on this rehabilitation could prove a difficult barrier to overcome in the population of stroke patients, where depression is a not uncommon secondary effect of the stroke.
A bigger issue would appear to be the type of treatment received just after the expression of a stroke. The National Institute of Neurological Disorders and Stroke (NINDS), a component of the National Insitutes of Health, issued a statement in which they said that experts feel that "few eligible stroke patients receive treatments that save lives and reduce disability".
They note that patients who have ischemic stroke have the most potential of reducing deaths and disabilities. They point to the clinical trial findings "that patients who received t-PA treatment within three hours of their initial stroke symptoms were at least 30% more likely than untreated patients to recover from their stroke with little or no disability after three months". The big problem is that patients arrive at the hospital after the three-hour window for which the thrombolytic treatments work.
It remains most important that individuals recognize the symptoms of stroke and seek immediate attention. The main symptoms listed by the NINDS are:
It will be up to those around a stroke victim to recognize
these symptoms and act fast. According to Dr. John R. Marler,
associate director for clinical studies at NINDS, "Stroke is
a condition that is easy to see. There are few other medical
conditions that come on so suddenly and that are so noticeable to
a bystander.
Footnote:
E. Taub et. al. (1999). Constraint-Induced Movement
Therapy: A
New Family of Techniques with Broad Application to Physical
Rehabilitation - A Clinical Review. Journal of Rehabilitation
Research and
Development, 36, 3, 237-251
For more information on stroke see the other articles on this
topic in this web site or call the NINDS at 877-562-3434 for a
brochure on stroke.
FOR AN INFORMATIVE AND PERSONAL ARTICLE ON PRACTICAL SUGGESTIONS WHEN SELECTING A NURSING HOME SEE OUR ARTICLE "How to Select a Nursing Home"
Harold Rubin, MS, ABD, CRC, Guest Lecturer
Updated February 16, 2007
To e-mail: hrubin12@nyc.rr.com or rubin@brainlink.com