Rehabilitation Technique Improves Limb Movement in MS Patients, Phase 2 Trial Shows

Constraint-induced movement therapy (CIMT), a rehabilitation technique originally developed for stroke patients, may also be effective in improving limb use in the daily activities of multiple sclerosis (MS) patients, results from a Phase 2 trial show.

Findings were reported in the study, “Phase II Randomized Controlled Trial of Constraint-Induced Movement Therapy in Multiple Sclerosis. Part 1: Effects on Real-World Function,” published in the journal Neurorehabilitation and Neural Repair.

In a second study, “Phase II Randomized Controlled Trial of Constraint-Induced Movement Therapy in Multiple Sclerosis. Part 2: Effect on White Matter Integrity,” published in the same journal, researchers found that CIMT results in changes in the white matter structure in the brains of MS patients, indicating that the improved capacity is the result of measurable changes in the brain at the end of the treatment.

“These are momentous findings, which could be game-changing for patients with MS,” Victor Mark, MD, primary investigator of both studies and an associate professor in the department of physical medicine and rehabilitation at the University of Alabama School of Medicine in Birmingham, said in a press release.

CIMT has proven effective in improving limb movement in patients with physically disabling disorders, such as strokes, cerebral palsy, and traumatic brain injuries.

The therapy was developed based on the theory of “learned non-use,” in which, after a stroke or other condition causing limb impairment, patients learn to not use that limb for daily activities, relying instead on the better limb.

CIMT focuses on restraining the better limb to more intensively train the more affected limb on movements and activities related to daily living. Behavioral techniques are also included in CIMT, such as behavioral shaping, which involves achieving motor goals in small increments along with positive feedback and encouragement, and methods used to assist patients in transferring the training benefits of the therapy from the clinical setting to the real world, called the transfer package.

This randomized Phase 2 trial (NCT01081275) compared the use of CIMT with a therapy called complementary and alternative medicine (CAM) in improving the upper limb function of 20 MS patients.

While the CAM group received 35 hours of holistic exercises including yoga and pool exercise, the CIMT group underwent 35 hours of intense rehabilitation over a 10-day period, along with behavioral shaping and the transfer package. Patients’ functional ability was evaluated using the Motor Activity Log (MAL) report, measured before and after the therapy.

The CIMT group showed more improvement in functional activity than the CAM group. On average, patients in the CIMT group improved 2.7 points on the MAL scale, which ranges from zero to five points, while CAM patients improved only 0.5 points.

Additionally, the results remained the same at one year after treatment, suggesting that CIMT can sustain improvements in the real-world use of the more affected arm in MS patients for at least one year.

“CIMT has been shown to be effective following motor deficit,” Mark said. “What is truly fascinating is its effect on a degenerative disease such as MS. We know CI Therapy is effective for stroke and cerebral palsy, which are static diseases — patients don’t get worse. What we are showing here is that CI Therapy can also improve function in patients with a progressively worsening disease.”

In the second study, Mark and first author Ameen Barghi, now a student at Harvard Medical School, showed an improvement in the movement of water molecules within the brains of patients in the CIMT group, indicating healthier white matter. In contrast, the CAM group showed no improvements.

“While certainly preliminary, these findings suggest that the adverse changes in white matter integrity induced by MS might be reversed by CI Therapy,” Mark said.

The team now plans to investigate the potential benefit of CIMT in the lower extremities of MS patients, how long the beneficial effects of this therapy last, and whether repeated courses of CIMT could be helpful.

“There is a great deal of interest in improving rehabilitation techniques in multiples sclerosis,” Mark said. “The disease often strikes young people — 28 is the median age of onset — and it commonly gets progressively worse. There are drugs that can slow the progression, but we don’t have medications to cure the disease. Rehabilitation is the best option to improve daily living activities for those whose conditions are worsening.”

The National Institutes of Health and the National Multiple Sclerosis Society funded the studies.