4.1 Upper Extremity Interventions Post Acquired Brain Injury

4.1.1  Constraint Induced Movement Therapy (CIMT)

What is constraint induced movement therapy?  How does constraint induced movement therapy work?  What are the minimal requirements to use it in the most affected upper extremity?

  1. CIMT involves: a) motor restriction of the less affected upper extremity and; b) intensive motor training of the more affected upper extremity.
     
  2. Works to counteract “learned non-use” of the most affected limb by removing dependence on the less affected limb.
     
  3.  Ideally the patient should be able to voluntarily extend their wrist and fingers in the affected hand.

What evidence is there for constraint induced movement therapy? 

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

Constraint induced movement therapy (CIMT) is an intervention directed at improving the function of the more affected upper extremity following brain injury.  The 2 primary components involve: 1) intensive motor training of the more affected upper extremity (up to 6 hours per day); 2) motor restriction of the less affected upper extremity 1. CIMT originates 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 2.

Although there is evidence in the stroke population to suggest that CIMT is clinically effective, many stroke and ABI 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 to implement it 2.  Due to this intense resource requirement, further study of the needed intensity for CIMT is required 1.

Two studies evaluating the effect of constraint induced movement therapy post acquired brain injury were identified: 

In the initial study by Page and Levine 3, patients received 3 sessions of occupational therapy and physiotherapy weekly for 10 weeks with their less affected arm restrained for 5 hours daily.  Each of the 3 patients demonstrated improvements in the amount and quality of use of the affected upper extremity.

The second study by Shaw et al. 4reported significant improvements in both laboratory and real world spontaneous use of the more affected upper limb following two weeks of constraint induced movement therapy in 22 TBI patients.

4.1.2  Hand Splinting

What is the purpose of hand splinting following an acquired brain Injury?

  1.  Hand splinting (see diagram 1) following an acquired brain injury serves to prevent contractures and deformities and to reduce spasticity.

What evidence is there for the benefit of nocturnal hand splinting post ABI?

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

The purpose of hand splinting following an acquired brain injury is to prevent contractures and deformities and to reduce spasticity. Splints are not likely to be used for functional purposes 5. There are biomechanical and neurophysiologic rationales for splinting the spastic hand 6. 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.

Only one randomized controlled trial was identified evaluating the effectiveness of hand splinting post acquired brain injury. One study evaluated the effect of night time hand splinting in conjunction with conventional therapy compared to therapy alone 6. Overall results did not demonstrate significant benefits of nocturnal hand splinting.

There is a need to further research both the biomechanical and neurophysiologic effects of splinting in the individuals with acquired brain injury as this practice is common in both acute and rehabilitation settings.

4.1.3  Improving Fine Motor Coordination in Adults with Brain Injury


What evidence is there for rehabilitation improving fine motor coordination post ABI?
  1. Based on a single RCT, there is Level 1 evidence that functional fine motor control retraining activities results in improved fine motor coordination in addition to re-establishing life skills.
     
  2. There is Level 2 evidence that visual feedback grip force training improved tracking and transfer performance.

The negative symptoms of upper motor neuron syndrome, independent of spasticity, include: weakness, slowness of movement and loss of finger dexterity 7. Although gross motor function may return early in the recovery following a brain injury, persistent fine motor deficits may persist and present a considerable challenge for both the individual and the clinicians treating them.  

Two studies were identified that targeted fine motor coordination impairments in people who have experienced ABI. These studies highlight some of the treatment modalities that are being utilized to improve fine motor ability. Using tasks based in both functional and simulated activities and applying the principles of visual feedback the results of these two limited studies are insufficient to guide clinical practice in this area. There is room for both rigorous studies in the use of traditional methods as well as new innovative solutions.

Neistadt 8examined the effects of puzzle construction and kitchen activities on fine motor coordination in a group of adult men with brain injury. Occupational therapists used two types of activities in coordination retraining for adults with brain injury: 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.

Kriz et al. 9explored the effect of visual feed-back based training on grip force – a fundamental aspect of grasping and handling objects. Patients were selected from a larger group based on etiologies of their hand function.  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.