Constraint-InducedMovementTherapyanditsApplicationto强制性运动疗法及其应用.ppt

Constraint-Induced Movement Therapy and its Application to Physical and Occupational Therapy Nicole M. Boyko, PT/s Background Information n730,000 strokes/yr n50% patients have motor deficits n30-66% of patients are unable to use affected UE for ADLS following stroke What is Constraint-Induced Movement Therapy? nA technique in which the patient uses concentrated, repeated practice of the affected extremity in order to facilitate movement Shaping: a behavioral technique in which quality of movement is improved progressively in small steps nFamily of techniques includes: Restraining of less affected UE in hand splint and/or sling while subsequently shaping the hemiplegic UE Wearing glove/mitt on less affected hand while shaping hemiplegic hand Shaping of hemiplegic UE or LE without restraint of unaffected side Intense PT of hemiplegic side 5 hrs/day x 10 week days without restraint of unaffected side (pts asked not to use unaffected side) Rationale n“Learned nonuse”: a conditioned suppression of mvmt that occurs when pt is initially unsuccessful at using affected extremity immediately post-injury and is reinforced by successful compensation with unaffected extremity. nShortened rehab LOS forces therapists to focus on teaching compensatory techniques in order to maximize fxn for safe return to home nAreas of the cortex controlling movements of the affected limb shrink following stroke due to a combination of direct insult and learned nonuse nPreliminary studies show that repeated forced use of impaired limb results in improved mvmt and enlargement of these areas. Current Research nEXCITE (Extremity Constraint Induced Therapy Evaluation) 5 yr NIH supported trial Sites: U of Alabama at Birmingham, Emory U, UNC/Wake Forest School of Medicine, UCLA, UFL at Gainesville, Ohio State Protocol: less affected UE restrained in sling for 90% of waking hours x 2 wks; training of most affected UE 6 hrs/day with 1 hr rest x 10 weekdays nDiagnoses for which CI is being researched: CVA (UE and LE), SCI (LE only), hip fx/replacement, focal hand dystonia in musicians, cerebral palsy in children Availability of CIMT nTaub training clinic opened at UAB in Aug 2001 nProvides 2-3 wks CIMT for UE primarily for patients post stroke nMedicare does not cover Private pay: 2 wks: $6700, 3 wks: $12, 700 nCI therapy research labs offer CIMT for strokes, SCI, hip Fx, CP and hand dystonia for free to qualifying pts at select locations Literature Review nSubjects/Methods 61 y/o African-American female 4 mo s/p ischemic lacunar infarct of (L) post limb of internal capsule Fxnl status: (I) ADLs, amb device, no voluntary use of (R) UE Received CIMT using mitt on (L) UE for 90% waking hrs x 14 days Practice performing ADLS with (R) UE in clinic 6 hrs/day x 10 days with 1-2 hrs/day rest Blanton and Wolf (1999) Literature Review nMeasures Taken before, after, 3 mo f/u Wolf Motor Function Test (14 timed, 2 strength) Motor Activity Log (30 ADLS) nResults Improved on all items on WMFT Prior to Rx, using (R) UE for 1/30 tasks on MAL After Rx, using (R) UE 50% as much on 25/30 Upon 3 mo f/u, using (R) UE for 30/30 tasks Blanton and Wolf (1999) Literature Review nSubjects/Methods 4 patients in CIMT grp, 5 in placebo group Inclusion criteria: 20 wrist ext, 10 finger ext Exp grp:CIMT with unaffected UE in resting hand splint for 90% of waking hrs x 14 days Sling also used during 6 hrs/day of Rx x 10 days in performing activities such as eating, throwing a ball, playing board games, writing, sweeping Placebo: told they had greater capacity to use affected UE and instructed in passive ex Taub et al (1999) Literature Review nMeasures: WMFT, MAL, Arm Motor Ability Test nResults Experimental grp showed significant increases on WMFT and AMAT while controls showed no change or a decline Experimental grp showed a very large significant increase in real-world affected extremity use as measured by MAL which persisted at 2 yr f/u. Controls showed no change or a decline. Taub et al. (1999) Literature Review nPurpose: to use CIMT as a model to assess therapy-induced plasticity in stroke patients nSubjects/Methods 10 men and 3 women with chronic hemiplegia post stroke Inclusion criteria same as previous Taub study CIMT with unaffected UE in resting hand splint for 90% waking hrs x 12 days Sling also applied to unaffected UE in clinic for 6 hrs/day of Rx for 8 days to increase quality of mvmt and use of affected UE Liepert et al. (2000) Literature Review nMeasures: MAL, transcranial magnetic stimulation mapping of motor output, motor threshold, and amplitude weighted center of activation sites (CoG) nResults 1 day post Rx, 37.5% more activity in affected hemisphere was noted Increased cortical representation area in affected hemisphere Increase in ADLs persisting at 6 mo f/u Liepert et al. (2000) Conclusions nCIMT has been proven effective in subacute and chronic stroke for all but the 25% of pts with most severely impaired extremity fxn nCIMT may reverse the “learned nonuse” behavior by making pts more willing to use the affected extremity in functional ADLs nCIMT seems to result in cortical reorganization which represents the pts actual potential for recovery of fxn in the affected extremities Questions for Acute Care Practitioners to Ponder nCan com