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"What is "Constraint Induced Movement Therapy"?"
By Steven L. Wolf, Ph.D., PT
The idea behind this notion is that people who have had a stroke might gain more mobility and function in their “bad” arm and hand if they are forced to use it with greater frequency. This “forced use” is achieved by having you wear a mitt or glove on your better hand that is rigid enough so that you cannot “cheat” and bend your fingers to grab hold of objects. Hence you are dependent upon the use of the weaker arm and hand. It is believed that by repetitive use over the course of just a few weeks, the improvements will be retained for a long time as long as you persist in the effort. There is even some evidence to show that there are changes in your brain called “massed practice cortical reorganization” that accompany this repetitive use.
However, it is not exactly as simple as it sounds. The re-training should be supervised by a physical or occupational therapist who knows what they are doing…..who can help you increase your endurance and concentration over time……and who can make the tasks you practice successively harder and more challenging; for it is believed that the “problem solving” aspects that are part of the “relearning experience” are essential to re-training and maybe even rewiring your brain.
The actual training involves 4-8 hours a day for two weeks during which time you practice functional tasks in small progressive steps, called “repetitive task practice” and with repeated trials or bouts of about 30 second intervals where the number of “successes” during that time are charted and reviewed in a procedure called “adaptive task practice” or “shaping”. While some of these tasks may at first appear foolish or irrelevant, they actually build upon one another. For example, it may seem irrelevant to see how many times you can pick up blocks and move them into a can in 30 seconds with your “bad” arm. However, if the blocks get smaller with training and the aperture of the then can gets smaller, you can see the skill level required. Now, repeat that same sequence standing rather than sitting and then standing further away from the can. Can you see the progression and the increasing difficulty? Moreover, you quickly learn that this activity might be an important precursor to doing something like putting buttons or pens, or coins away……which are functionally activities you do every day and certainly would like to do better with your “bad” arm and hand, right? The more you practice with greater intensity the more you “relearn” to use that limb by acquiring a new skill set. Kind of like learning golf strokes and procedures for the first time, except now you are “re-learning” a skill that once probably came far more easily to you than golf!!!
So, can just any person who has had a stroke succeed with this constraint induced therapy? Well that is the question we are studying right now. For the time being, the evidence seems to suggest that those people who succeed the most and retain their improvements are people who can demonstrate some ability to open their hand and raise the back of their wrist upward three times in one minute while seated and the wrist over the edge of a table, forearm flat, and palm down.
I would advise you to find a skilled clinician should you wish to pursue this training. I would advise you that it can appear frustrating at times and you might want to “give up” but don’t. I doubt you would be reading this article if you were the type of person who does give up easily, because you probably wouldn’t be a golfer. If all else gets you down, come play golf with me……my performance on the links can make anyone look good and feel even better.
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Steven L. Wolf, Ph.D., PT, FAPTA, received his AB in Biology from Clark University in Worcester MA, his physical therapy certificate from Columbia University, AN MS in physical therapy from Boston University, an MS in Anatomy from Emory University and his Ph.D. in neurophysiology from Emory as well. He has been researching issues related to motor control and movement science that are relevant to physical therapy for over 30 years. Dr. Wolf has defined the selection criteria for the application of EMG biofeedback to successfully restore upper extremity function among chronic patients with stroke, via funding from NIDDR and NINDS. This series of studies spans 15 years and has resulted in over 80-refereed publications. Findings from this work paved the way to defining the minimal motor criteria for the application of forced use (constraint induced movement therapy) among chronic patients with stroke. At present he is the Principal Investigator for the EXCITE (Extremity Constraint Induced Therapy Evaluation) national, randomized clinical trial funded by the National Center for Medical Rehabilitation Research of NICHHD and the National Institute of Neurological Disease and Stroke of the NIH. This blinded study examines the effectiveness of constraint-induced therapy among patients with sub-acute stroke. His interests in feedback led to the comparison of center of pressure biofeedback with Tai Chi for falls reduction in older adults. The observation that Tai Chi was a viable procedure to delay the onset of falls and improve the quality of life among geriatric patients has resulted in NIH support to conduct a randomized clinical trial applying Tai Chi to more frail, older individuals. Collectively his work in biofeedback and Tai Chi both still defined by the Center on Alternative and Complimentary Medicine at the NIH and by the National Institute on Aging has produced over 130 publications in refereed journals, in excess of $30 million in grants, and research support for more than 27 graduate students.