Modified Constraint-Induced Movement Therapy for Stroke

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Description

Modified Constraint-Induced Movement Therapy (mCIMT) is an intervention used to improve functionality and mobility in the more affected upper extremity post stroke. It is used as an alternative to the original constraint induced movement therapy.

The original CIMT involves the restraint of the individual’s less impaired upper extremity with use of a safety mitt. The Mitt is left on for 90% of the day, over a 2-week intervention period in conjunction with 6 hours a day, 5 days of week of task specific training(1). CIMT is intensive and sometimes difficult to implement, with patients sometimes growing tired of wearing the mitt (2), affecting adherence to the protocol. A survey indicated that patients prefer a protocol that lasted more weeks with fewer sessions or shorter periods of wearing restrictive devices such as the mitts(3).Other barriers to implementing the original CIMT protocol include the resource intensity and cost of the therapeutic protocol. Therapists identify time requirements, difficult developing a challenging 6 hour program, and interference with other duties and other patients on their caseload as barriers to using the original CIMT protocol (4). The modified CIMT (mCIMT) protocol was developed as an alternative to the intensive nature of CIMT, and involves less time utilizing constraint over a longer intervention period (3)

The goal of CIMT, and subsequently mCIMT is to address the learned non-use and decreased motor function in an affected upper extremity post stroke/CVA (5). With the expectation that the patient/client is using their more affected upper extremity for everyday activities while the less affected upper extremity is placed in constraint, the patient performs gross motor tasks, fine motor tasks, and ADLs during the intervention time (5).

Components of mCIMT

Currently, there is evidence for many different formants of mCIMT.

Formats of mCIMT differ in the amount of practice and constraint implemented, but all share 3 fundamental components utilized in the treatment intervention, which stem from the original CIMT.

The three fundamental components that are utilized in every session of mCIMT are (6):

• Restraint of the less impaired upper extremity, using a mitt.
• Repetitive Task Practice
• Application of behavioural techniques (Deemed most important = Shaping)

• • Shaping:
    • “involves progressively increasing the difficulty of training tasks as the performance of patients improves, and providing immediate encouraging feedback when patients make even small gains.”(7).
    • Shaping tasks are specifically selected for patients based on their personal joint movements that show the most pronounced movement deficits, the joint movements that the acting therapist believes to have the most potential for movement improvement, and patient preference of tasks that have potential to produce similar movements. With shaping, progression of movement tasks is made in a systematic, quantified and parametric way on specific, personalized task to that person. This makes the intervention time specific and meaningful to the patient/client, as well as positive - as feedback is always positive and encouraging, very rarely negative (8).

Research varies in timing of the applied mCIMT. Early studies described structured sessions of functional, task-specific (hyperlink?) practice that lasts 30 minutes, with 5 hours of constraint of the less affected side, for 5 days a week for 10 weeks (3).

A meta-analysis and review included modified approaches with less than 6 hours of constraint a day, with intensive therapy that ranged from 30 minutes a day to 3 hours a day, with an intervention period ranging from 2 weeks to 10 weeks (9).

A second comprehensive meta-analysis outlines mCIMT therapy sessions performed for 30 minutes at a time, 3 times per week, over a 10 week period. (6)

Comparing mCIMT with CIMT, mCIMT has a distributed practice schedule (CIMT employs massed practice), has a reduced clinical treatment time (time spent patient-therapist), and therefore provides the patient with an increased amount of time to be spent on home-based practice using the more affected upper extremity, functionally, and with ADLs (6).

Indications

According to the Canadian Best Practice Guidelines, mCIMT (like CIMT) therapy is recommended for post-stroke patients who have minimal sensory and cognitive deficits, and are able to demonstrate a minimum of 20° of active wrist extension, and 10° of active finger extension (10).

Outcome Measures

Outcome measures most commonly used throughout the literature alongside mCIMT include the Fugl Meyer Assessment (hyperlink) and Functional Independence Measure (FIM) for disability and, Action Research Arm for motor function (9,11).

Other outcome measures used throughout the literature in conjunction with mCIMT are(11):

To measure disability:

• FIM (hyperlink)
• Barthel index (BI)

To measure secondary outcomes of arm motor function:

• Wolf motor function test (only score) (WMFT)
• Action Research Arm test (ARAT)
• Arm motor ability test (AMAT)
• Emory function test (EMF)
• assessment of motor and process skills (AMPS)

To measure secondary outcome: perceived arm motor function

• Motor activity log (MAL)
• Amount of use (AoU)
• And quality of use (QoU)

Secondary outcome: Arm motor impairment

• Fugl meyer assessment (FMA)
• Chedoke mcmaster impairment inventory (CMII)
• Hand strength

Secondary outcome: Dexterity

• Nine hole peg test (NHPT) [low score indicated positive outcome]
• Grooved pegboard test (GPT)

Secondary outcome: Quality of Life

• Stroke Impact Scale (SIS)

Evidence

Several studies have found that mCIMT improves function in the affected limb of patients after stroke. A systematic review by Shi et al. (9) found that mCIMT after stroke has a net significant effect on disability and a significant effect on upper extremity function. A literature review by Fleet et al. (6) found that mCIMT protocol is an effective intervention for UE recovery post stroke. In a randomised controlled clinical trial found that mCIMT resulted in significant functional changes in timed movement and improved ipsilesional cortical excitability in patients with acute subcortical infarction (13). Sethy et al, (14) found that mCIMT may improve functional use of the affected limb in chronic hemi-paretic stroke patients and it is effective for upper extremity hemiparesis in comparison to conventional treatment. Doussoulin et al. (12), found that both individual and group mCIMT increases the function and use of the upper extremity, with the increases being higher with the group mCIMT in a single-blind, randomized parallel study. A randomized control trial by Yadav et al. ((15)) found that four weeks of mCIMT is effective in improving the motor function in the affected, paretic upper limb of stroke patients. In a study by Ju and Yoon (16), mCIMT was found to have a significant effect on motor function and ADLs in stroke patients. mCIMT has also shown promise for improvement in populations other than stroke. Furthermore, mCIMT has been shown to be effective to promote balance and gait improvements in hemi-paretic patients after stroke in a randomized study done by Fuzaro et al. (17). For example, Psychouli and Kennedy (18) found that mCIMT as a home-based intervention for children with cerebral palsy is effective.

Meta-analytic evidence suggests that mCIMT is as influential and productive as original CIMT in promoting the use and functional recovery of an affected limb post-stroke (9). As well, with the reduction in clinical time (and therefore reduction in use of resources), mCIMT is shown to be easier, and more capable to manage clinically for both the therapist and patient/client (9).

Systematic review examined the literature on the 10 week, mCIMT protocol (specified above), and shows that it is an effective treatment for the promotion of recovery in the upper extremity post stroke (9). The outcome measures studied (UE of the Fugl-Meyer, ARAT, Motor Activity Log (MAL)) all demonstrated a positive improvement for patients using the mCIMT protocol with regards to upper extremity impairment and function(9). As well, in most studies done, the degree of change met or was greater than the MCID of the above stated outcome measures, respectively. (indicating that the patients who received mCIMT saw a change in UE function that is clinically meaningful, compared to control or no-therapy groups).

Stemming from this, effectiveness of UE recovery was observed across all stages of recovery post-stroke, including: acute, subacute, and chronic post-stroke stages. Seeing this, it is important to note that even though effectiveness was shown through studies in all stages of post-stroke recovery, the majority of evidence comes from research on chronic stroke population. This was determined to be indicated by an intermediate level of evidence (9).