Vanessa asked me if it would be a good idea to tie her father’s “good” arm.
Clearly, tying the healthy arm of a hemiplegic patient is not a wise decision for a number of reasons that we will discuss together below.
For now it is useful to say that the idea conceived by Vanessa in rehabilitation is called CIMT (Constraint Induced Movement Therapy), that is, movement therapy induced by constriction, which is carried out precisely as she had thought it, it is literally immobilizing the healthy arm of the hemiplegic patient to constrain him to move his plegic limb.
This rehabilitation procedure for hemiplegic patients is in boga in the United States, where it is promoted as an innovation; In Anglo-Saxon countries this type of muscular and motivational physiotherapy is also very popular. In fact, the intuition of stimulating movement of the hemiplegic limb by immobilizing the healthy one, had already been thought by an Italian doctor a few decades ago.
Let’s go back to Vanessa’s question:
Is it correct to immobilize the healthy limb of a patient with hemiparesis to stimulate him to move the limb on the side affected by hemiplegia?
Let’s reason with the CIMT
It would undoubtedly be magnificent if it was that simple: Rehabilitation clinics would be made up only by corridors to force stroke patients to walk, and therapists would just use ropes to tie up their healthy limbs.
Beyond sarcasm, we must point out that behind these alternatives there is neither malice nor bad faith from those who have proposed them. The basic question, which also moves many professionals to think that the CIMT may be an inadequate and counterproductive solution, is actually very subtle and delicate.
It is a knowledge problem related to the brain, movement and recovery. We are in a period in which, in terms of rehabilitation, scientific discoveries regarding brain functions have not yet matured and, as if that was not enough, not everyone has been able to translate the newest knowledge into rehabilitation actions and exercises for CVA post-recovery.
In fact, in recent centuries, the sciences from which the world of rehabilitation extracts knowledge have made remarkable progress, revealing a lot about the functioning of our body.
Initially, when studies on the human body anatomy were still far away, the possibility of influencing movement and recovery was attributed solely to motivation.
Around 1700, studies already carried out on electricity showed that it is about the muscle instead, thanks to its ability to contract when being traversed by electrical energy, it representes a fundamental element for movement. Therefore all recovery activities were also obviously focused on the muscle. Facing a mobility problem, the goal of recovery was the muscle and its contractile properties and therefore, muscle strengthening.
Towards the mid-1800s, thanks to Sherrington’s studies, neurophysiology benefited from a great discovery, this being the nervous conduction of reflexes and their participation in movement. Only after a hundred years, in the world of rehabilitation, these scientific contributions were considered and it was then that, in the middle of the last century, methodologies for the treatment of the effects after a stroke such as Kabat, Vojta and Bobath, who placed the stimulation of nervous reflexes as the center of their work to influence the recovery of movement. Recently, however, were the brain functions involved in movement identified and the cognitive organization that allows men to move and speak was partially revealed. This is the source of the brilliant insights of an Italian physician, Prof. Carlo Perfetti, who began to suggest exercises for the hemiplegic patient that involved not only motivation, muscles, and reflexes, but also those brain functions altered by stroke. This way of performing rehabilitation is commonly known as the Perfetti Method or Neurocognitive Rehabilitation.
Although it may seem paradoxical, the reality is that the CIMT, or Vanessa’s proposal to tie her father’s healthy arm, post stroke therapy in boga in the United States is a therapeutic option that belongs to the area of scientific progress in which had not yet even been discovered the importance of the muscles and therefore refers only to the motivation to move, transformed, in this case, into constriction and need.
Requiring movement of the plegic limb when the patient has not yet learned to control abnormal reactivity to stretching of the muscles (the component of spasticity that produces a reflex contraction of the muscles as they are extended) cannot result otherwise than a poor move from a quality point of view. Furthermore, whenever abnormal reactivity to stretching occurs, it is as if we are “keeping it alive” rather than curing it.
In addition to the abnormal reactivity to stretching, known as hypertonia, the fact of forcibly moving the limb affected by hemiparesis, would determine the appearance of irradiation, another component of spasticity, for which the intervention of others muscles is recorded, as well as those involved in completing a difficult action. This additional participation in a healthy condition, serves to help us during the execution of difficult tasks, such as raising the other arm while lifting a suitcase, on the contrary in the hemiplegic patient, unfortunately the irradiation always involves the same muscles and usually tends to close the thumb and hand, bend the wrist and flex the elbow.
In fact, it is common for the person with hemiplegia who is subjected to inadequate efforts to see his spasticity increase, progressively decreasing the possibilities of movement.
Another reason why it is counterproductive to tie the healthy arm and force the hemiplegic patient to move the arm with paresis, is given by the fact that each action we take is the result of the participation of the whole body. I mean that, if I have to take an object with my right arm, my legs and hips will also be involved to orient and counterbalance the load with regard to the weight of my arm and the object, and my left arm will also help me to prolong the torso and the right arm towards the object, providing additional support on the thighs. Therefore, tying the limb that would participate in the movement means altering the reality of the action, making it more complex and exposing the hemiplegic patient to greater radiation.
In conclusion, taking in consideration that the world of rehabilitation seems to regress and that the supporters of the CIMT were among the few who produced “scientific experiments” aimed at demonstrating the efficacy of this practice, I can only present here my humble personal opinion, affirming that for the reasons stated above, I would never allow a relative of mine to carry out the CIMT and in the same way I would never authorize it for a patient.
