Upper Extremity Interventions Post Acquired Brain Injury

Constraint Induced Movement Therapy

Constraint induced movement therapy (CIMT) is an intervention directed at improving the function of the more affected upper extremity following brain injury. The two primary components involve: 1) intensive motor training of the more affected upper extremity (up to six hours per day) and 2) motor restriction of the less affected upper extremity (Dettmers et al. 2005). CIMT originated from research suggesting that the affected limb post brain injury is negatively impacted by “learned non-use” due to increased dependence on the intact limb (Grotta et al. 2004).

Although there is evidence in the stroke population to suggest that CIMT is clinically effective, many patients do not qualify for this type of therapy due to limited movement in the upper extremity. CIMT ideally requires that the patient can voluntarily extend their wrist and fingers in the affected hand which limits the number of patients for whom it is applicable.  A further significant limitation of CIMT is the amount of resources required for its implementation (Grotta et al. 2004).Two studies evaluating the effect of CIMT post traumatic Brain Injury (TBI) were identified.

Individual Studies

Table: Constraint Induced Movement Therapy in the Upper Extremities

Discussion

The effectiveness of modified CIMT was studied by Page and Levine (2003), with participants showing improvements in both the amount and quality of use of the more affected limb. CIMT was also studied by Shaw et al. (2005) and showed similar results. Significant improvements were seen in both laboratory and real world spontaneous use of the more affected upper limb following two weeks of CIMT. Although all participants benefited from the intervention, the gains made by those placed in the “less adherent” group were strongly correlated with the participant’s degree of adherence (Shaw et al. 2005). This correlation was not evident in the “more adherent” group; with the authors suggesting that adherence beyond a certain level does not contribute to additional benefits (Shaw et al. 2005). The gains were maintained at one month and use of the affected limb decreased by 21% at two years post treatment. Given these two studies, CIMT for the upper extremity looks promising. 

Conclusion

There is Level 4 evidence for the effectiveness of constraint induced movement therapy in improving upper extremity use post ABI.

 

Constraint induced movement therapy provides benefit for the more affected upper extremity post ABI.

 

Hand Splinting

The purpose of hand splinting following an ABI is to prevent contractures and deformities and to reduce spasticity. Splints are not likely to be used for functional purposes (Djergaian 1996). There are biomechanical and neurophysiologic rationales for splinting the spastic hand (Lannin et al. 2003). The biomechanical approach attempts to prevent contractures by physically preventing shortening of muscle and connective tissues. The neurophysiologic approach is based on the concept that the splint can inhibit reflexive contraction of the muscle.  Ultimately, the aim is to reduce deformity and contractures in the hand.  

Individual Studies

Table: Hand Splinting in the Upper Extremities Post Acquired Brain Injury

Discussion

One study evaluated the effect of night time hand splinting in conjunction with conventional therapy compared to therapy alone (Lannin et al. 2003). Overall results did not demonstrate significant benefits of nocturnal hand splinting. A second randomized controlled trial (RCT) examined soft hand splinting, manual stretching and no intervention (Thibaut et al. 2015). Results suggest that soft hand splinting for 30 minutes resulted in improved hand opening and reduced spasticity of the flexor finger muscles. The hand splint was said to be feasible to use in daily care, as the splint was comfortable and easy to apply. There is a need to further research both the biomechanical and neurophysiologic effects of splinting in the individuals with ABI as this practice is used in both acute and rehabilitation settings.

Conclusion

Based on a single RCT, there is Level 1b evidence that nocturnal hand splinting does not improve range of motion, function or pain control post ABI.

Based on a single RCT, there is Level 2 evidence that soft hand splinting improves spasticity and hand opening post ABI.

 

Overnight hand splinting does not provide clinical benefit for individuals with brain injury.

Soft hand splinting may be beneficial for improving spasticity and hand opening.

 

Improving Fine Motor Coordination in Adults with Brain Injury

As discussed previously, the negative symptoms of UMNS, independent of spasticity, include: weakness, slowness of movement and loss of finger dexterity (Mayer 1997).  Although gross motor function may return early in the recovery following a brain injury, fine motor deficits may persist and present a considerable challenge for both the individual and the clinicians treating them. Studies that targeted fine motor coordination impairments post ABI were identified. These studies highlight some of the treatment modalities that are being utilized to improve fine motor ability. 

Individual Studies

Table: Fine Motor Coordination Interventions for Adults with Brain Injury

Discussion

Neistadt (1994) examined fine motor coordination in a group of adult men with brain injury after two types of coordination retraining activities: tabletop activities (i.e., peg board activities, puzzles etc.) and functional activities (i.e., meal preparation). The study suggests that functional activities may be slightly more effective than table top activities in promoting fine motor coordination in persons with brain injury. Another study found that visual feedback-based training of grip force is useful for individuals post brain injury (Kriz et al. 1995). More specifically, a light weight force transducer was held between the pulp of index finger and thumb of the impaired hand. In response to visual cues delivered via computer monitor, all tasks involved the gradual increase and decrease of grip force in training and transfer protocols. Regardless of the individual pattern of impairments, all but one patient succeeded in improving their tracking performance and transferring regained capabilities to other tasks.

The most recent fine motor coordination study compared the use of gesture recognition biofeedback to standard repetitive training without feedback; results showed a significant decrease in task completion time for those who received feedback (Yungher & Craelius 2012). This intervention is both simple to execute (e.g., no precise placement of sensors, etc.) and the assessment is straightforward. The authors suggest that this intervention leads to improvements in fine motor function of the hand with minimal supervision (Yungher & Craelius 2012). Despite these studies, there is limited evidence to guide clinical practice in this area.  

Conclusions

Based on a single RCT, there is Level 1b evidence that both functional and tabletop fine motor control retraining activities result in improved fine motor coordination; however functional retraining activities were more effective in improving fine motor tasks in the dominant hand.

There is Level 2 evidence that visual feedback grip force training improved tracking and transfer performance.

There is Level 2 evidence that gesture recognition biofeedback leads to greater improvements in fine motor function of the hand compared to standard repetitive training without feedback. 

 

Functional dexterity tasks improve fine motor coordination.

Gesture recognition biofeedback is a simple and effective way of improving fine motor function of the hand.