UF researchers help stroke patients relearn motor skills

David Lowenthal, M.D., Ph.D., stared intently at his nemesis — a dried red bean resting on the table in front of him — while his right hand, the stronger, more dominant hand, was constrained by a thick white mitt equipped with a mesh compartment for his fingers. After concentrating on the legume for several seconds, he slowly raised his slightly trembling left hand in an effort to pick up the bean between his index finger and thumb, missing once, but then emerging victorious in his second attempt to pluck it off the table and move it three or four inches away from him. For Lowenthal, an eight-year stroke survivor, there are no small victories, only baby steps in a long journey that has propelled him toward his goal of improving the function of the left side of his body that was affected by the stroke. “Going through rehabilitation is not for sissies,” joked Lowenthal, a UF professor of medicine, pharmacology and exercise science. “The journey has been arduous but highly rewarding.” As a participant in the Stroke I.M.P.A.C.T. Study for stroke survivors, Lowenthal, 66, has endured an intense regimen of constraint-induced movement therapy, or CIMT, in an effort to regain the motor skills that will allow him to write or throw a ball with his left hand, his dominant hand before the stroke. During this form of therapy, participants’ least-affected hands are constrained in mitts for 90 percent of the time they are awake while they use the most-affected hands during repetitive exercises where even the smallest improvements could have a significant effect on their quality of life. Kathye Light, Ph.D., P.T., a UF associate professor in the department of physical therapy in the College of Public Health and Health Professions, is the principal investigator of the study and principal author of its research grant. She will examine the benefits of CIMT home therapy versus therapy done exclusively in a lab with a trainer. Subjects are randomly selected for either part of the study. Both sets of participants spend six hours on CIMT exercises each day. The home therapy group spends one hour of this time working with a trainer in the lab and the rest of the time doing the exercises on their own. Patients selected for full lab training perform the same program but do so completely under the guidance of a trainer in the clinic. Light and her colleagues are interested in discovering if performing exercises at home and spending less time with a trainer can reap the same benefits as those who work exclusively with trainers or physical therapists for several hours every week. Another part of the study will evaluate if a second course of CIMT, for survivors who have previously received the treatment, yields added benefit and improved function. Funding hope Many stroke survivors are shocked to find out that a two-week CIMT program could cost as much as buying a small car. The time and labor-intensive nature of the therapy account for the expense — about $10,000 to $15,000 for a two-week treatment, Light estimated. “Insurance will never pay for the expense of sitting for six hours a day for 10 days with a therapist,” said Fran Greenberg, the study’s coordinator. “If this study shows that one hour a day reaps the same benefits, stroke survivors may have a better chance of an insurance company paying for further treatment.” Prior to I.M.P.A.C.T., Light served as co-principal investigator for Extremity Constraint-Induced Therapy Evaluation, a study that showed CIMT helped stroke survivors improve function years after their strokes occurred. “In the past, neurologists and other physicians have suggested that patients can make little improvement six months or more after a stroke,” Light said. “We’ve found that’s not true. We’ve worked with people 20 years after their strokes who were able to make great progress and regain function.” Light began the I.M.P.A.C.T study in 2005 after she was awarded a five-year research grant funded by the National Institutes of Health. The multisite research study at UF, the University of South Carolina and Colorado State University takes the preceding study one step further by examining the parameters surrounding CIMT and will end in June 2010. No pain, no gain In this study, the doctor has never been happier to be the patient. Lowenthal knew he would undergo aggressive physical therapy on his left hand and arm — the side most affected by his stroke — while the less-affected hand would be placed in a mitt to spur use of the weaker arm to perform activities. Although participants are never pushed to the point of discomfort, the repetition and time in the lab can be mentally and physically taxing. “Since his stroke, he has become a napper,” said Ronnie, 63, Lowenthal’s wife of nearly 20 years. “There were times when he would train in the lab all day and then go and do some work in the office, which was extremely tiring, but well worth it.” The lab itself is anything but the stereotypical clinical setting. There are no researchers in sterile-looking white lab coats bustling around the room with clipboards. Rather, participants work with trainers, mostly physical therapy doctoral students, in a room that resembles a place for summer camp activities than a Mecca for scientific research. Here participants perform exercises, such as Lowenthal’s battle with the bean, designed to improve fine motor skills, flexibility and range of motion while trainers record daily progress. Jenga, checkers, Scrabble and puzzles are stacked on lab shelves. In the corner, there is a piano and a whiteboard for participants to draw pictures using their most-affected hands. Plastic containers and cans line the countertops where subjects practice making meals and eating lunch. One of the lab’s cabinet cubby holes holds the key to one of Lowenthal’s favorite exercises: the beanbag toss. He winds up like a seasoned pitcher on a mound, clutching the bubble-gum pink beanbag in his hand and then struggles to maintain balance for a moment — a reminder of why he’s there. Lowenthal points to the ceiling — but it’s a fake-out, and he delivers his best “fastball” to one of his trainers standing across the room. “This was one of my goals before I came here — to be able to write my name and throw a ball,” he said, in his low, soft-spoken voice, a result of the stroke. “I will leave here having accomplished both goals.” Back to the basics Before suffering two strokes within 24 hours in January 2000, Lowenthal was the poster child for healthy living. He was an avid long-distance runner who had completed 15 marathons and exercised at least an hour every day. He watched what he ate, didn’t smoke or drink. He seemed to do everything right. In the hours following the stroke, physicians doubted Lowenthal would make it through the night, and if he did, they thought he would never walk again. After nine months of rehab, sweat and determination, Lowenthal escorted his daughter down the aisle at her wedding in September 2000 without the use of a cane or walker. He applied the same determination during his stay in Light’s lab and said he feels other stroke survivors should take advantage of participating in the study, which is offered at no cost for the subjects. “I came here two weeks ago with significant defects, and I leave here with a ray of hope,” he said. Lowenthal’s wife agrees the therapy has helped return a welcomed sense of normalcy to her family’s life. “People should knock down the door to get in there and get the treatment,” Ronnie said. “It showed me, and it will show other people that you can reconnect the brain to function. If David had to fly across the country to get this treatment it would have been worth it. Hands down.” For more information on the Stroke I.M.P.A.C.T. Study, call study coordinator Fran Greenberg at 352-273-5274, e-mail impact@phhp.ufl.edu or visit www.impact.phhp.ufl.edu.