Constraint-Induced Movement Therapy for Motor Recovery in Chronic Stroke Patients.

Constraint-Induced Movement Therapy for Motor Recovery in Chronic Stroke Patients Kunkel A, Kopp B, Muller G, et al (Department of Psychology, Humboldt University; Department of Radiology, Free University; Department of Neurology, Charite Hospital, Berlin, Germany; Department of Psychology, University of Alabama at Birmingham, Birmingham, Ala), Arch Phys Med Rehabil. 1999;80:624-628.

This study represents an ongoing investigation into therapies that address the issue of "learned nonuse," a mechanism that one of the authors hypothesized nearly 20 years ago to explain certain patients' decreased limb function following stroke. According to the authors, learned nonuse occurs after patients with stroke attempt to use an extremity affected by the stroke before "spontaneous recovery of function" takes place. After these attempts fail, the patients use compensatory movements of the unaffected extremity, which "impedes attempts to further rehabilitate the affected extremity."

The study reports the results of constraint-induced movement therapy in a convenience sample of 5 patients (4 women, 1 man; age range=47-66 years) who had experienced a stroke at least 1 year prior to the study's initiation. In what previous researchers have called a "forced-use" paradigm, each patient's unaffected upper extremity was restrained using a combination of a resting hand splint and a sling. According to the researchers, constraint-induced movement therapy would overcome learned nonuse by restraining the unaffected lower extremity and forcing the patient to train the affected extremity. Subjects received 6 hours of behavioral training for the affected extremity each weekday for 14 days, and they agreed to a treatment contract that stipulated that they would wear the splint and sling restraint for 90% of their waking hours.

Patients were eligible for the study if they were less than 80 years of age, if their strokes had occurred at least 1 year before the study, and if they were free of serious sensory, cognitive, and language deficits. Patients were excluded from the study if they were severely depressed or if their strokes had affected the primary sensory or motor cortices.

Using motor scales they had previously published and tested (the Actual Amount of Use Test and Arm Motor Ability Test) along with the Motor Activity Log and the Wolf Motor Function Test, the authors measured changes in patients' use of their affected upper limbs before and after the 2-week intervention period. They used Friedman one-way ANOVAs to determine overall change in all of the study variables from pretreatment to posttreatment and to the 3-month follow-up.

Results of the Wolf Motor Function Test and the Arm Motor Ability Test indicated that motor performance, as measured under laboratory conditions, increased substantially at the end of treatment compared with pretreatment values. The Actual Amount of Use Test and the Motor Activity Log revealed even greater improvements in motor performance, which was construed by the authors as increased use of the upper extremity in "real world" situations (that is, situations outside of the clinic or laboratory setting). They also reported that the effect sizes seen in this study were large and comparable to previous studies of constraint-induced or forced-use interventions. The improved function persisted at least until the time of a 3-month follow-up evaluation.

The authors concluded that constraint-induced therapy is a viable treatment for people with persistent limitations in upper-extremity function following a stroke. They felt that this treatment may be especially useful in helping patients regain use of their upper extremity for activities of daily living and other activities that reflect use of the upper extremity in everyday life.

David M Thompson, PT
University of Oklahoma Health Sciences Center
Oklahoma City, Okla