December 4, 2014

Constraint Therapy is Good and Bad

When a new graduate told a blogger that stroke recovery happens in the first two years I decided to write about constraint therapy.  It was designed by Edward Taub who did not believe recovery after a stroke is time limited.  Constraint therapy involves putting a mitt on the sound hand for 1+ hours of therapy that focuses exclusively on the hemiplegic hand plus leaving a mitt on the sound hand for 3+ hours at home each day to force the hemiplegic hand to work.  Since 1993 many constraint therapy studies have found clients can recover hand function for years after a stroke. 

Constraint therapy is good because it challenged long held beliefs about neuroplasticity.  However, it is appropriate for a limited pool of clients.  1. Stroke survivors must already be able to extend (straighten) their fingers 10 degrees and their wrist 20 degrees.  2. It is good for men who have women to take care of them.  It would be nice if every husband would go grocery shopping, cook, and do laundry while their wives constrain their sound hand at home every day.  3. Some stroke survivors experience crushing fatigue.  I had to decide what NOT to do every day for two years.   

Current research offers an alternative.  Hayner found guiding both hands to work while making lunch, eating, and cleaning up helped stroke survivors improve as much as subjects whose hand was constrained during the same activity (1).  Sterr reported that stroke survivors who were helped to use their hemiplegic hand for 90 or 180 minutes improved as much as subjects who received constraint therapy for the same amount of time (2).  These and other studies have shown that mass practice can be less intense and come in several forms and still produce recovery.  

How can stroke survivors force so much hand use?  I do exercises with a spring-loaded splint (SaeboFlex) that helps me open my hand 100 times.  I live alone so my hemiplegic hand opens to hold 100+ objects while my sound hand manipulates those objects.  Even brief hand use adds up.  In 11 years my hemiplegic hand has opened to hold a tube of toothpaste 16,060 times so my sound hand can take the cap off and put the cap back on after I put toothpaste on my toothbrush.

Bottom Line: Taub showed therapists and stroke survivors they need to let go of old myths.

1. Hayner K, Gibson G, Giles G. Comparison of constraint-induced therapy and bilateral treatment
    of equal intensity in people with chronic upper-extremity dysfunction after cardiovascular    
    accident.  American Journal of Occupational Therapy. 2010;64(4):528-539.
2.  Sterr A, Oneill D, Dean P, Herron K.  CI therapy is beneficial to patients with chronic low-
     functioning hemiparesis after stroke. Front. Neurol. 2014;5: