by Franco Yap, PT, Alta Vista Rehabilitation & Healthcare, Brownsville, TX -
The 1990s has been considered the decade of the brain. With advancements in neuro-imaging and the publication of more and more research in the realm of neurologic recovery, there has been a greater awareness and understanding into the mysteries of the brain. Recovery after a stroke is possible. The centuries-old notion that the adult brain is fixed and unchanging is now being reexamined and questioned. “Arguably, the most important breakthrough in neuroscience since scientists first sketched out the brain’s basic anatomy is the revolutionary discovery of Neuroplasticity. This concept that the brain is malleable and able to recover and change, even after an injury, continues to show a lot of hope for those dealing with neurologic injury.
Recently, the University of Alabama has been offering a week-long constrained-induced (CI) therapy training course for clinicians. CI therapy has been derived from basic behavioral neuroscience research with primates, pioneered by Dr. Edward Taub of the UAB CI Therapy Research Group. Typically, CI therapy involves constraining (usually with a mitt restraint) the unaffected arm in patients with hemiparetic stroke or hemiparetic cerebral palsy (HCP) for 90 percent of waking hours while engaging the affected “weaker” limb in a range of everyday activities. The treatment sessions are usually six hours per day for two weeks, although recently there also have been reports that three hours of therapy per day has been shown to be of equal benefit for patients.
This concept is revolutionary in that over the past few decades, conventional rehabilitation therapy has focused more on compensatory measures and use of the unaffected “good side” in the performance of functional motor tasks. The idea of CI therapy is to force the patient to use the affected extremity more in order to facilitate motor recovery. With the use of objective measures, close monitoring and behavioral techniques, it has been shown that about 80 percent of stroke patients who have lost arm function can improve substantially. Over the last 20 years, a substantial body of evidence has accumulated to support the efficacy of CI therapy for hemi paresis following chronic stroke; i.e., more than one year post-injury.
The training seminar involved an introduction to CI therapy, screening/recruitment of patients, treatment protocols, outcome measures and a home skill assignment package. Participants attended lectures given by Dr. Taub and his team and lab training exercises with actual patients. CI therapy protocol involved the use of behavioral techniques like shaping and task practice, adherence enhancement strategies and constrained use of the affected UE with a mitt restraint.
It is common in the rehabilitation world for patients to exhibit a decline in function once discharged from skilled therapy. Education and problems with compliance to home exercise programs given to patients often are overlooked by most therapy approaches. Therapists would work hard to get patients to a certain level appropriate for discharge, only to see them readmitted after several months or days. CI therapy is unique in its repeated focus on bridging the gap between progress made in the clinic and the carryover of continued use of these functional skills at home. Instruments like the Behavioral contract (a written document detailing the patient’s sworn compliance to the use of the constraint (mitt restraint) and Home Skills Assignment (a list of tasks the patient had to perform at home using the affected limb) were always emphasized for enhanced compliance. Every day before each treatment session, the Motor Activity Log, a structured interview instrument, would be used to measure and monitor the use of the affected limb on a list of daily activities. The patients would also have follow-up interviews scheduled after their discharge from CI therapy. This robust protocol, along with the use of Shaping and Massed practice, enforces a strong adherence and retention of learned motor skills.
CI therapy is but one of the many approaches that is part of the current renaissance in neuro-rehabilitation, and it is one of the few that is supported by randomized control multi-center trials. It continues to be refined by ongoing research and is currently being developed for use in the improvement of speech pathologies, lower extremity rehabilitation and other neurological diseases like Traumatic brain injury and Multiple sclerosis. It definitely shows a lot of promise for the future, and there has never been a more exciting time for physical medicine and rehabilitation.