Friday, April 6, 2007

Lower Extremity mCIT

Two things are available on this web page: 
  • A chart to show the various ways researchers have implemented leg CIT. Click on the chart for a link to the actual article.
  • A Modified leg CIT protocol developed by our lab.,d.dmo
 Lower Extremity Modified CIT (mCIT):
Suggested Inclusion/Exclusion Criteria
The following are the suggested inclusion/exclusion criteria for lower extremity constraint induced therapy.
(1) Walk with no more than a straight cane and/or AFO
(2) Lower extremity deficit, as defined as contact guard or less when walking
(3) 5° of dorsiflexion and 5° of plantarflexion
(4) No cognitive deficits, as evidenced by a score of less than 80% on the mini mental exam
(5) No hemorrhagic lesions
(6) No excessive spasticity (as measured by a score of “3” or less on the Modified Ashworth Spasticity Scale)
(7) No excessive pain (as measured by a score of “4” or more on the Visual Analog Scale) in the affected limb

Hemiparetic gait: Consequences
One would think that forced use can occur naturally as a consequence of the activities in which the lower extremities are involved (e.g., walking, climbing stairs). However, it is a common observation that individuals with hemiparesis exhibit asymmetry in quasi-static standing postures and during functional movements (e.g., Bohannon & Larkin, 1985; Winstein et al., 1989). Patients with CVA also naturally develop strategies for ambulating that incorporate little support using the paretic lower extremity. Such weight asymmetries and impaired balance function may be a consequence of a learned disuse of the paretic leg (Taub and colleagues, 1999). Specifically, unilaterally involved patients tend to modify their gait so that the hemiparetic LE is placed in something approximating the proper position to enter the stance phase, but the limb provides very little, if any, support. The patient is left with an antalgic-type gait. This gait, if left alone may well become "functional” in that it may provide transport. However, if left unmodified, it may have negative consequences orthopedically and socially. Furthermore, continued weight-bearing asymmetry may continue and foster a further disuse. 

Lower Extremity Modified Constraint Induced Therapy
The following exercises will not be attempted until adequate range of motion has been obtained in the earlier stages of rehabilitation. An individual must demonstrate the potential to fully bear weight through the affected LE and have no evidence of swelling in the ankle joint and exhibit no pain with standing or stress. Participants will be provided with assistance appropriate to the exercise. All exercises will be completed without assistive devices or any orthotics that are not used for structural support (e.g., an ankle-foot orthosis would not be used but a shoe insert that provides support to the foot could be used). When appropriate the participant will be treated without shoes to facilitate proprioceptive and tactile feedback while reducing potential muscular support. 10 minutes will be used for stretching and/or stabilization per the supervising PT. Forced-use progression during stepping. The following exercises will be instituted to promote standing from a sitting or semi-sitting position followed by taking a step with the affected extremity. This series of exercises will be progressed along the following 3 parameters:

Elimination of base of support (BOS) while gradually increasing dependence on the affected lower limb using the following 3 variables:

1. Elevation/ degradation of sitting surface. As the surface is raised the participant is forced to bear more weight through the lower extremities. As the surface is lowered the participant is forced to do relatively more work to stand.
2. Elevation of the unaffected limb foot onto an incrementally raised platform. This forces the effected limb to accept an increased amount of body weight.
3. Incremental elimination of support through upper extremities.

During all the variables stated, above, there will be a gradual increase of the length of time on which the participant bears weight through the affected lower extremity.

Specific exercises

Linkage of two behaviors.
The participant will be instructed to stand as detailed above. The participant will be instructed to followed by taking a step with the unaffected limb.
Repetitive sit to stand. The participant will complete multiple sit to stand transfers using a standard strait-backed chair with armrests. Progression will be provided by elevating the foot of the uninvolved extremity with a progressively thicker platforms, forcing weight on to the involved limb.
Balancing on one foot. The participant will be instructed to on the affected lower extremity only while utilizing parallel bars. Progression will be towards increased amount of time and less support through the upper extremities.
Step up/step down, stair ascend/descend. The goal will be ascending and descending a staircase. The participant will start out by stepping up on a 4'' corrugated rubber surfaced step using the affected limb. Once both feet are on the step the participant will step down off the other side of the step using their unaffected limb. An 11-stair staircase, consisting of 7" stairs will be used to ascend/descend. Ascension: Participant will be instructed to put the affected foot on the stair above the level on which they are standing and ascend the stairs, one at a time, in this manner. Descending: Participant will be instructed to descend stairs by placing the uninvolved limb on the stair on which they are standing.
Floor ambulation. The participant will walk on hard and carpeted surfaces.
Lunges. with the affected limb only
Wall slides. Participant is instructed to do traditional wall slides (squats). Placing progressively thicker platforms under the unaffected limb will emphasize the affected extremity.
Ankle Pumps. Dorsi and platarflexion exercise done in long-sitting or supine.

Table 2: A typical exercise session
Assistive devices and orthotics
Assistive devices and orthotics can reinforce compensatory strategies and weaken muscles. Therefore, at the beginning of each mCIT session, assitive devices and orthotics will be removed, and will not be used during the testing or either of the intervention phases. Freedom of natural muscle development, coordination and proprioceptive awareness is essential to normalized gait. All exercises will be provided with ample guarding and will be documented using treatment cards maintained by the therapist. Handrails will be provided during activities that warrant them.
Home component
The participants will be involved in specific weight bearing and non-weight bearing activities to be done at home. These exercises will consist of a mix of the interventions being done clinically in our study. However, emphasis will be placed on safety and will focus on non-weight bearing repetitive practice of component parts of ambulation (i.e. repeated dorsiflexion with the affected side while sitting). Home use logs will be used to verify compliance.

The home component will include

1 hour of walking (does not have to be continuous walking)

30 minutes of an NWB exercise program

Plantar flexors stretch

Plantar/Dorsi repetitive practice

Total knee extensions

Knee to chest (supine)

Heel slides in supine


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