Hemiplegia

Case Report

Background and Purpose. Constraint-induced movement therapy (CIMT) has been documented to improve motor function in the upper extremity of people with mild hemiparesis. The use of CIMT has not been documented for people with severe hemiparesis. This case report describes a CIMT program for an individual with severe upperextremity deficits as a result of stroke. Case Description. The client was a 53-year-old woman who had a stroke 15 years previously and had no isolated movement in her right upper extremity. Methods. The client completed a 3-week CIMT program during which she restrained her left upper extremity and participated in intensive training of her right upper extremity. Task practice and shaping were the primary techniques used for training. Outcomes. Increased scores were noted from pretreatment to posttreatment on the Motor Activity Log, Graded Wolf Motor Function Test (GWMFT), and Fugl-Meyer Evaluation of Physical Performance. Further progress on the GWMFT was noted at the 6-month follow-up. Fugl-Meyer test scores remained higher than at pretreatment, but Motor Activity Log scores returned to near baseline by the 6-month follow-up. The speed of performance on the GWFMT did not change. Although some scores increased, the client reported and demonstrated no progress in functional use of the involved upper extremity at the end of the program. Discussion. This case report describes the use of CIMT with an individual who had severe chronic motor deficits as a result of stroke. Further investigation of CIMT, as well as investigation of CIMT in combination with other motor recovery interventions, is warranted. [Bonifer N, Anderson KM. Application of constraint-induced movement therapy for an individual with severe chronic upper-extremity hemiplegia. Phys Ther. 2003;83:384-398.]

KeyWords: Constraint-induced movement therapy, Hemiplegia, Learned nonuse, Rehabilitation, Stroke.

Nancy (McNamara) Bonifer, Kristin M Anderson

Stroke is the leading cause of disability in the United States.1 More than 750,000 people are estimated to have strokes each year in the United States and over 4 million people in the United States are living with a disability as a result of stroke.1,2 Interventions that address the sensorimotor impairments resulting from stroke, therefore, are important.

The concept of learned nonuse has been used to explain the motor deficits that often occur following stroke.3-7 Learned nonuse develops as a result of an upper motor neuron lesion that depresses the central nervous system and motor activity. When people who have sustained a stroke or brain injury initially attempt to move or use the affected body part or parts, they may experience failure and frustration. The individual learns how to compensate for this lack of movement by using the uninvolved or less involved extremities or the trunk, or both. The compensatory strategies become habit4 and eventually the individual does not attempt to move the affected extremity even when it is possible neurologically. The individual has learned to not use the affected extremity.

Few, if any, rehabilitation techniques are proven to restore function or overcome learned nonuse in the affected upper extremity following a stroke. The demands of today's society and health care environment often necessitate the attainment of the highest functional level possible in a brief amount of time. For this reason, the therapeutic focus or a client's choice is often on compensating for lost movement by relying primarily on the side not affected by the stroke for activities of daily living (ADL).3,8-10 Performing ADL tasks with one arm may still leave the individual with limited abilities.11,12 Four years after stroke, many people report loss of arm function as a major problem, even though 96% of those studied reached independence in ADL according to their Barthel Index scores.12 Persistent reliance on one side of the body also may result in consequences such as overuse syndromes, pain, frustration, and embarrassment.11,13,14

Constraint-induced movement therapy (CIMT) is an intervention that has research support for improving motor ability following a stroke or brain injury. Several investigations in the past 2 decades have demonstrated the effectiveness of CIMT with individuals who have residual upper-extremity weakness as the result of an upper motor neuron lesion.3-5,15-20 The basic components of CIMT involve restraint of the unaffected arm for 90% of waking hours for a 2- to 3-week period in conjunction with repetitive training of the more affected upper extremity.3,15-19,21 The less affected upper extremity is restrained with a mitt, sling, or glove. Clients typically participate in 6 to 7 hours of therapy a day plus home activities and ADL. A behavioral agreement is used to detail activities to be performed at home while wearing the restraint. This component of the program is intended to promote clients' adherence. The client also keeps a treatment diary to track use of the affected arm when away from the clinic.

Since 1999, the effects of UNIT have been investigated using neuroimaging techniques with people who had a stroke more than 6 months previously. These studies included imaging via electroencephalogram22,23 and focal transcranial magnetic stimulation. 16.17 These imaging techniques provide evidence of neuroplasticity following CIMT. The cortical changes seen with neuroimaging correspond to the functional and laboratory improvements demonstrated with motor assessments. The clients in these neuroimaging studies had typical CIMT (restraint 90% of waking hours, 6 hours of training for 10 out of 14 days, and a daily diary), with the exception of 2 studies in which participants received treatment for 8 out of 12 program days.17.22

Subject criteria for most published CIMT research primarily included the amount of movement a client must be able to perform with the more affected upper extremit.3-5,16-20,24,25 All movement criteria included the ability to start from a resting position of forearm pronation and wrist flexion and actively extend each metacarpophalangeal (MCP) and interphalangeal (IP) joint at least 10 degrees and extend the wrist at least 20 degrees.26 Individuals participating in these studies demonstrated improvements in the amount of use and quality of movement in the more involved upper extremity as well as carryover of skills from the clinic to the real world.3-5,15-20,24,25

Constraint-induced movement therapy, however, has not been found to benefit all individuals with hemiparesis. The majority of participants in CIMT investigations have met the inclusion criteria for movement. The ability to actively extend the more involved wrist 20 degrees and extend each MCP and IP joint at least 10 degrees, however, is not characteristic of many people with chronic hemiparesis.

Preliminary work investigating CIMT with clients with less functional ability of the hemiparetic arm also has had favorable results. Taub and Morris27 reported improvement in 11 of 11 individuals who had at least 10 degrees of active wrist extension, 10 degrees of active thumb abduction, and 10 degrees of active extension of any other 2 digits, or roughly enough finger extension to release a tennis ball. The investigators also reported successful outcomes with 15 out of 16 individuals from an even lower functioning group. The minimum motor criteria for these subjects was the ability to "lift a wash rag off a tabletop using any type of prehension they could manage, and then release the rag."27(p283)

To date, only a single brief mention has been made about the results of a UNIT program with an individual who had little to no movement. Taub et al described the client as having "almost no ability to move his fingers."4(p245) This person did not meet the minimum motor criteria of being able to grasp, lift, and release a washcloth. The authors described the outcome of a CIMT treatment program with this individual as a "treatment failure."4(p245) They did not provide details of the intervention program.

No studies have been published about application of CIMT with people who do not meet the motor criteria of 10 degrees of active MCP and IP joint extension and 20 degrees of active wrist extension. Our hospital receives numerous inquiries about CIMT from people with severe sensorimotor deficits as result of stroke. We estimate that over a 20-month period (June 2000February 2002), approximately 42% (147 out of 352) of the potential client inquiries we received for CIMT were from individuals who could not perform the washcloth test. Because a CIMT program with an individual with this much movement impairment has not been described, the purpose of this case report is to describe a CIMT program with a woman who had little movement of her wrist and hand more than 15 years after a stroke.

Case Description Client

"JM" was a 53-year-old right-handed woman. About 15 years before, at the age of 37 years, she had weakness and confusion while approaching the finish line of a 10-km running race. She was immediately transported to the local emergency department and was noted to have aphasia and right hemiparesis of her upper and lower extremities. Prior to the stroke, she had no history of cardiac or hypertensive disease. Two computed tomography scans were essentially normal but suggested mild edema in the left hemisphere, with no evidence of intracranial hemorrhage or ischemic infarct. Angiography revealed slow blood flow and some narrowing of the left internal carotid artery as compared with the right side. According to her medical records, these findings may have been due to arterial spasm or some increased resistance to the left anterior circulation such as a cortical vein thrombosis. Based on her symptoms, she most likely had a left middle cerebral artery occlusion. During her hospitalization, physicians discovered that JM had a mild, intermittent mitral valve prolapse, which may have precipitated her stroke. JM reported participating in inpatient rehabilitation for 10 weeks, followed by home health physical therapy and speech and language therapy intermittently for 2 years.

Screening

The client responded to posted information about a CIMT research project at Spalding Rehabilitation Hospital (Aurora, Colo). An initial telephone interview was completed with her. During this interview, she stated that she was essentially one-handed (using her left arm alone) for ADL and functional activities. She drove and maintained a busy family and social life. She no longer worked, but prior to her stroke she was a social worker. Her goals for the program were to regain some use of her right upper extremity and to hold her grandchild. JM met the initial screening criteria of:

* stroke more than I year ago

* no serious uncontrolled medical complications

* ability to follow directions (written, verbal, or demonstration)

* availability of a caregiver 24 hours a day for 3 weeks

* not currently receiving skilled therapy or treatment for the involved upper extremity

During her initial screening visit and her pretreatment testing, she appeared to meet the minimum motor criterion for a study being conducted at our facility: the ability to grasp a washcloth from a tabletop, lift it, and release it. During her treatment program and at posttreatment testing and follow-up testing, however, she could not grasp, lift, and release the washcloth. Upon further review of her pretreatment videotape, it is not clear whether she was doing 100% of the task with her right arm; it appeared that she may have assisted her right hand with her left hand. For this reason, we thought that she did not meet the minimum motor criterion and that her motor ability was lower than initially determined. We decided that it was more appropriate to describe her case separately.

During her initial visit to the clinic, JM was pleasant and apparently in good health. She walked without an assistive device or orthosis and stated she was able to walk at least 3.2 km (2 miles). She had expressive aphasia but managed to accurately make her needs known. She initiated her involvement in the program by telephoning our clinic to inquire about it. After completion of the screening process, she gave written consent to participate in a 3-week CIMT program.

Prior to her stroke, JM was right-hand dominant. Since the stroke, she had been functioning almost completely with her left upper extremity. She did not use her right upper extremity for writing, eating, household activities such as turning on lights, answering the telephone, or opening doors or drawers. She also did not use it for grooming, hygiene, or dressing, and she could not unlock a door with a key or open the refrigerator with her right hand. She did use her right upper extremity as a gross assist to remove clothes from the dryer. She could not move the fingers of her right hand.

JM had full passive range of motion (PROM) in her right upper extremity, with the exception of shoulder flexion and wrist extension. We did not record PROM measurements because range of motion was measured grossly as a part of the Fugl-Meyer Evaluation of Physical Performance. On the Fugl-Meyer test, passive shoulder abduction is tested only to 90 degrees. She reported pain in the shoulder with passive lateral (external) rotation but with no other passive movements of the extremity. When she attempted to perform activities that required right shoulder movement, JM used trunk substitution or scapular elevation to "move" her right arm. When asked to bring food to her mouth, for example, instead of shoulder and elbow flexion, JM used scapular retraction, shoulder elevation, trunk lateral flexion to the left, thoracic flexion, cervical lateral flexion to the left and cervical protraction. When palpating her right shoulder, the client appeared to have an approximately 1.27-cm (0.5-in) glenohumeral subluxation, but she reported no pain. Later in the day, JM clarified her response to state that she had intermittent right shoulder pain when she attempted to move her right upper extremity. She described a "popping or clicking" sensation in her shoulder when she attempted to elevate her arm.

During one of the initial administrations of the Motor Activity Log (MAL), while trying to use the rating scales, JM reported that she had a little trouble with reading. She appeared to read and write well, however, when she completed all of the prestudy paperwork herself and corresponded with one of the authors on a number of occasions via e-mail. Her husband, LM, filled out her daily diary with her verbal input, but this was necessary because JM could not write with her right hand. The MAL rating scales (which are lengthy) were read to her on 3 occasions to assist with the test.

Preintervention Testing

One day prior to her week CIMT program, JM completed preintervention testing, which consisted of:

* a motor assessment (the washcloth test)

* the Graded Wolf Motor Function Test (GWMFT)

* the MAL

* upper-extremity portions of the Fugl-Meyer Evaluation of Physical Performance

* the Brief Neuropsychological Cognitive Evaluation (BNCE)

* the Mini-Mental State Examination (MMSE)

References

1 Williams GR. Incidence and characteristics of total stroke in the United States. BMC Neurol 2001;1:2.

2 National Stroke Association. The cost of stroke to all Americans. Available at: http://www.stroke.org/brain-stat.cfm. Accessed December 14, 2001.

3 Wolf SL, LeCraw D, Barton L, Jann B. Forced use of hemiplegic upper extremities to reverse the effect of learned nonuse among chronic stroke and head-injured patients. Exp Neurol. 1989;104: 125-132.

4 Taub E, Uswatte G, Pidikiti R. Constraint-induced movement therapy: a new family of techniques with broad application to physical rehabilitation-a clinical review. J Rehabil Res Dev. 1999;36:237-251.

5 Blanton S, Wolf SL. An application of upper-extremity constraintinduced movement therapy in a patient with subacute stroke. Phys Ther. 1999;79:847-853.

6 Taub E. Somatosensory deafferentation research with monkeys: implications for rehab medicine. In: Ince LP, ed. Behavioral Psychology in Rehabilitation Medicine: Clinical Applications. New York, NY: Williams & Wilkins; 1980:371-401.

7 Taub E. Movement in nonhuman primates deprived of somatosensory feedback. Exerc Sport Sci Rev. 1977;4:335-374.

8 Nakayama H,Jorgensen HS, Raaschou HO, Olsen TS. Compensation in recovery of upper extremity function after stroke: the Copenhagen stroke study. Arch Phys Med RehabiL 1994;75:852-857.

9 Newborn B. Quality of life for long term recovery in stroke. Topics in Stroke Rehabilitation. 1998;5(2):61-63.

10 Bach-y-Rita P. Theoretical and practical considerations in the restoration of function after stroke. Topics in Stroke Rehabilitation. 2001;8(3):1-15.

11 DiMauro S. A survivor's perspective. In: Gillen G, Burkhardt A, eds. Stroke Rehabilitation: A Function Based Approach. St Louis, Mo: Mosby-Year Book; 1998:508-511.

12 Broeks JG, Lankhorst GJ, Rumping K, Prevo AJH. The long-term outcome of arm function after stroke: results of a follow-up study. Disability and Rehabilitation. 1999;21:357-364.

13 Sato Y, Kaji M, Tsuru T, Oizumi K. Carpal tunnel syndrome involving unaffected limbs of stroke patients. Stroke. 1999;30:414-418.

14 Mayer TK One-handed in a two-handed world. Topics in Stroke Rehabilitation. 2000;7(2):50-56.

15 Morris D, Crago JE, DeLuca SC, et al. Constraint-induced movement therapy for motor recovery after stroke. Neurorehabilitation. 1997;9:29-43.

16 Liepert J, Miltner WHR, Bauder H, et al. Motor cortex plasticity during constraint-induced movement therapy in stroke patients. Neurosci Lett. 1998;250:5-8.

17 Liepert J, Bauder H, Wolfgang HR, et al. Treatment-induced cortical reorganization for stroke in humans. Stroke. 2000;31:1210-1216.

18 Kunkel A, Kopp B, Muller G, et al. Constraint-induced movement therapy for motor recovery in chronic stroke patients. Arch Phys Med Rehabil. 1999;80:624-628.

19 Taub E, Miller NE, Novack TA, et al. Technique to improve chronic motor deficit after stroke. Arch Phys Med Rehabil. 1993:74:347-354.

20 Miltner WHR, Bauder H, Sommer M, et al. Effects of constraintinduced movement therapy on patients with chronic motor deficits after stroke: a replication. Stroke. 1999;30:586-592.

21 Taub E. New discovery equals change in clinical practice [guest editorial]. J Rehabil Res Dev. 1999;36(3):vii-viii.

22 Bauder H, Sommer M, Taub E, Miltner WHR. Effects of CI therapy on movement-related brain potentials [abstract]. Psychophysiol. 1999: 36(suppl 1):531.

23 Kopp B, Kunkel A, Muhlnickel W, et al. Plasticity in the motor system related to therapy-induced improvement of movement after stroke. Neuroreport. 1999;10:807-810.

24 Uswatte G, Taub E. Constraint-induced movement therapy: new approaches to outcome measurement in rehabilitation. In: Struss DT, Winocur G, Robertson IH, eds. Cognitive Neurorehabilitation: A Comprehensive Approach. Cambridge, Mass: Cambridge University Press; 1999: 215-222.

25 Ostendorf CG, Wolf SL. Effect of forced use of the upper extremity of a hemiplegic patient on changes in function. Phys Then 1981;61: 1022-1028.

26 Morris DM, Taub E. Constraint-induced therapy approach to restoring function after neurological injury. Topics in Stroke Rehabilitation. 2001;8(3):16-30.

27 Taub E, Morris DM. Constraint-induced movement therapy to enhance recovery after stroke. Curr Atheroscler Rep. 2001;3:279-286. 28 van der LeeJH, Wagenaar RC, Lankhorst GJ, et at. Forced use of the upper extremity in chronic stroke patients: results from a single-blind randomized clinical trial. Stroke. 1999;30:2369-2375.

29 Morris DM, Uswatte G, Crago JE, et al. The reliability of the wolf motor function test for assessing upper extremity function after stroke. Arch Phys Med Rehabil. 2001;82:750-755.

30 Constraint-Induced Movement Therapy Research Group. Manual: Graded Wolf Motor Function Test [test instructions]. Birmingham, Ala: University of Alabama at Birmingham and Birmingham Veteran's Administration Center; August 2000.

31 Wolf SL, Catlin PA, Ellis M, et al. Assessing Wolf motor function test as outcome measure for research in patients after stroke. Stroke. 2001;32:1635-1639.

32 Constraint-Induced Movement Therapy Research Group. Manual: Upper Extremity Motor Activity Log (UE/MAL). Birmingham, Ala: University of Alabama at Birmingham and Birmingham Veteran's Administration Center; August 2000.

33 Taub E, Uswatte G. Constraint-induced movement therapy and massed practice [letter to the editor]. Stroke. 2000;31:986-988.

34 van der Lee JH, Lankhorst GJ, Bouter LM. Constraint-induced movement therapy and massed practice [letter to the editor; response]. Stroke. 2000;31(4):988.

35 Duncan PW, Propst M, Nelson SG. Reliability of the Fugl-Meyer assessment of sensorimotor recovery following cerebrovascular accident. Phys Ther. 1983;63:1606-1610.

36 Folstein MF, Folstein SE, McHugh PR. "Mini-Mental State" : a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975; 12: 189-198

37 Tonkonogy J. The Brief Neuropsychological Cogntive Examination (BNCE) Manual. Los Angeles , Calif: Western Psychological Services; 1997: 43-51

38 Fugl-Meyer AR, Jaasko L, Leyman I, Olsson S Steglind S. The post-stroke hemiplegic patient. Scand J Rehabil Med. 1975;7:13-31.

39 Bleecker ML, Bolla-Wilson K, Kawas C, Agnew J. Age-specific norms for the Mini-Mental State Exam. Neurology. 1988;38:1565-1568.

40 Morris DM, Crago JE, Uswatte G, Taub E. Behavioral components of constraint-induced movement therapy [poster presentation]. Neurology Report. 2000;24:201.

N Bonifer, PT, MS, NCS, is Physical Therapy Lead, Spalding Rehabilitation Hospital, 900 Potomac St, Aurora, CO 80011 (USA) (Nancy, Bonifer@HealthONEcares.com) Address all correspondence to Ms Bonifer.

KM Anderson, ORT, is Staff Occupational Therapist, Spalding Rehabilitation Hospital.

Both authors provided concept/idea/project design, writing, data collection, and subjects. Ms Bonifer provided data analysis, project management, fund procurement, and clerical support. Ms Anderson provided consultation (including review of manuscript before submission). David Reinhard, MD, Kim Gorgens, PhD, and Elena Draznin, MD, provided consultation. The authors greatly appreciate the efforts of Holle Balzer, PT, MPT, Peggy Kelly, OTR, and Fred Hudson, RN, for assistance with data collection. The authors thank David Morris, PT, MS, and Edward Taub, PhD, for providing expert clinical information via consultation and providing us with copies of the Motor Activity Log, Wolf Motor Function Test, and Graded Wolf Motor Function Test. The authors also thank Steven L Wolf, PT, PhD, FAPTA, for providing expert clinical information. A special thanks is extended to the client and caregiver, who made this case report possible.

The program protocol was approved by the HealthONE Alliance Institutional Review Board.

This project was supported by a grant from the Spalding Community Foundation and HealthONE Spalding Rehabilitation Hospital, Aurora, Colo.

This article was submitted February 22, 2002, and was accepted November 3, 2002.

Copyright American Physical Therapy Association Apr 2003
Provided by ProQuest Information and Learning Company. All rights Reserved