By. Victor W. Mark, MD, Edward Taub, PhD, Gitendra Uswatte, PhD, Khurram Bashir, MD, MPH, Gary R. Cutter, PhD, Camille C. Bryson, MS, PT, Staci Bishop-McKay, BS, and Mary H. Bowman, OTR/L

Impaired mobility is a major cause for reduced quality of life in multiple sclerosis (MS). Accordingly, over the past 30 years nearly 100 peer-reviewed studies have investigated various forms of physical therapy involving the lower extremities for MS, including standard inpatient rehabilitation and experimental outpatient approaches such as aerobic exercise, progressive resistance strength training, and robotic therapy. Although such physical training can improve or maintain physical endurance, limb strength, cardiopulmonary fitness, or general well-being, for the most part the 50 studies to date have not evaluated whether the training benefits can transfer from the clinic or laboratory—where measurement is made primarily of maximal performance after prompting by the experimenter—to spontaneous use of the impaired limbs in the real world after return to the community.

An additional important consideration is that experimental physical rehabilitation approaches to MS to date have only seldom employed the type of methods to increase the relevance of therapies for activities in the life situation, of the sort used in various behavioral analysis programs for the control of obesity, smoking, or alcohol abuse. Indeed, such approaches are not formally or systematically incorporated in physical rehabilitation for neurological disorders in general. Nonetheless, a few recent studies have suggested that these techniques can bolster outcomes from physical rehabilitation. Studies on low back pain have shown that combining several techniques that are designed to increase the patient’s adherence to the treatment (a treatment contract, emphasizing to the patient his or her active participation in the treatment outcome, and maintaining a home diary) with exercise training can significantly improve self-rated disability over several years of follow-up relative to the same exercise training 6 without such techniques. More recent research has shown that upper extremity Constraint-Induced Movement therapy (CI therapy) for post-stroke hemiparesis that includes procedures to increase the relevance for everyday life of the training for the patient (described below) can produce significant improvements in real-world upper extremity use, as assessed by the Motor Activity Log (MAL), compared to taskoriented training without these procedures. Moreover, this study showed that CI therapy was associated with significant cortical grey matter increases over sensorimotor areas (as determined by voxel-based morphometry of brain MRI scans) while there was no grey matter change following task-oriented training alone.

Numerous studies have shown that CI therapy can successfully treat the reduction of spontaneous upper extremity use in the real world after stroke, MS, traumatic brain injury, and cerebral palsy. Moreover, specially adapted forms of CI therapy have also successfully treated real-world lower extremity deficits after stroke and spinal cord injury as well as verbal communication deficits in post-stroke aphasia. Regardless of the part of the body that is primarily affected, the goal of CI therapy is to overcome either the reduced spontaneous use or the maladaptive use of the more-affected part of the body during functional activities. The term “Constraint- Induced Movement therapy” is considered appropriate to designate the upper extremity form of the treatment as well as the variation for the lower extremities, since the term “constraint” is meant to refer either to physical restraint of a less impaired extremity by a device or constraints imposed by behavioral procedures that limit use of compensatory strategies, or both.

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Mark, V. W., Taub, E., Uswatte, G., Bashir, K., Cutter, G. R., Bryson, C. C., … & Bowman, M. H. (2013). Constraint-induced movement therapy for the lower extremities in multiple sclerosis: case series with 4-year follow-up. Archives of physical medicine and rehabilitation, 94(4), 753-760.