Constraint Leads to Freedom
Therapy May Increase Mobility for Stroke Patients

When Burt Kilmer began experimental constraint therapy only a week after having a stroke, the 55-year-old mechanic had almost no function on his left side.

He had difficulty walking, and he couldn’t pick up any of the colorful pegs the occupational therapist instructed him to plug into holes on a board.

“I couldn’t grasp anything with my left hand. It was frustrating,” Kilmer said. “All I wanted to do was use my good side, but the therapist told me not to. The point of the therapy was to force me to use my bad hand so I would get better faster.”

For two weeks, under the care of researchers at The University of Texas Medical School at Houston, Kilmer endured what is known as constraint therapy. He spent 90 percent of his waking hours with his “good” right hand in a mitt that resembles a pingpong paddle.

The mitt, which consists of a splint, fabric and a little bit of elastic, isn’t exactly high-tech. It’s a simple device, but could be the key to recovery for a portion of the 600,000 Americans who suffer ischemic strokes each year.

The mitt’s sole function is to prevent stroke patients from bending their “good” hand and fingers, thus forcing them to use the limb that was damaged during their brain attack.

Several small clinical trials have consistently shown that stroke survivors can improve motor function with constraint therapy, even years after their injury.

Neurologists at UT-Houston felt these results were intriguing and wanted to investigate further. Last year, using a grant from the National Institute of Neurological Disorders and Stroke at the Institutes of Health, they began testing a theory that recovery would be faster and more profound in patients who started constraint therapy within 14 days of their stroke.

“When a patient has a stroke and one side of the body is affected, we see a phenomenon called learned non-use,” said stroke fellow Elizabeth Noser, M.D. “Patients learn to compensate with their good side, and essentially ignore the damaged limbs.”

The non-use not only hinders recovery, but also can prompt medical complications, including shoulder pain and tendonitis.

“We are researching whether we can prevent stroke patients from ever learning non-use,” she said. “If we can force them to use their weak side and do aggressive therapy soon after the stroke, we may be able to promote healing in the brain, improve motor function and prevent other medical complications.”

Previous studies prompted concern that initiating rehabilitation too early could actually cause more brain damage to the stroke patient, but Noser said the pilot study performed at UT-Houston found that constraint therapy was feasible and safe to begin within 14 days of a stroke.

To qualify for the research, patients must have at least 10 degrees of movement in the disabled hand, minimal movement in the arm and the mental capacity to follow instructions.

At the beginning and end of the therapy, researchers use transcranial magnetic stimulation, a noninvasive technique to map out neurons that control hand movement.

During the next two weeks, the patients spend three hours each day in occupational therapy. They must wear the mitt 90 percent of their waking hours, including the three hours each day that they are in occupational therapy.

“It’s very intense,” Noser said. “It’s a lot of therapy for our patients, but they do great. We find that more neurons are being recruited after the therapy, and that means the brain is healing.”

Take Kilmer, for example. He now works out three to four times a week and has the skills he needs to care for himself.

“I don’t think I could thread a needle, but my wife can’t either, and she’s never had a stroke,” Kilmer joked. “I think it really helped me.”

The constraint therapy will continue for another two years, during which time 44 stroke survivors will be enrolled, making it the largest clinical trial of its kind.

Research participants will be tested again two years after the constraint therapy to determine if the effects are sustainable.

“Our goal is to heal people to the best of our ability so our stroke patients can be healthier and live independently,” John Choi, M.D., director of the neurorecovery program at UT-Houston, said.

---

©2006 Texas Medical Center

---

E-Mail: tmcinfo@texmedctr.tmc.edu
URL: http://www.tmc.edu/tmcnews/05_15_03/page_11.html