Published in UAB Insight, Summer 2008
Rehabilitation Technique Targets Learned Nonuse
The slow, relentless progression of disability caused by multiple sclerosis (MS) has long been regarded as unchangeable, discouraging physicians and patients from considering rehabilitation to improve physical functioning. New research, however, is showing that with appropriate therapy MS patients can attain significant, meaningful gains in physical function.
Victor W. Mark, MD, a neurologist in UAB's Department of Physical Medicine and Rehabilitation, and colleagues are studying Constraint-Induced Movement Therapy (CIMT), a form of physical therapy first developed for stroke patients with upper or lower extremity hemiparesis, for individuals with MS.
"Our research has shown that lack of use of a hemiparetic limb is due not only to damage to the brain, but also to compensatory behaviors acquired by the patient. Patients with chronic hemiparesis stop using the more-affected limb and rely on the less-affected extremity. When asked, however, many patients show they can still move their affected limb well enough for everyday tasks," he says. "CIMT retrains patients to overcome this learned nonuse and spontaneously complete activities with their more-
affected limb. This can significantly increase their ability to complete everyday tasks."
Use-dependant Neuroplasticity
CIMT combines restraint of the less-affected extremity with massed practice of repetitive movements and a transfer package that includes a behavioral contract, home practice, and daily review between patient and therapist to solve problems that arise in real-world settings.
Developed more than 20 years ago by UAB behavioral neuroscientist Edward Taub, PhD, CIMT overturned the belief that motor deficits in chronic stroke patients are refractory to therapy. Multiple clinical trials confirm that CIMT in stroke patients produces substantial motor improvements and significant structural cortical remodeling months to decades after injury.
"Biologically, MS resembles stroke," says Mark, who is medical director of UAB's CIMT research program. "It seemed clear that patients with certain forms of MS - the nonrelapsing primary and secondary progressive forms - might respond to this therapy and achieve sustained improvements in motor function."
Mark and colleagues adapted CIMT to accommodate the fatigue that characterizes MS and have completed a small pilot study funded by the National Multiple Sclerosis Society. This initial investigation found that CIMT produces significant and immediate improvements in patients' motor ability for at least 4 weeks posttreatment. Some individuals who underwent longer follow-up regressed slightly at 6 months, while others maintained improvements for 1 or 2 years.
"Gains were comparable to improvements seen in similarly treated stroke patients," Mark says. "After therapy, the more-affected arm automatically participates more, and people who were essentially one-handed before therapy become two-handed."
Mark also is studying the effects of CIMT on lower extremity deficits. "Initial results are promising. Patients' endurance for walking increases and their gait becomes more symmetrical," he says. "Overall, patients are very responsive to this therapy - they find the improvements liberating. Although MS is a progressive disorder, we hope, at a minimum, to give patients extended periods of improved function."
FOR MORE INFORMATION:
Dr. Victor Mark
1.800.UAB.MIST
mist@uabmc.edu