Constraint Induced Movement Therapy

Original Editor - Ben Kasehagen

Top Contributors - Evan Thomas and Candace Goh

Introduction

The term Constraint-Induced Movement Therapy (CIMT) describes a package of interventions designed to decrease the impact of a stroke on the upper-limb (UL) function of some stroke survivors. [1] It is a behavioural approach to neurorehabilitation[2] based on "Learned- Nonuse".  

CIMT is typically performed for individuals following a cerebrovascular accident (CVA) as between 30-66% of CVA survivors will experience some functional loss in their impaired limb.[3] Furthermore, CIMT has also been performed for individuals with cerebral palsy (CP), traumatic brain injury (TBI) and multiple sclerosis (MS).The aim of CIMT is to improve and increase the use of the more affected extremity while restricting the use of the less affected arm.

The three major components of CIMT include:[1]

  • Repetitive, structured, practice intensive therapy in the more affected arm
  • Restraint of the less affected arm
  • Application of a package of behavioural techniques that transfers gains from the clinical setting to the real world (i.e. making it functional)

History

The term is derived from the studies of non-human primates in which somatosensory deafferentation of a single forelimb, after which the animal fails to use that limb. Originally developed by Dr Edward Taub who demonstrated that monkeys with a surgical deafferentation (i.e. somatic sensation was abolished) of a forelimb, ceased using the affected extremity.[4][5] Through failed attempts to use the deafferented forelimb, the monkeys developed compensation methods to avoid using the affected limb, that is, they effectively learned not to use their affected extremity termed learned nonuse.[4][5]

Indication

Participants who have suffered a stroke require some hand function, high motivation, minimal cognitive dysfunction, adequate balance and adequate walking ability while wearing the restraint to be eligible to participate in CIMT interventions.[5]

The minimum motor criterion for inclusion[2] into therapy is:

  • 10° wrist extension
  • 10° thumb abduction
  • 10° finger extension


Clinical Intervention

Participants wear a mitt on the less affected arm 90% of their waking hours

Perform repetitive task-oriented training with the affected arm 6-7 hours per day

Perform for 10 - 15 consecutive weekdays

There are 3 major components;

  1. Shaping is a training method in which a motor task is gradually made more difficult.[4] Shaping programs are individualized consisting of 10-15 tasks selected primarily from a basic battery of tasks.[4] Each task is usually performed in a set of 10-30 sec trials. At the end of each set of 10 trials, the task is changes. Only one shaping parameter is changed at a time. Requires constant therapist involvement.
  2. Task practice is repetitive practice of individual functional tasks that takes roughly 15-20mins.[4] Rest is provided as required. Encouragement is given on an infrequent basis (i.e. every 5 mins) with feedback at end of task as well about how they performed.[4] Requires less therapist involvement.
  3. Package of behavioural techniques is designed to transfer gains from the clinic to daily life.[4] Includes a behavioural contract that identifies tasks that the participant will attempt to perform. Furthermore, this allows for identification of barriers and problem solving to overcome these obstacles. The daily administration of the motor activity log promotes adherence.
[6]


Although the short- and long-term benefits of CIMT have already been described, it is well known that most individuals have one upper limb
which performs daily skills more proficiently. Thus, it is possible that upper limb dominance prior to stroke may interfere with the acquisition and the maintenance of upper limb skills, due to the specific brain activation patterns or the amount of upper limb use during daily activities. Twenty-two chronic stroke survivors with mild to moderate motor impairments received individual home-based mCIMT with or without trunk restraints, five times per week, three hours daily over two weeks. In this study, the participants were separated into a dominant group, which had their paretic upper limb as dominant before the stroke (n=8), and non-dominant group (n=14) for analyses. The ability to perform unimanual tasks was measured by the Wolf Motor Function Test (WMFT) and the Motor Activity Log (MAL), whereas the capacity to perform bimanual tasks was measured using the Bilateral Activity Assessment Scale (BAAS).

The authors concluded that upper limb dominance did not interfere with the acquisition of upper limb skills after mCIMT. However, the participants whose paretic upper limb was dominant demonstrated better abilities to maintain the unilateral gains. The bilateral improvements were maintained, regardless of upper limb dominance.

Key Evidence

Home based modified CIMT [7]

Aim - To compare four weeks of a home-based CIMT program (CMIThome) with a signature two weeks CIMT program (CIMTclassic)

Method

  • n=7 chronic CVA pts in each group
  • CIMThome – Initial one-day training including the instruction of a family member. Training performed at the patients home. 2 hrs of daily training at pt’s home with supervision by the instructed family member for 20 consecutive days. The constraint of unaffected hand for 60% of waking hours. Once weekly physio home visit to supervision and adapt exercises. Pts received 15 hrs of professional physio supervision in total
  • CMITclassic - Original technique – training administered via physiotherapist 6hrs every weekday for two weeks. Overall 60hrs professional supervision
  • Outcome measures performed prior, immediately after and six months after interventions. Outcomes include Wolf motor function test (WMFT) and Motor activity log (MAL)

Results - Significant improvements in motor function on both WMFT and MAL immediately after and at 6/12 in both groups
Clinical application - A home program may be feasible, effective and requires less therapist supervision, therefore, is cost effective. Future research requires a larger sample size.

Constraint-Induced Movement Therapy Compared to Dose-Matched Interventions for Upper-Limb Dysfunction in Adult Survivors of Stroke: A Systematic Review with Meta-analysis [8]  

Aim: To summarize the existing literature examining constraint-induced movement therapy (CIMT), relative to dose-matched control interventions, for upper-limb (UL) dysfunction in adult survivors of stroke. Methods: CINAHL, Cochrane Library, Embase, NARIC/CIRRIE—Rehabdata, PEDro, PubMed, Scopus, and Web of Science were searched from their inception to February 2011. Trial quality was described using the PEDro scale. The findings were summarized with meta-analysis. Results: For the 22 trials identified, the mean (SD) PEDro score was 6.4 (1.2). Meta-analysis showed CIMT to be superior to dose-matched interventions based on indicators of UL motor capacity (15 trials, n=432; standardized mean difference [SMD]=0.47, 95% CI, 0.27–0.66) and UL ability (14 trials, n=352; SMD=0.80, 95% CI, 0.57–1.02); Functional Independence Measure scores (6 trials, n=182; mean difference [MD]=5.05, 95% CI, 2.23–7.87); and Motor Activity Log scores (Amount of Use: 12 trials, n=318; MD=1.05, 95% CI, 0.85–1.24; Quality of Movement: 11 trials, n=330; MD=0.89, 95% CI, 0.69–1.08). Conclusions: Compared to control interventions of equal duration and dose, CIMT produced greater improvements in a variety of indicators of UL function in adult survivors of a stroke with the residual movement of their upper limb.

Constraint-Induced Movement Therapy (CIMT): Current Perspectives and Future Directions [9]

Constraint-induced movement therapy (CIMT) has gained considerable popularity as a treatment technique for upper extremity rehabilitation among patients with mild-to-moderate stroke. While substantial evidence has emerged to support its applicability, issues remain unanswered regarding the best and most practical approach. Following the establishment of what can be called the “signature” CIMT approach characterized by intense clinic/laboratory-based practice, several distributed forms of training comparison approach that addressed limitations in the literature extracted from the PEDro review was suggested. Efforts by researchers to improve methodology and standardization of protocols can greatly assist the practicing clinician in analyzing EBP and incorporating best practices into clinical practice. Establishing a standardized best-model alternative CIMT protocol would also allow stroke guidelines to make clearer, more definitive recommendations regarding CIMT.

Effects of modified constraint-induced movement therapy in the recovery of upper extremity function affected by a stroke: a single-blind randomized parallel trial - comparing group versus individual intervention[10]

Aim - To determine the effectiveness of modified CIMT in group therapy compared with individual intervention, in improving the use and functionality of a paretic upper limb during ADLs.

Method

  • n=36 patients who had had a stroke > 6 months previously were divided randomly into two intervention groups.
  • The independent variable was the implementation of group or individual modalities for 3 h for 10 consecutive days.
  • Dependent variables were evaluated by the Motor Activity Log and Action Research Arm Test, at baseline (preintervention evaluation), end (postintervention evaluation), and 6 months after intervention (follow-up).

Results - Both types of intervention generated increases in the function and use of the upper extremity, with these increases being higher in the group therapy. The effects of the group therapy modality were maintained 6 months after the intervention ended.

Clinical implication - Use of modified CIMT in group setting may be more effective than individual intervention. Further study with larger sample size would be useful.

References

  1. 1.0 1.1 Morris DM, Taub E, Mark VW. Constraint-induced movement therapy: characterizing the intervention protocol. Eura Medicophys. 2006;42(3):257–68
  2. 2.0 2.1 Taub, E. and Uswatte, G. Constraint-induced movement therapy: answers and questions after two decades of research. 2006 NeuroRehabilitation, 21(2), 93-95.
  3. Kwakkel, G., Kollen, B. J. and Wagenaar, R. C. Therapy impact on functional recovery in stroke rehabilitation: a critical review of the literature. 1999 Physiotherapy, 85(7), 377-391.
  4. 4.0 4.1 4.2 4.3 4.4 4.5 4.6 Uswatte, G., Taub, E., Morris, D., Barman, J., & Crago, J. Contribution of the shaping and restraint components of constraint-induced movement therapy to treatment outcome. 2006 NeuroRehabilitation, 21(2), 147-156.
  5. 5.0 5.1 5.2 Brogårdh, C. Constraint Induced Movement Therapy: influence of restraint and type of training on performance and on brain plasticity. 2006
  6. physicaltherapyvideo. Stroke Therapy: Constraint Induced Movement Therapy for Arms. Available from: http://www.youtube.com/watch?v=8F-Pgukdjj8 [last accessed 13/08/16]
  7. Barzel, A., Liepert, J., Haevernick, K., Eisele, M., Ketels, G., Rijntjes, M., & van den Bussche, H. (2009). Comparison of two types of Constraint-Induced Movement Therapy in chronic stroke patients: A pilot study. Restorative neurology and neuroscience, 27(6), 675-682
  8. Ted Stevenson, MSc(PT),corresponding author Leyda Thalman, BMR(OT), Heather Christie, MSc(PT),and William Poluha, MSc, MLIS :Constraint-Induced Movement Therapy Compared to Dose-Matched Interventions for Upper-Limb Dysfunction in Adult Survivors of Stroke: A Systematic Review with Meta-analysis;Physiotherapy Canada 2012; 64(4);397–413; doi:10.3138/ptc.2011-24
  9. Aimee P. Reiss, Steven L. Wolf, Elizabeth A. Hammel, Erin L. McLeod, and Erin A. WilliamsConstraint-Induced Movement Therapy (CIMT): Current Perspectives and Future Directions; Stroke Res Treat. 2012; 2012: 159391.
  10. Doussoulin A, Rivas C, Rivas R, Saiz J. Effects of modified constraint-induced movement therapy in the recovery of upper extremity function affected by a stroke: a single-blind randomized parallel trial-comparing group versus individual intervention. International Journal of Rehabilitation Research. 2018 Mar 1;41(1):35-40.