The development of learned non-use and the application of constraint-induced therapy in a patient with a musculoskeletal injury: A case report

Case Study Report
Population: Adult

Gail Stern, PT, PhD, NCS, Professor, American International College

Kellie Forrest, PT, DPT, American International College

Eghe Asemota, PT, DPT, American International College

Keywords: Plasticity, Learned Non-Use, Constraint Induced Therapy

Background and Purpose: Current literature does not describe the neuroplastic development of learned non-use and the application of constraint-induced movement therapy in patients with musculoskeletal injuries and subsequent immobilization and pain. The purpose of this case report is to describe how the theory of learned non-use and constraint-induced therapy was applied in the physical therapy management of a non-ambulatory patient with a painful hip fracture.

Case Description: An 83 year old male with a minimally displaced avulsion fracture of the right femur lesser trochanter developed learned non-use secondary to persistent right hip pain with movement and weakness. He initially presented with maximally assisted bed mobility and transfers, 2-/5 strength at his right lower extremity (RLE), 8/10 pain (visual analog scale) and post fracture restrictions of no active hip abduction and 50% RLE weight bearing. He was unable in ambulation due to pain and muscle weakness.

Following the resolution of pain and strength deficits, the patient continued to be limited in his ability to move in bed, transfer, ambulate and bear weight at his RLE. It was hypothesized that the patient developed learned non-use of his RLE due to pain and immobilization.  Constraint-induced therapy (CIT) for bilateral lower extremities was used as his primary intervention to regress the development of learned non-use and negative neuroplastic changes. CIT for this patient consisted of massed/repetitive practice of LE tasks (sit to stand, pre-gait activities, ambulation) to promote functional mobility, increased weight bearing and proprioceptive feedback of the RLE.

The patient participated in physical therapy for 6 times a week (up to 60 minutes a day) at a sub-acute rehabilitation center. CIT was initiated at week five of an eleven week course of treatment.

Outcomes: The patient improved in his ability to perform bed mobility, transfers and ambulation. At the time of discharge the patient was able to ambulate with a rolling walker for up to 30 feet with minimal assistance, move from sit to stand with contact guard and perform a stand/step transfer and bed mobility with minimal assistance.

Discussion: Through intensive functional practice this patient was able to regain the use of his RLE for all transitional motion. Initially pain, weakness and immobility were this patient’s primary impairments. When these issues were resolved the patient did not use his RLE during functional activities. While most commonly observed in individuals with neurological diagnoses, it appeared that this patient learned not to use his RLE because of negative feedback from pain and weakness following a musculoskeletal injury. The patient benefited from an intensive functional training program to remediate the development of learned non-use following a musculoskeletal injury. Further research is warranted to describe the musculoskeletal conditions that may lead to the development of learned non-use and to identify the specific practice parameters to remediate negative neuroplasticity in this practice pattern.

Stern, Gail , PT, PhD, NCS; Forrest, Kellie , PT; Asemota, Eghe , PT. The development of learned non-use and the application of constraint-induced therapy in a patient with a musculoskeletal injury: A case report. Poster Presentation. IV STEP Conference, American Physical Therapy Association, Columbus, OH, July 17, 2016. Online.