CIMT – Constraint-Induced Movement Therapy

It didn’t take very long to find out that conventional therapy has a pretty grim outlook on the potential for recovery from perinatal stroke.  Makes sense, as 1 hour per week with a therapist, especially for a reserved baby who doesn’t particularly care for strangers (such as the therapist), is not going to accomplish a lot.  With a bit of research, the first alternative (or cutting edge) therapy I encountered was constraint-induced movement therapy.

Constraint Induced Movement Therapy (CIMT)

Constraint induced movement therapy has its origins from Dr. Edward Taub’s work with monkeys in the early 1980’s.  He showed that monkeys with neurological injuries could show some recovery when forced to use their impaired limb – which he termed constraint-induced movement therapy.  After his work with monkeys, Dr. Taub moved to Birmingham, Alabama in the late 1980’s and began to focus on stroke recovery.  Dr. Taub and his team made great gains in the field of neuroplasticity, and his therapy, shortened to CIMT, has been increasingly used on adult and pediatric stroke victims.

Ever since I read about Dr. Taub in The Brain That Changes Itself by Dr. Norman Doidge (a great read for neuroplasticity, btw), I wanted to take E to Alabama for CIMT.

In the meantime, however, we convinced E’s PT and OT to help us apply a splint and do some at home modified CIMT (mCIMT).  Here is what we have done:

6 months – several hours a day for 3 weeks, then off and on to 12 months – we used a tensor bandage to wrap up E’s unaffected arm for eating and play.  She tolerated this surprisingly well and retrospectively I wish we would have done WAY more.  mCIMT helped her to be more aware of her right arm and hand, which she sometimes ignored.

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9 months – 133 hours of splint-on time over 3 weeks (about 6.5 hours a day).  We had E’s therapists make her a resting hand splint for her unaffected side, that we velcroed on and put a sock over.  Again this was really well tolerated and I wish we would have done more.  It is really scary, though, when you want to try something but the therapists and neurologists are saying “you have to be very careful that you don’t negatively affect the development of her other side…long term side effects are unknown…”.  mCIMT helped her to be more aware of her right arm and hand again.

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18 months – 84 hours of splint-on time over 3 weeks (average 4 hr/day) – E really started to fight the splint going back on this time.  It was difficult to do any actual “therapeutic” activity and E would just refuse to eat, or play.  This was a really tough stage and we didn’t do much therapy for a while.  mCIMT did help with the right sided neglect, which had been worsening slowly over time.

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22 months – 45 hours of splint-on time in 3 weeks (just over 2 hrs a day) – We decided to try modified CIMT again…  Our OT kindly got special permission and organized a constraint camp.  Only 2 other kids signed up, and one dropped out after the first day!  Constraint therapy is not for the faint of heart I suppose. E liked the camp (1.75 hours with an OT and assistant twice a week for 3 weeks), but hated getting the splint put on, cried much of the time, and was pretty miserable with the loss of her “playing” hand…  mCIMT didn’t do much for us at this time, as she was just too miserable….

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3 years – It took a year for me to get enough courage to try CIMT again.  This time, we went for the full meal deal – cast on 24/7 for 26 days.  And…. it was AWESOME!!!  The first day is a bit of a bummer when they realize you aren’t going to take the cast off, but then… acceptance!  Yes, there were many of her favorite toys that she just didn’t play with because it was just too hard with Mr. Right Hand.  But we were able to make some great gains in awareness and movement in E’s right arm and hand, which she had been neglecting a lot in the past year while focusing on walking.  This was mostly passive constraint, or “forced use” – E just went about her day and I assisted her to do what she wanted to do.  One thing we did start was an hour of iPad time for Righty while lefty is casted, every single day.  E was just barely able to use her pinky to play iPad games; it was pretty frustrating, but she persisted.

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3.5 years – We did another round of at home 24/7 constraint (forced use) for 22 days.  Again, not too much actual “therapy”, but going around her day wearing a cast… We noticed a lot of carryover from July and again, after the first day, the cast was No Big Deal!!!  By now, E was pretty good at doing iPad with her right pinky, so we started wrapping her other fingers down with stretchy wrap and forcing Pointer to do iPad.  Again, this was very very difficult for her at first.

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3.5 years – We did it!  With some generous help from our family, we were able to go to Birmingham, Alabama for constraint therapy.  This was 17 days of 24/7 long-arm casting, with intensive OT 3.5 hours a day, 4 days a week, for 3 weeks.  (We did Children’s of Alabama program, headed by Dr. Taub.  There is also an offshoot there that does 6 hours of OT, 5 days a week, for 4 weeks, called ACQUIREc.)  The program was very…intense…and I can’t imagine E doing the longer program !?! at this age (and she has a long attention span!).  It involved a lot of sitting at a desk and doing repetitive games with Tricky Mr. Right Hand.  Towards the end of the therapy we saw the emergence of – Supination (turning her hand palm up)!!!!  Pinching!!!!  Wrist Extension!!!!  Three extremely difficult movements for E.  We stayed at the Ronald McDonald House, which was absolutely fantastic.  We all got the Norwalk virus, bad sinus colds, and eye infections, which was not so fantastic.

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Yes, Dr. Taub himself.  How cool is that?!?

Since our return home, we have continued on with an hour a day of iPad for Rt Pointer, as well as trying to do shaping (supination, wrist extension, pinching) daily.  We have seen some amazing progress, including just in the last two weeks – E is able to pinch and feed herself popcorn twists, and today, hold a lollipop to lick (all with the help of the wonderful stretchy wrap!).

Obviously, we are huge believers in CIMT.

I strongly believe that in this life, nothing happens by accident or coincidence – things aren’t determined by fate or luck (good or bad).  I believe there is an overarching story – a beautiful picture of love, loss, and redemption – and that there is Someone who cares and is in control.  You are already a part of this story, whether you know or believe it or not.  While the end of the story has already been written, your own part lays open before you for you to choose your ultimate destiny.  Perhaps our coinciding struggles have been finely orchestrated to lead you to this one moment: The Bridge to God.

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“Praise be to the God and Father of our Lord Jesus Christ. The Father of compassion, the God of all comfort, who comforts us in all our troubles so that we can comfort those in any trouble with the comfort we ourselves have received from God. For just as the sufferings of Christ flow into our lives, so also should the comfort of Christ overflow.” (2 Corinthians 1:3-5)

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Our Journey Begins

E was born full-term after an uneventful pregnancy and a ridiculously long (64 hr) labor.  Although undeniably stressed from delivery, and needing some resuscitation, she seemed to make a complete recovery and didn’t even have to spend time in the NICU.  We were so relieved.

Then at around 3 months old, E started batting at toys with her left hand, while her right hand stayed mostly in a little fist.  We mentioned this to our family physician at her wellness check, and she who referred us to the Children’s Center for assessment.  I spent hours on the internet researching early handedness in infants.  Again and again, hemiplegic cerebral palsy came up.  When she was 6 months old, we were seen by the developmental pediatrician at the Children’s Center.  She told us that due to E’s difficult delivery, she had likely suffered a brachial plexus injury and would recover with therapy.  I could hardly bear to ask… “so… it’s not cerebral palsy?”  And the answer was “no, definitely not”.  We were so relieved and started an hour of combined PT and OT weekly.  Still, down in my heart, I knew that this was not something that was going to just “go away”.

When she was 9 months old, an MRI demonstrated that E had suffered a stroke sometime around the time of her birth (termed a perinatal stroke).  Her official diagnosis is “presumed perinatal ischemic stroke” (PPIS) as well as “right hemiparetic cerebral palsy”.  Stroke is one of the leading causes of cerebral palsy.

And so began our journey.

It was crushing to find out that our precious daughter had a stroke.  Strokes seemed like something older adults have – not children, and certainly not babies!

I definitely had to grieve. I was angry for a long time.  I had a lot of what if’s and should haves…. particularly I wish I would have pushed harder for a c-section, and I agonized over labor & delivery mismanagement.  We will never know if that would have spared E this struggle.

(But that is one of the harsh realities of this life, isn’t it?  We wish to control – life, death, and everything in between.  “In our day and age”, these things shouldn’t happen.  But “in our day and age”, *many* things DO happen which are unfortunate.  Even though we live in an advanced society, when it comes right down to it, there are many things that are out of our control…  Why?  I believe we know deep down that we were made for something better – for the happy and healthy “utopia” we all yearn for and try to achieve through various means.  God describes this as having put “eternity in [our] hearts”.  Our world is a fallen one, because we have inherited a fallen nature – collectively we have chosen to follow our own ways instead of God’s ways… And in a fallen world, bad things happen to good people and bad people alike.  God does not promise to spare us the harsh realities of life in a fallen world, we look around the globe at countless examples.  Not only that, but God willingly took on these harsh realities and came and lived among us, as one of us – He truly understands.  God promises to carry us through – to give us hope for today, and hope for tomorrow.)

It is possible that E had the stroke in-utero before labor began (or at some point soon after delivery – she did cry a lot the first night).  I asked neurologists and therapists, read scientific papers online, and borrowed neurology textbooks to try to figure out exactly where her stroke was, what it meant, and how it could have happened.  I had a lot of questions but there were no answers as to why.  Neither of us had any risk factors (other than the long labor and occiput posterior- sunnyside – presentation).

It was really difficult for me to be with other moms with young children.  When I was just with E, her sweetness and my excitement in her every accomplishment was wonderful.  Because her milestones were hard won, we relished in each small accomplishment!  Being around other young children, however, made her motor delays stand out like a neon sign to me.  I struggled with post-partum depression for a long time (mainly from other complications that I had had during delivery), and found that playdates or mom’s groups would  push me over the edge and I would end up crying in a bathroom somewhere.

I did come to terms with E’s stroke on some level, eventually (probably when she was around 2.5 yrs old).  This helped me to be able to move on with therapy for her – to be able to pursue more than just what was offered conventionally.

What did help me reach a measure of acceptance was releasing the guilt, regret, and control… There must be a reason why God allowed E’s stroke to occur.  Perhaps it is to make her, and our whole family, more sensitive to those with disabilities (which it has!  And there certainly are more children who struggle with one thing or another than I would have thought before!).  Perhaps it is to meet people we otherwise never would have (which has certainly happened!).  Perhaps it is just because bad things do happen to good people in a fallen world- including babies.  Some things we will never know on this side of eternity, and must trust in our heavenly Father just as E places her trust in us as her parents.

“And we know that for those who love God all things work together for good, for those who are called according to his purpose.”  Romans 8:28

Perinatal stroke claims the lives of many babies.  We are certainly fortunate that E’s stroke was relatively small and that she is a survivor.  For that we are truly thankful!!!

I strongly believe that in this life, nothing happens by accident or coincidence – things aren’t determined by fate or luck (good or bad).  I believe there is an overarching story – a beautiful picture of love, loss, and redemption – and that there is Someone who cares and is in control.  You are already a part of this story, whether you know or believe it or not.  While the end of the story has already been written, your own part lays open before you for you to choose your ultimate destiny.  Perhaps our coinciding struggles have been finely orchestrated to lead you to this one moment: The Bridge to God.

download

“Praise be to the God and Father of our Lord Jesus Christ. The Father of compassion, the God of all comfort, who comforts us in all our troubles so that we can comfort those in any trouble with the comfort we ourselves have received from God. For just as the sufferings of Christ flow into our lives, so also should the comfort of Christ overflow.” (2 Corinthians 1:3-5)

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A FEW FACTS ABOUT PEDIATRIC STROKE

  • Perinatal, neonatal, infant and childhood stroke are some of the most common causes of hemiplegia or hemiparesis in children.
  • Perinatal arterial ischemic stroke is the most common form of stroke in children and it occurs in 1 in every 2800 live births.
  • Sixty percent of these children have specific symptoms such as recurrent focal seizures in the first three days of life.
  • However, forty percent of children with early stroke do not have symptoms and the stroke is recognized later with delays in movement, development, learning, or seizures.
  • Children often receive occupational and physical therapies for decades to help them learn functional skills of daily living and increase movement if they’re experiencing motor difficulties.

(FROM THE CHILDREN’S HEMIPLEGIA AND STROKE ASSOCIATION WEBSITE  http://www.chasa.org/)