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| Programming
the Brain to Reorganize After a Stroke |
By EMILY YELLIN
BIRMINGHAM, Ala.,
For Jesse Reed, 67, washing the dishes is a thrill.
For Janis Keeney, 43, switching a light on or off
is so satisfying. And James Faust, 65, is grateful
every time he mows his lawn.
All three are stroke survivors who have gone through
a promising therapy
here at the University of Alabama-Birmingham's Spain
Rehabilitation Clinic that
has helped them regain use of their disabled arms
to varying degrees.
"I had completely written my arm off,"
said Mr. Faust, who had a stroke in 1993 that disabled
the right side of his body. "I just quit using
it because it wouldn't do what I wanted it to do.
I had deep thoughts about having it amputated to
get it out of my way." But then his wife read
an ad about experimental rehabilitation called
constraint-induced movement therapy for stroke survivors.
So in 1995 Mr. Faust became a research subject.
Mr. Reed, who had a stroke that disabled his left
side in 1994, also joined the study in 1995. Mr.
Reed said that before the therapy, his left arm
"was just a limb that was hanging on my body,
but they got me to program in my mind that this
hand and limb could be used again."
That reprogramming of the brain is the point of
constraint-induced therapy. In a new study of the
technique, conducted in Germany and described in
this month's issue of Stroke: Journal of the American
Heart Association, scientists showed for the first
time that the brain could reorganize itself after
a stroke. Researchers made a map of the area of
the brain that controlled arm movement on the injured
side of the body in 13 stroke survivors, and found
that after the two- to three-week therapy, not only
was use returning to the arms but that the mapped
area of the brain had nearly doubled in size.
The study emphasized, though, that the therapy
was successful only if patients worked at it full
time, as Mr. Faust did. Researchers believe that
part of what causes the disability is that the patients
have learned not to use the limb and that only through
intense use will the therapy rewire the brain sufficiently.
During two weeks of work with a physical therapist
six hours a day, five days
a week at the clinic, Mr. Faust said, his able left
arm was immobilized in a sling, and his left hand
was in a large mitten, forcing him to perform simple
tasks with his disabled right arm. He began by turning
over index cards and moving checkers onto squares.
"I didn't tell any difference until about
the third day," Mr. Faust said. "And then
there was a sensation in my arm that I hadn't had.
I felt a little tingling. It was like my nerves
were waking up." Then he graduated to threading
a shoelace through a series of holes and moving
washers up and down on screws.
Working at the clinic and on his own at home on
weekends, he began to regain
use of the arm and to do things he thought he might
never do again, like eating dinner holding the fork
with his right hand, just as he had done before
the stroke. Dr. Edward Taub leads the constraint-induced
therapy research in the clinical
psychology department at the University of Alabama
and was also one of the authors of the recent study
in Germany.
His research assistant in Alabama, Gitendra Uswatte,
said the stroke survivors were divided into four
categories, depending on the severity of damage
from their strokes. Mr. Faust was in the first quarter
who started out with the most ability.
Mr. Reed was in the second quarter. Mr. Faust estimated
that his arm had now
recovered about 95 percent of its use. Mr. Reed
said that he thought his arm had regained 65 percent
to 70 percent of its use, and that while he used
to do the dishes just to help his wife, now he liked
doing them more because he considered it part of
his therapy.
Janis Keeney was in the third quarter of stroke
survivors in the studies. Starting out with very
limited ability, she said the therapy had brought
"not great improvement" but enough to
change her life.
Ms. Keeney's stroke occurred in 1997, when she
was 40 and the mother of an
8-month-old girl and a 2-year-old boy. "Before
the therapy," she said, "it was hard to
hold them in my lap because I needed both hands.
But now I can hold my children."
A former engineer, Ms. Kenney has come to appreciate
her ability to do even
the simplest tasks, like switching on a light or
opening a dresser drawer. "It's not total improvement,
but it's some," she said.
Although more research needs to be done before
this therapy will be widely accepted, a new private
clinic is scheduled to open in Birmingham this fall
to provide constraint-induced therapy to stroke
survivors.
Other researchers also say that more studies need
to be done because the number of people in this
study was so small and participants were not compared
with a control group. Similar research is also being
done at the university on the effectiveness of this
therapy on legs. And there are also trials being
conducted here on the effectiveness of this type
of therapy for those who have lost the use of a
limb after traumatic brain injury, spinal cord injury
and hip fractures.
"It's certainly not just for folks who have
had strokes," said Jean E. Crago,
a physical therapist at the university who has worked
with Dr. Taub on this therapy. "We see it as
for anyone who for whatever reason is not using
a limb
or a body part optimally."
Mr. Faust is such a believer that he has taken
part in the experimental therapy for his leg as
well. That, he said, is why he longer walks with
a cane. "The doctors weren't sure I would make
it through the night when I had my stroke,"
he said. "Now, I manage to mow my grass --
and I've got almost two acres."
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