LEARNING THE BASICS AGAIN STROKE VICTIMS BENEFITING FROM NEW THERAPY TO 'TRICK THE BRAIN' INTO REDEVELOPING HAND AND ARM MOVEMENT.

Byline: Steven Rosen Correspondent

In a small classroom at Kaiser Permanente's Woodland Hills hospital, four stroke patients sit with white restraining mitts covering one hand while they attempt simple tasks with the opposite hand.

The therapy session is an innovative stroke-rehabilitation technique called Constraint-Induced Movement Therapy (CIMT). The stroke patients force themselves to improve dexterity in their impaired side without instinctively relying on their strong hand, covered by the mitt.

As is common with strokes, which are caused when a ruptured or otherwise-impaired blood vessel blocks oxygen flow to the brain, theirs resulted in motor dysfunction affecting arm and hand movement on one side of their bodies. A stroke can snap the brain's connection to the body, affecting such vital functions as movement, speech and vision.

These can be hard to relearn, especially if there's impairment to a right-handed person's right side and vice versa. But CIMT is a relatively new therapy that shows promise with hand movement.

At the hospital class, Bob Newman, 55, of Moorpark tries to put bright plastic pegs into holes in a board. Dolores Giordano, 65, of Studio City moves plastic rings from one side of a curved arc to the other and back.

Sitting in a wheelchair, 64-year-old Bette Bjorklund of West Hills intently uses tweezers to add bolts to screws. And Oscar Escay, 57, of Moorpark buckles and unbuckles leather straps attached to a briefcase-sized piece of wood.

They all get one-on-one assistance - Bjorklund from her fiance; Escay from his teenage son - while Vida Hernandez, the hospital's occupational therapist and clinical specialist in neurology, supervises. And they also practice at home.

``I couldn't even open and close my fingers,'' Giordano says of the initial impact of her 2004 stroke on her left hand. ``Having a mitt on was crucial to retraining my brain. But it's hard. I remember I had dinner one night and I just threw the glove on the floor. But I had to pick it back up and put it on. If you want to teach yourself to use your hand again, that's what you have to do.''

Now she's so good Hernandez has to slow down her movements to make sure she is exercising her index finger.

``The goal is to get them to start using their arm without even thinking about it,'' Hernandez says. ``What happens is that, when they first have a stroke, they can't use their hand or arm (on one side). Then the swelling goes away but the brain doesn't realize it. Traditional therapy teaches them to rely on the (good) hand.

``The more they do that, the further the brain gets away from knowing the other hand can once again move,'' she says. ``So the brain is telling them, 'You can't do it.' But I'm saying, 'Yes, you can.' ''

Not only are strokes the No. 3 cause of death in the U.S., but they're the leading cause of adult disability, according to statistics provided by Kaiser from the National Institute of Neurological Disorders and Stroke. Some 700,000 people a year have strokes. They don't benefit from the same public awareness as heart attacks or cancer, but that might be changing due to recent news-making strokes suffered by Senate Minority Leader Harry Reid and Coretta Scott King, the widow of Martin Luther King. (Reid's was minor, King's more severe.)

To be admitted to Hernandez's sessions, she requires patients have some motor control in their affected hands. They must be able to extend a wrist 20 degrees from any resting point, extend fingers by 10 degrees and have some motion in the thumb. That means the brain is able to send information to the hand.

``The idea is if you have some wrist extension, you have everything else,'' she says.

Further, she says, this therapy can be helpful for people who have given up reliance on stroke-impaired hands for as much as 15 years. But that is a challenge.

``After so long, it can be hard psychologically to switch back to the other arm becoming the dominant extremity. But I've never had a patient who didn't improve.''

CIMT appears to have its limits, however. ``You've got to have some connectivity to the brain,'' says Dr. Thomas Hedge, medical director for Northridge Hospital Medical Center. ``Otherwise, you're just frustrating the patient.''

However, he said, only 15 to 20 percent of strokes leave the victim with totally dead cells governing the brain's control over the impaired areas of the body.

CIMT was developed by Edward Taub, a psychology professor at University of Alabama - Birmingham. He originally applied anesthesia to the limbs of primates to study their recovery. In the early 1980s, trials were done at Georgia's Emory University that showed some progress with stroke patients wearing mitts or slings.

The first large-scale clinical study of the therapy's effect was recently done at seven universities, including USC. It was funded by the National Center for Medical Rehabilitation Research. Several hundred patients who already had some voluntary movement in a stroke-impaired upper limb were observed undergoing CIMT.

They had had their stroke three to 12 months before being admitted to the research study. Because the study's ``primary outcome paper'' has yet to be published, the findings are embargoed. Ultimately, they will be posted at www.excitewustl.edu.

``What will come out in our paper is the degree of benefit,'' explains USC's Carolee Winstein, a physical therapist specializing in stroke rehabilitation and co-principal investigator of the multisite study. ``What are the best predictors of who responds best to this intervention? And what are the critical ingredients? Once we know that, it opens up a whole new arena of what's possible.''

Winstein had approval to speak about a smaller companion study at USC that measured changes in brain activity among patients receiving two weeks' worth of intensive CIMT.

``I can tell you we definitely saw improvement,'' she says. ``You get nice changes in brain activity associated with the improvements in hand function.''

And she's already proposing follow-up research, focusing on the importance of restraining mitts to the therapy.

``We don't know how much of the improved hand function is due to the intense practice and how much is simply due to the use of the constraint itself,'' she says. ``If you can benefit from intense physical therapy, why do you need a constraint?''

CAPTION(S):

3 photos

Photo:

(1 -- cover -- color) Life after a stroke

New therapy helps regain strength

Photo courtesy of photos.com

(2 -- color) Stroke patient Oscar Escay writes with his stroke-affected hand during Constraint-Induced Movement Therapy at Kaiser Permanente Medical Center in Woodland Hills.

Tom Mendoza/Staff Photographer

(3) Occupational therapist Vida Hernandez, standing, instructs and assists stroke patients during therapy that uses the CIMT method of rehabilitation.