October 16, 2009
Modified Constraint Induced Movement Therapy Discussion
In early 2008, an online discussion took place between two researchers regarding the implementation details of Constraint Induced Movement Therapy (CIMT). Dr. Steven Wolf, the principle investigator of the 2006 EXCITE study makes some interesting comments about Dr. Steven Page’s mCIT trial (Modified Constraint Induced Therapy).The following compares a few of the main components of Dr. Wolf’s CIMT and Dr. Page’s mCIT:
| CIMT | mCIT | |
| Location | clinic | home |
| Hours of Daily Therapy | 6 hours* | 0.5 hours |
| Duration of Therapy | 3-6 weeks | 10 weeks |
| Daily Arm Restraint** | 9 hours/day for 2 weeks | 5 hours/day for 5 days/week for 10 weeks |
| Benefit to Patient | Statistically Significant: refer to article |
Statistically Significant: refer to article |
* patients experiencing fatigue are not be required to complete 6 hours/day
** CIMT and mCIT require that patients restrain their less affected limb for periods of time during the day.
October 14, 2009
Constraint Induced Therapy at Home
What is Constraint Induced Therapy (CIT)?
Initially called “forced use therapy,” constraint induced (movement) therapy (CIT) is the principle of immobilizing one hand so that the participant uses only the other hand during therapy. During hand rehabilitation in stroke, for example, participants wear a mitten on their less affected hand and perform exercise tasks with only their weak hand.
For many years researchers had known that intensive exercise therapy (IET) accelerated recovery in the central nervous system. The related term “neuroplasticity” was introduced to describe the ability of the nervous system to reorganize itself after injury.
In a 2006 randomized controlled trial, stroke rehabilitation researchers found that CIT resulted in larger improvements than conventional therapy. So, it appears that CIT can be an important component of a successful recovery after a neurological injury such as stroke or spinal cord injury.
Here’s a video of Constraint Induced Movement Therapy:
What are the limitations of CIT?
In most cases, CIT providers require subjects to have a minimum level of functional movement in their affected limb. This excludes many people with moderate levels of disability. Perhaps the major limitation of CIT in its original form is the requirement that participants spend up to 3 weeks in a clinic. This can be prohibitively expensive, sometimes costing more than $20,000 for therapy, accommodation, and travel.
Only a few rehabilitation clinics offer the “authorized” version of CIT, so you may need to relocate for a period of time to participate. In most cases, this is very expensive, so it is worth contacting your insurance company before you embark on this option. Less intensive protocols have been suggested, e.g. modified CIT (mCIT) in which a therapist supervises CIT for 30 minutes/day, 3 times/week for 10 weeks and in addition the participant performs self-directed exercise tasks 5 hours/day, 5 days/week with a mitt on the less affected hand. The supervised portions can occur at home if the therapist uses a telerehabilitation link.
Finally, you can conduct a program on your own. You will set up a regimen of training exercises for yourself and wear a mitt on your less affected hand. Do a Google search for mCIT (or Modified Constraint Induced Therapy) before beginning so that you understand what’s involved. Be sure to ask your doctor or physical or occupational therapist whether they recommend self-directed mCIT BEFORE you begin
New ways of delivering Intensive Exercise Therapy (IET)
The latest approach to upper extremity rehabilitation is to use devices that provide task-specific IET of the shoulder, arm and hand. The tasks include “range-of-motion” of the shoulder and arm as well as grasp and release tasks of the hand. The latest devices, like the ReJoyce system for example, use computers to track these movements and control highly-motivating computer games.
Telerehabilitation providers are beginning to emerge online. In this case, a provider will run through an assessment with you online. Provided you fit their criteria and have physician approval, they will ship you the necessary equipment. Your caregiver will set up the equipment and the provider will schedule rehabilitation sessions with you. During these sessions, a therapist will supervise you directly using a web cam. Often, the therapist can configure the equipment in your home to match your exercise requirements. You will likely need to have your caregiver present for these sessions for safety reasons. Telerehabilitation is usually much less expensive than in-clinic rehabilitation.
October 13, 2009
Maximize At-Home Recovery after Stroke
After a stroke, home-based rehabilitation will be an important part of your path to recovery.
Here are some tips to maximize your recovery at home:
1. Getting active about your stroke care. After discharge from an acute care or rehabilitation facility, you may be inclined to let a caregiver take the reigns. It is vital to make sure you work with your caregiver and take an active stance on your health and rehab including: discussing your disabilities with your caregiver as soon as possible, acquiring the appropriate assistive devices, establishing a supervised exercise regimen (in accordance with your physician’s recommendations, of course).
2. Finding the right assistive devices. These include “reachers” (for dressing yourself if you have weakness in your arm or hand), large-handled cutlery to assist you with eating, analysis of your diet if you have trouble swallowing, canes and/or walkers to maximize your independence and mobility, an ankle-foot orthosis (AFO) or functional electrical stimulator (FES) for your leg if you suffer from foot-drop or for your hand to help with grasp and release. Your physician, therapist, caregiver and personal research will yield some very handy results to help you regain independence.
3. Recognizing and treating signs of depression quickly. Depression is common in people who have had a stroke, especially after the acute phase of stroke rehab has ended. If you develop signs of depression, make sure you let your caregiver and doctor know.
4. Getting involved in a rehabilitation program as soon as possible. Establishing a routine of exercise and rehabilitation early on will help you get motivated about your recovery. There are lots of options ranging from self-guided exercises with simple equipment to Internet-based stroke exercise therapy, in some cases with clinical supervision. All are available to you at varying costs. The sooner you get involved, the sooner you can accelerate your recovery. It is important to note that, even if you had a stroke several years ago, supervised movement rehabilitation may help you.
5. Getting social. Many people living with stroke complain of feeling isolated due to poor mobility. Telerehabilitation is a great way of reducing this feeling of isolation. It allows you regularly to speak with a therapist while you engage in home-based rehabilitation. Other options include support groups, online social networking, family visits and assistive devices that allow you to regain mobility.
6. Being consistent. Recovering from stroke is hard work, but it is rewarding. Try scheduling your rehabilitation into 6-week blocks and be consistent! After every 6-week block, determine how much you’ve improved (some stroke rehabilitation systems will let you track your progress) and plan your next 6-week block based on your experience.
7. Exercising at home. Stroke survivors in the past received health services, including therapy in a rehabilitation facility for up to 3 months. Healthcare systems can now only afford to provide this for 2 to 3 weeks. This increases the attractiveness of home-based rehabilitation alternatives.
Home-based stroke therapy offers major advantages, such as the elimination of travel to a clinic, frequent rehabilitation sessions, a more familiar and relaxed environment, and heightened family awareness. The disadvantage is that hands-on contact between client and therapist is missing. Fortunately, recent advances in home-based telerehabilitation provides an exciting solution. Direct contact between client and therapist is restored and in fact it can be greatly increased in frequency, maximizing the effectiveness of the therapy. Telerehabilitation allows clients and therapists to communicate using an audio/video link over the Internet. Furthermore, specially designed exercise devices installed in the participant’s home allow the therapist not only to supervise standardized exercises but also to control the difficulty of the exercises and get precise data on how the participant is improving. This eliminates the need for the therapist to travel to the client’s home (which can take up to 8% of their day, according to a study conducted by Forster and Young in 1990). Additionally, it reduces isolation of clients from their therapists and therapists from their multi-disciplinary team in the clinic.
8. Is home-based rehabilitation effective? A scientific group in New Zealand (Baskett et al.) published results of a study in 1999 indicating that clients engaged in home-based therapy improved as much as those engaged in outpatient-based therapy. There was no significant advantage to outpatient therapy. Home-based recovery has the further advantage of improving caregiver confidence and reducing the social isolation of the patient, likely improving psychosocial well being.
9. What does home-based stroke therapy consist of? Home-based stroke rehab can be directed either by a therapist or by the client. In the case of physical rehabilitation, clients undertake a daily exercise regimen with a focus on recovering movement in their affected limb. In addition to verbal advice from clinicians, written descriptions of preferred exercises to improve tasks of daily living and improve mobility.are sometimes made available.
Several medical devices are also available to help complement home-based stroke exercise and recovery. These include FES (Functional Electrical Stimulation) devices available for the arm, hand and leg. These FES devices provide trains of electrical pulses that activate the nerves and muscles in a client’s affected limb. Most of these devices have exercise modes that patients can use to reduce stiffness and spasticity. Some can be used to augment a patient’s ability during normal daily activities - this type is typically called a neuroprosthetic.
Specialized at-home exercise devices are available commercially for at-home stroke recovery. These range from simple rubber meshes for hand grasp and release, to sophisticated (and expensive) bicycles with FES components. Several telerehabilitation devices are available for at-home stroke rehabilitation - try a Google search for “stroke telerehabilitation” to find a list of these providers.
Home-based stroke rehabilitation is tremendously valuable to both patients and society in general. It saves time, cost, and can yield very positive results.
October 2, 2009
Stroke Rehabilitation and Recovery
Stroke is a debilitating brain injury that affects more than 1 million people in N. America and the UK every year. Stroke survivors are often left with long-term disabilities that affect their mobility, speech and cognition, any of which may lead to a loss of independence. Stroke recovery can be divided into three periods: short-term (acute), long-term and chronic disability management.
During the acute recovery phase within the first few months of a stroke, patients will generally work with a team of physical, occupational and speech therapists. Most of this rehabilitation treatment occurs in a clinical environment. Patients either stay at the facility for a few weeks, or are treated as out-patients, while living at home or at another care facility. Depending on the nature of their disabilities, patients spend several hours every day re-training their affected limbs, practising compensation methods for activities of daily living (ADL), undergoing exercise therapy for spastic muscles, and learning management techniques. Patients with poor hand and arm control will usually work with an occupational therapist to complete increasingly complicated ADLs as their recovery progresses. The ADLs will include hand, arm and shoulder exercises ranging from simple range of motion games (e.g. “pass a balloon” using the affected arm), to manipulating small items, such as pegs. Performance tests may be done to gauge the rate of recovery. A few of the more progressive clinics have equipment designed to automate certain exercise tasks and tests and make them more engaging and interesting.
During the acute recovery phase, a patient suffering from speech problems will likely work daily with a speech pathologist. Depending on the nature of the speech disability, the patient can expect to either match words with corresponding pictures, play pronunciation games, or practise reading, writing or self-expression. Again, patients may be tested during regular intervals to gauge their level of recovery.
Patients with very severe disabilities may not benefit from rehabilitation during this acute recovery stage, and may be placed in long-term disability facilities instead.
After about 6 months of acute recovery, patients enter the long-term recovery phase, during which recovery usually progresses at a slower rate. Some modern techniques, such as constraint-induced therapy (CIT), have been reported in recent trials to produce significant gains even when initiated years after a stroke and when there have been long breaks from rehabilitation. The long-term stroke recovery phase is usually completed either at a person’s home, with semi-regular visits to occupational, speech, or physical therapy clinics. Of course, regular checkups by a person’s GP are advisable. Unfortunately, many stroke survivors cease active rehabilitation after the acute phase, which usually means they never reach their full recovery potential.
Recently, several medical companies and institutions have started offering telerehabilitation services over the Internet. Such services make long-term stroke recovery easier to manage, particularly since they are usually conducted in people’s homes directly, eliminating the need for patients to travel to clinics or other locations. These services range in price and effectiveness, and people should be careful to participate in a program that has been scientifically proven to be of benefit.
Recovery of function can continue for years after a stroke but in some cases additional devices or drugs can significantly aid in the process. These include botox injections to reduce muscle spasticity and pain, and medical devices such as foot and hand/arm nerve stimulators to improve walking and hand movement.
Stroke recovery and rehabilitation is a lot of hard work, but can often yield very encouraging results that can significantly improve people’s lives.
