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Stroke is the ________ leading cause of death About _________ survive age group population

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3rd 60% to 80% more so 65 and older African Americans > European Americans

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Stroke is the Leading cause of _________ in adults in the United States Stroke survivors represent the __________ (34% of first admissions)

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disability largest group admitted to inpatient rehabilitation hospitals

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Epidemiology and Incidence Childhood Hemiplegia/Hemiparesis

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stroke CP

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what is the problem with stroke

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Many stroke survivors are left with significant deficits. Deficits produce long-term need for assistance from caregivers and society

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_____________ after stroke is one of the most prevalent diagnoses treated by therapists

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Upper-limb hemipareparesis

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History

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Relatively new approach (late 70's to early 80's)

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_________, MD began studies of ____________" Therapy at Emory University

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Steven Wolf forced use

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_________, MD initiated research with _____________ at the University of Alabama-Birmingham

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Edward Taub non-human primates

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Both scientists as well as many others

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continue to develop this approach

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Learned non-use

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Substantial neurological injury leads to depression in motor and/or perceptual function Animal attempts to use the deafferented limb Continued attempts to use deafferented limb produces failure, pain, incoordination, falling, etc., Animal begins to function adequately with 3 limbs, reinforcing 3 limb function

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Nonuse response tendency persists,

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preventing monkeys from learning that after several months, the limb is potentially usable

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Learned Non-use conclusion:

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the animals never learned they could eventually use the limb (learned non-use or learned helplessness)

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Learned Non-use in Humans

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When a person's brain is damaged by a stroke, it often becomes more difficult to move an arm. The person therefore tends to use the arm less. This leads to shrinkage of the regions of the brain that control arm movement Movement of the arm gets even more difficult.

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Processes of Learned Non-use

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Decrease in size of cortical representation of limb Punishment of use of affected arm Reinforcement of use of intact arm

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the three processes of learned non-use interact to

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produce a cycle during which the person uses the arm less and less

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the three processes of learned non-use is potentially

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reversible and can be overcome by the application of an appropriate intervention

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Children with early CNS damage (prenatal, perinatal, and early postnatal) differ from

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adults with a sudden CNS lesion bc children don't have neural pathways for this use

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Childhood VS Adult Response to CNS damage

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Underlying neural framework for movement with complex cortical pathways has not yet developed.

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Childhood VS Adult Response to CNS damage results in

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atypical movement patterns, which include ignoring or disregarding one body part(s).

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Childhood VS Adult Response to CNS damage Unlike the adult who once had normal movement patterns then loses them, the child

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never acquired typical movement.

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Constraint-induced therapy also referred to as:

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CIMT CIT CI Therapy Forced non-use

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developmental disregard

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Children with CNS damage use compensatory or idiosyncratic methods to accomplish desired goals. Difference between the two sides becomes more noticeable with age and functional use. Lack of development on one side leads to increased attention (regard) to body parts that function with greater ease and yield positive outcomes. Pays less and less attention to body parts that are not functioning well Lack of feedback at the sensory and motor levels for those body parts that are seldom or never used.

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in children, instead of calling it learned non-use it is called

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developmental disregard

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Rationale for CIMT

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Learning produces changes in the effectiveness of neural connections Learning can lead to structural alterations in the brain Every day events can strengthen or weaken synaptic connections (stimulation, deprivation, and learning).

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the process

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Constraining movements of the less-affected arm by placing it in a protective safety mitt Intensively training the correct use of the more-affected arm

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_____ of waking hours for constraining movements

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90%

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how long do you constrain movements

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Approximately 2 weeks

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Intensively training the correct use of the more-affected arm

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Shaping therapy for motor learning is provided in a supervised therapeutic setting for 6 hours per day Several hours of forced-use in daily living skills outside of the rehab setting

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Method of Constraint/Restraint for Adults

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Resulting hand splint with sling Nursing restraint mitt 90% of waking hours

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Method of Constraint/Restraint for peds

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long arm cast Work 24 hours of a day

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Length and Intensity of process for Adult CIMT

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about 2 weeks 6-8 hours each day

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Length and Intensity of process for peds CIMT

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21 days over a 26 day period, 6 hours each day

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Treatment principles for Adult CIMT

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Operant training techniques Massed Practice Repetition Encouragement in attempting new movements building strength

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Treatment principles for Peds CIMT

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Operant training techniques Massed Practice Repetition Encouragement in attempting new movements building strength

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Difference from Conventional Therapy

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CIMT induces concentrated, repetitive practice of more-affected limb--based on Duration, Intensity CI therapy helps a patient relearn everything from brushing their teeth to salting their food again.

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Inclusion Criteria for adults

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Some hand function Able to walk for relatively short distances without an assistive device High level of motivation and commitment Sufficient endurance Adequate cognition

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Some hand function

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cannot be flaccid

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High level of motivation and commitment

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need to be able to handle 6-8 hours a day

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Inclusion criteria for pediatrics

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Asymmetric abilities between two arms No movement requirements prior to implementation of treatment

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Contraindications for adult

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must not have chronic pain that would be exacerbated by the intensity of the program should not have medical complications that would prevent compliance with the length of the program

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must not have chronic pain that would be exacerbated by the intensity of the program

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often shoulder dislocation

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Contraindications for peds

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Severe limitations of bilateral UE Acute or chronic serious illness Seizure disorder that disrupts daily participation Severe MR, Autism, or sensory impairment Severe behavior problem Infant younger than 8 months

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Constraint

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Splint Mitt Sling Cast

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Techniques

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Hand over hand Fading Modeling

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The treatment is thought to work because

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it overcomes a strong tendency not to use the weaker arm (learned non-use) that develops early after stroke.

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CIMT produces a large

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"rewiring" of the brain; that is, after treatment, more of the brain works to move the weaker arm than before therapy.

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cortical reorganization After CIMT,

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area surrounding the infarct (usually not used for hand control) get recruited

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Cortical reorganizations These are synapses in the brain that are

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previously not used for a particular function, but have the potential for activation after the usually dominant system has failed.

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Cortical reorganization Such neurons

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get utilized and, by repetition and practice, can be set into constant use

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Mechanism of action

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Changing learning contingencies Reinforces use learning Blocking nonuse learning

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Mechanism of Action: Sustained, repeated practice of functional arm movements induces

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expansion of contralateral cortical area controlling movement

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fading

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removing hand over hand gradually

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Taub attributes only 20 percent of the improvement to ____________, and 80 percent to the ____________

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constraining the good arm intensity of practice

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modeling

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showing them what to do

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other uses for CI therapy

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Upper limb of chronic and sub acute CVA Upper limb of chronic TBI Lower limb of CVA patients The arm in young children with cerebral palsy Combined with Botox Concentrated use of a residual limb as a treatment for phantom limb pain

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Page et al (2002) Survey

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68 % of patients said they were not interested in participating in CIT 2/3 of patients who said they would participate in CIT program said they were somewhat or extremely unlikely to adhere to the CIT protocol 80% of patients said they would participate if protocol is modified 60% of therapists said that patients were extremely unlikely to adhere to such protocol Majority of therapists felt that many facilities did not have the resources needed to execute such protocol

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Page survey found that CIT is

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effective, but limited. Although it has been shown to be effective in laboratory research, CIT may have low clinical practicality in some environments.

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limitations

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Motivation Adherence Reimbursement Safety Generalizability to some environments? needs to be more occupation based yet repetitive

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Strengths

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Better use of the previously not used involved extremity in real life, functional situations Supported by evidence based practice.

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Better use of the previously not used involved extremity in real life, functional situations:

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Quality of movement Quantity of movement Speed of movement

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Possible solution

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Modifying the protocol. It is not so much the nature of the techniques that require revision but rather the intensity with which they are delivered.

Modified Constraint-Induced Movement Therapy for Therapists – Flashcards

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