CIMT on Lower Extremity

[vad guy]

Has any tried this on a stroke patient with left-sided hemiparesis? I’m interested in trying it.

I actually had a stroke 15 months ago at 25y/o. A vertebral artery dissection left me hemiplegic. Since the incident I’ve improved quite a bit but I still have problems with my gait (a slight limp, my strides are very short and my ankle is weak). My therapist told me that I use my right leg more than I should and that I need to use put more pressure on my left.

I’d like to try this out, I have a knee brace and was hoping to try out a modified schedule using a knee brace. Any suggestions or advice about exercises etc

Thanks in advance

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[gcoe]

Hi

I haven't used it myself but I do find it interesting and worth consideration. Given your motivation, that you had a bleed, and your age, these factors will work in your favour. On the down side the time since the hemorrhage, progress is likely to be slow at this point. A "kick-ass" approach like CIMT was originally designed for people like yourself later down the track and has shown to be effective in the later stages of recovery of the arm, when we don't expect there to be a huge amount of improvement.

But does it work for the lower limb? Unfortunately there isn’t much written up about the effectiveness CIMT for the lower limb. There is one study that looked at patient’s experiences of practicing with the affected limb when the unaffected limb is constrained in a splint, like you have described. So this study reported on how patients felt and thought about the programme, not the effectiveness of the programme. I have included it in case you might like to see what the patients said about it – Generally patients seemed to like it because it gave them hope and they experienced improvements. However they did find it tough, daunting and frustrating.

When one thinks of CIMT we tend to get very focused on the constraining. However the far more important part of the procedure is what you do with the unconstrained limb, not what you do with the unaffected limb. The intensive nature (several hours a day) with what we call massed practice is what counts. There is overwhelming evidence that making programmes intensive – ie just increasing the amount of practice is better than non massed practice and CIMT is characterised by extremely intensive practice. So depending on what you do with the affected limb, it may well help you. I also think give your age and your future that lies ahead anything that improves function has to be good.

However there are a few cautions to keep in mind:

1. The upper limbs and lower limbs are wired up differently in the brain – so we can’t just assume what works for the upper limb will work for the lower limb. There is much more representation in the higher centres of the dominant arm working by itself.

2. In the upper limb there are many more activities that are carried out by just one arm than there are with the lower limb. In fact most activities (about 60%) use both arms simultaneously but even here some of those activities one arm is hugely more active and performing more demanding activity than the other. Just think of things like reading a book when holding it, eating a meal, opening a jar etc. CIMT only trains the affected arm so the effect on bimanual activities is still rather unknown. The tools used to assess the effectiveness of the programme only look at one arm activities, not two arm activities. this could actually be a major limitation of CIMT - that it doesn't address the bimanual nature of most activities.

3. In contrast the lower limbs are almost exclusively involved in bilateral activities – in fact only a few man-made type activities like operating peddles on vehicles and machines, involve just one activity. Think of standing up from sitting standing, standing on one leg, kicking a ball, walking, step climbing, running, reaching for things on a top shelf while standing and so on. All bilateral activities. This is where there is a real unknown about CIMT for the lower limb. Just because you practice unilateral activities doesn’t mean real life bilateral activities you will use the affected leg more.

So if I were you I would approach it with an open mind, and give it a go, but I would not stop practicing usual mobility and balance activities. There are other lower limb therapies that might work just as well or better – such as intensive treadmill and overground walking programmes, and the balance programmes (see below) and supervised resistance training to name just a few.

Along with the CIMT for lower limb study I have also included one pilot type study that used massed practice for improving balance, and shows promise.

All the best with your continued rehab.
Additional Comment I forgot:
Here are those references I promised.

[martin123]

hi to all here i am new here and i am very happy to be a part of this community

[vad guy]

Thanks. I actually didnt have a hemorrhage it was an ischemic stroke. I had a dissection a month earlier (unknown at the time) and while it was healing I reaggrevated the still healing cut in my vertebral artery which then sent a clot to my brain. Pretty rare.

I've actually started doing the intensive treadmill training (3x10mins running) three times a week and we'll see how that turns out. This seems interesting so I figured it doesnt hurt to try. It'll at least force me to put more weight on my left knee and thereby making it stronger.

[gcoe]

Oh ok so it was an ischemic event. I presuemd from the dissection you had a bleed. Still...you clearly have motivation and your age on your side. The treadmill sounds great! I agree that having a go at the CIMT may build up your strength which is probably what you need at this stage.

[ESPhysio]

Hi Vad Guy,
this is my first post so bear with me. I hope your rehab is continuing to go well and that you are managing to stick with it. Neuroplasticity will occur, but it takes time and practice and effort. If your strides are still short, it might be worth having another look at what your pelvis and trunk mucles are doing. A quick way of checking is to do some high kneeling and four point kneeling work. If you collapse in a heap (on a soft surface hopefully) then it would suggest that some strength training in the whole hip/ trunk/ pelvis system might help. For ankle weakness and instability, do exactly what you would do to treat an ankle instability problem. Good luck and keep going.