Teaching the brain to “rewire” itself following a major head injury or stroke is the basis of Constraint-Induced Movement Therapy (CIMT), which was developed by University of Alabama at Birmingham (UAB) professor Dr. Edward Taub. More than 400 adults in Birmingham have benefited from this therapy, and since May 2007, 26 children have been treated at the Children’s Hospital of Alabama with techniques based on years of research by Taub and collaborators at UAB. Angi Griffin, MA, OT/L, who is pediatric CI therapy program manager at Children’s Hospital of Alabama, said research on pediatric CIMT began about 10 years ago and the techniques have proven successful on many children. Taub’s research has shown that patients can learn to use the weaker hand and arm and, therefore, not rely primarily on the stronger hand and arm. Pediatric CIMT has benefited many children with cerebral palsy, early stroke, hemispherectomy or traumatic brain injury. “CI therapy has significantly improved quality of movement and substantially increased the amount of use of the more-affected extremities in the activities of daily living for a large majority of children who have received the treatment,” said Griffin. Specific benefits may include improved quality of hand use, the emergence of new movements of the affected arm or hand not performed previously (e.g., thumb-forefinger grasp and patients using the more-affected hand to manipulate utensils and feed themselves), more spontaneous use of the more affected arm or hand, and improved hand function such as fine motor and grasp. CIMT has four major components: restraining, shaping, intensity and the transfer package. The stronger arm is completely restrained for up to three weeks using a lightweight fiberglass cast extending from the upper arm to the fingertips. “A child with an affected arm will neglect that arm if he or she can’t use it,” Griffin said. “CIMT is based on the theory of learned non-use. When you force them to use the affected arm — and make the activity one they can perform — they will see success.” Shaping is a technique the therapists use to reward successive approximations of motor behavior. Patients are trained to perform increasingly difficult tasks with their affected arm in small steps in situations that are appropriate for their stage of development and then are rewarded for improvement. The difficulty of the task may be increased by requiring a larger number of repetitions or by making the task progressively more difficult in small steps by, for example, altering the size of the object. “We help the children with activities of daily living such as eating, self-care and play. This will allow the child to put into practice the new skills that he or she will acquire and help them gain confidence and independence in a variety of situations,” Griffin said. Patients receive therapy three to four hours a day five days a week for a total of two to three weeks, depending on the severity of the symptoms. Following the therapy sessions, the transfer of therapy to the parents takes place. “We teach the parents specific strategies to help the child use his arm at home. The home therapy combined with increased intensity of task performance helps the children retain the improvement in affected arm function achieved in the therapy,” said Griffin. CIMT has been shown to produce a marked change in brain organization and function. Further research has shown that plastic brain reorganization takes place with successful therapy. “There is converging evidence that CIMT leads to very large use-dependent plastic brain changes, so that a more extensive area of the brain is involved in innervating movement than before therapy,” Griffin said. The Pediatric CIMT program at Children’s Hospital of Alabama is establishing a training program for pediatric CIMT to train occupational therapists and physical therapists from all over the United States and the world. The first training workshop will take place October 6-10, 2008, at Children’s Hospital. “We do evidence-based practice, and our training program is based on current research,” Griffin said. “We make sure we are doing state-of-the-science treatment with these children, and we want other people to be doing that, too.” August 2008