By Bob Shepard From UAB Magazine, Spring 2000 (Volume 20, Number 1)

In Alabama, a stroke patient uses her “disabled” arm and hand to bake a cake, transport it to UAB’s Spain Rehabilitation Center, cut it into slices, and serve it to her physical therapy team without any assistance from her good arm. In Italy, a concert pianist returns to the stage after being treated for what should have been a career-ending condition in his left hand. And in Germany, an amputee discovers, to his joy, that the phantom limb pain he has endured for many years has disappeared.

What do these patients have in common? All three have benefited from research conducted by UAB psychologist Edward Taub, Ph.D., and his colleagues.

The Downside of Doing Nothing

For years, the prevailing wisdom in the field of stroke rehabilitation has been that traditional methods have little beneficial effect for patients with chronic stroke, particularly over the long term. But in a small, crowded laboratory in UAB’s Spain Rehabilitaion Center, Taub and his rehab team are successfully treating stroke patients in a revolutionary way with an intense, two-week regimen called Constraint Induced Movement Therapy, or CI therapy.

“All of the patients in our project have experienced substantial improvement in the use of their affected arms for the activities of daily living,” says Taub. “CI therapy is effective because it combats a phenomenon that I call ‘learned nonuse.’”

In the immediate aftermath of a stroke, Taub explains, the severe trauma suffered by the brain can block a patient’s ability to move his or her arm and leg on one side of the body. As the months pass, the trauma lessens, releasing the block. During those months, however, the patient “learns” not to attempt to use the affected arm or leg, because it doesn’t work. Efforts to make it work are painful, or futile—perhaps even embarrassing. In addition, the patient hears negative messages from many health professionals who believe that nothing can be done.

But Taub’s studies, which have been conducted both at UAB and at the Birmingham Veterans Affairs Medical Center, have shown that learned nonuse can be overcome and reversed. His findings have emerged through many years of research with collaborators such as physiatrist Rama Pidikiti, M.D., physical therapist Jean Crago, M.S.P.T., and graduate assistants Gitendra Uswatte-Aratchi and Stephanie DeLuca.

Lighting Up the Lines

“There are maps in the brain that represent the entire human body, and each area on these maps controls the functioning of a different part of the body,” Taub says. “In the absence of central nervous system stimulation to the part of a map that controls the movement of a stroke patient’s arm, the brain begins to, in effect, rewire itself.”

During this rewiring process, called cortical reorganization, the unused portion of the brain, representing the nonfunctional part of the body, contracts and is invaded by nearby, still-functional areas of the brain. CI therapy, says Taub, is the cavalry charge that can restore function by repelling the invaders.

Patients spend two weeks in Taub’s laboratory, where they perform taxing physical therapy training with their affected arms for six to eight hours a day, forcing renewed stimulation to the previously unused areas of the brain. Each patient’s good, or unaffected, hand is constrained in a sling or other device to prevent its use. As a result, a second, massive cortical reorganization begins to take place as the brain once again receives signals from the affected arm, triggering new connections.

The results of CI therapy have been astonishing. Patients begin using their affected arms to dress themselves, write checks, sign their names, brush their teeth, and comb their hair. Some can even bake a cake.

“The key to CI therapy is massed practice,” says Taub. “The evidence shows that extended, concentrated therapy spurs cortical reorganization, allowing an affected limb to regain the ability to function.”

While Taub’s early work involved patients with only moderate impairment, his laboratory has since expanded its research to those with marked impairment. The data indicate that CI therapy works for this group of patients as well. Preliminary studies suggest that CI therapy could help patients with traumatic brain injury, spinal cord damage, and fractured hips. In fact, he says, CI therapy may have a role to play throughout the entire range of physical neurorehabilitation services.

Healing Musical Hands

Taub’s studies of cortical reorganization in stroke patients caused him and German collaborator Thomas Elbert, Ph.D., to wonder if similar “rewiring” processes might be involved in other disabling neurological conditions. If chronic lack of stimulation causes the brain to rewire itself, he reasoned, might chronic overstimulation prompt rewiring as well? What problems, for example, might be triggered by chronic hyperstimulation to the brain from overuse of a hand or arm? And might such problems be treated with some form of CI therapy?

To probe these questions, Taub realized he would have to find a ready made population of individuals whose jobs or hobbies required hand/arm manipulation far beyond what is normal for most people. Taub’s wife, Mildred Allen, a professional opera singer, suggested that he study string players—violinists and cellists.

Through magnetoencephalographic source imaging of the brains of willing string players, Taub and Elbert did indeed show increased cortical reorganization in the areas of the musicians’ brains that control their left hands, which perform intricate, rapid movements, but not in their right hands, which simply saw the bows back and forth.

In time, these findings led to new treatments for focal hand dystonia, a condition found among musicians—not only violinists and cellists, but also pianists, guitarists, and members of other occupational groups—who engage in extensive and forceful use of their fingers. The condition causes one or more fingers to become “dystonic,” or difficult to control, and results in a loss of coordination, which can be devastating to a professional musician. No successful treatment with long-term effects had ever been developed prior to the research conducted by Taub, Elbert, and Victor Candia of the University of Konstanz in Germany.

Taub and his European partners used magnetic resonance imaging to study the brains of 10 professional musicians suffering from focal hand dystonia. They discovered significant cortical reorganization, with a kind of “smearing” of the wiring that controls the fingers of the patients’ hands. In each case, the area of the brain controlling the dystonic finger had become “overrun” by the circuitry controlling the other fingers. A sort of CI therapy was devised, with the dystonic finger free to move and one or more of the other fingers restrained. Following repetitive exercises with their dystonic fingers, all 10 patients showed substantial improvement. Four, who had curtailed their solo careers due to the condition, were able to resume performing in concert settings.

Fixing Phantom Pain

Taub and his collaborators have discovered that cortical reorganization plays a role in yet another troublesome condition—phantom limb pain. Many amputees complain of pain radiating from the location of their missing limbs, and, at times, this pain can be so severe that it is disabling. But how can pain emanate from something that no longer exists?

Taub and his colleagues explain that cortical reorganization occurs in the brains of these amputees. In the absence of stimulation from their missing limbs, the areas of their brains corresponding to their missing limbs are invaded by neighboring circuitry. So there is once again nerve stimulation, but it comes not from their missing limbs but from the body parts corresponding to the invading neural circuits. Pain and sensation can follow.

The therapy in this case is a serendipitous one. Taub and his group, including Thomas Weiss, M.D., and Wolfgang Miltner, Ph.D., of the University of Jena in Germany, discovered that patients who used a particular prosthetic device called a Sauerbruch prosthesis experienced a substantial lessening of phantom pain, abolishing it completely in nine of 11 individuals. The design of the Sauerbruch, popular in Europe but little used in America, encourages and promotes extensive use of the residual part of the amputated limb. As a patient once again begins to employ that limb, the brain map receives renewed stimulation from the nerves of the limb. Much like the repeated exercises in CI therapy, this increased use causes a second cortical reorganization to take place in the brain map, shooing away the invading circuits, reversing their effects, and eliminating the pain.

Taub says that the most satisfying aspect of his work with CI therapy is the benefit it offers to patients disabled by stroke. In fact, he’s convinced that the therapy could bring renewed function to 75 percent of all stroke patients, if not more. He’s pleased, therefore, that the National Institutes of Health has launched a multi-site clinical trial to investigate potential applications of the therapy. Taub’s laboratory at UAB is one of the sites and serves as the national training center for all of the other locations involved in the study—which is the first stroke rehabilitation project ever supported by the NIH. At the conclusion of the four-year study, Taub hopes that his Constraint Induced Movement Therapy will be changing the lives of millions of stroke survivors.