Edward Taub, PhD; Gitendra Uswatte, MA; Rama Pidikiti, MD of the Physical Medicine and Rehabilitation Service, Birmingham Department of Veterans Affairs Medical Center, Birmingham, Alabama,U.S.A. discuss the much touted new technique called Constraint-Induced Movement Therapy or CI Therapy.
A new family of rehabilitation techniques, termed Constraint-Induced Movement Therapy or CI Therapy, has been developed that controlled experiments have shown is effective in producing large improvements in limb use in the real-world environment after cerebrovascular accident (CVA). The signature therapy involves constraining movements of the less-affected arm with a sling for 90% of waking hours for 2 weeks, while intensively training use of the more-affected arm. The common therapeutic factor in all CI Therapy techniques would appear to be inducing concentrated, repetitive practice of use of the more-affected limb. A number of neuroimaging and transcranial magnetic stimulation studies have shown that the massed practice of CI Therapy produces a massive use-dependent cortical reorganization that increases the area of cortex involved in the innervation of movement of the more-affected limb. The CI Therapy approach has been used successfully to date for the upper limb of patients with chronic and subacute CVA and patients with chronic traumatic brain injury and for the lower limb of patients with CVA, incomplete spinal cord injury, and fractured hip. The approach has recently been extended to focal hand dystonia of musicians and possibly phantom limb pain.
As an example of a disability where the CI therapy can be used: Cerebrovascular accident (CVA) is the leading cause of disability in the United States. A recent study indicates that the number of CVAs may be dramatically higher than was previously thought to be the case. The total number is now estimated to be approximately 730,000 every year and the data suggest that this may be an underestimate. Moreover, more than half of these individuals are left with motor disability. There seems little doubt that the number of CVA survivors will increase greatly as the population progressively ages over the next 50 years; a recent projection is that the prevalence of CVA will more than double during this period . A 1993 estimate placed the annual costs of CVAs at $30 billion, of which $17 billion were direct medical costs and $13 billion were indirect costs due to lost productivity . The American Heart Association estimates that the current direct and indirect costs of CVA are $43.3 billion per year . CVAs are a particular problem for the VA because of the large population of World War II and Korean War veterans who are now in the age ranges where CVAs are most frequent; in fiscal year 1997 the national VA system had 22,000 admissions for an acute CVA . The consequent motor deficits that veterans sustain result in very large costs to the VA and the Federal Government. The reduction of CVA-related disability thus represents a high VA and national health care priority.
At present, there is little experimental evidence available indicating that physical and occupational therapy is effective for patients with chronic CVA. The literature is even equivocal on the value of physical rehabilitation for sub-acute patients–see literature reviews from the past 10 years . In the Winter 1998 issue of the journal Topics in Stroke Rehabilitation devoted to “Functional Implications of Upper Extremity Management,” there was minimal discussion of specific therapeutic approaches to improving upper limb function, even though the title suggests that this would be a major, if not the main, topic covered. The small amount of material on upper limb treatment in that special issue may be a meaningful index of the fact that there are few empirically validated treatments to discuss at this time. The special issue did not review Constraint-Induced (CI) Movement Therapy, the treatment approach discussed in this article. The only literature review recent enough to evaluate published studies on CI Therapy cites it as being only one of three treatments for which there is empirical evidence of clinical efficacy and the only one to: 1) be supported with evidence from controlled randomized studies, and 2) have been shown to be effective for the upper limb . Moreover, CI Therapy does not involve medications or side effects, and there are no significant risks.
CI Therapy consists of a new set of rehabilitation techniques that data from controlled, randomized studies have indicated can substantially reduce the motor deficit of the more-affected limbs of many patients with chronic CVAs. The therapeutic effect has been demonstrated to transfer from the clinic to the real world; patients show increases in the daily use of their more-impaired limbs that are maintained, in the most powerful intervention, for at least 2 years after treatment . For the upper limb, the therapy involves inducing use of the more-affected limb for a target of 90 percent of waking hours by employing one of several methods for constraining or reducing use of the less-affected limb for 2 or 3 weeks. Concentrated, repetitive training of the more-affected limb is given daily for 6 hours, interspersed with 1 hour of rest, for each of the weekdays over the 2- or 3-week period (i.e., massed practice). The upper limb intervention has been tested to date with all but what we estimate to be the lowest functioning 25 percent of the chronic CVA population with significant residual motor deficit. For the lower limb, a somewhat different approach is used that does not involve less-affected limb restraint, but does include massed practice of functional lower limb activities (see below). This article reviews the development of CI Therapy from basic research with monkeys to its application to persons with CVA with upper limb deficits and its extension to the treatment of upper limb deficits in traumatic brain injury and lower limb deficits in persons with CVA, spinal cord injury, and hip fracture. The article also describes research suggesting that cortical reorganization is a possible mechanism that accounts for the persistent therapeutic effect of our intervention and discusses further rehabilitation applications that have emerged from this finding. The Tutor system has been developed to improve functional outcomes in physical rehabilitation with interactive rehabilitation exercises that include working with the Constraint-Induced Movement technique. CVA is but one of the health issues that can be helped by the Tutor system. Others include Parkinson’s, Brain and spinal cord injuries, upper and lower limb surgeries, CP, MS, Radial and Ulnar nerve injuries, development co-ordination disorders, Brachial Plexus injuries and Complex Regional Brain Syndrome.
The newly developed HandTutor and its sister devices (ArmTutor, LegTutor, 3DTutor) have become a key system in neuromuscular rehabilitation and physical therapy. These innovative devices implement an impairment based program with augmented feedback and encourage motor learning through intensive active exercises. These exercises are challenging and motivating and allow for repetitive training tailored to the patient’s performance. The Tutor system also includes objective quantitative evaluations that provide the therapist information to customize the most suitable rehabilitation program to the patient’s ability. Currently part of the rehabilitation program of leading U.S. and foreign hospitals the Tutors are also used in clinics and at home through the use of telerehabilitation. See www.handtutor.com
No comments:
Post a Comment