constraint induced manual therapy
TRANSCRIPT
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Constraint Constraint Induced Induced
Movement Movement TherapyTherapy.
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Stroke is one the leading causes of disability In 1999, more than 1,100,000 stroke survivors reported difficulty
with functional activitiesAmerican Heart Association,2001
Between 30% and 66% of stroke survivors report limited use of their affected arm (Van Der Lee et al, 1999)
Upper limb hemiparesis following stroke can make bathing, feeding dressing a challenge
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As a result, the stroke survivors learn to compensate with their stronger arm and progressively avoid the use of the weak arm when performing activities of daily living
This behavior may contribute to learned non use of the extremity
Learned non use refers to the mismatch between the true residual motor capabilities of the hemiplegic side compared with the extent to which a patient actually uses the impaired limb
Dawn M Aycock et al. what is CIT?; Journal Of Rehab Nurs, Aug 2004
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Human research on CI therapy was first developed for treatment of upper limb paresis in adult patients with stroke
Taub et al. APMR, 1993
Now studies in this field also include research in children with upper limb paresis after cerebral palsy
Other forms of CI therapy developed in the course of years for lower extremities, aphasia etc.
N Smania. Constraint induced therapy, editorial
Euramedicophys2006;42:239 - 242
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Human research on CI therapy was first developed for treatment of upper limb paresis in adult patients with stroke
Taub et al. APMR, 1993
Now studies in this field also include research in children with upper limb paresis after cerebral palsy
Other forms of CI therapy developed in the course of years for lower extremities, aphasia etc.
N Smania. Constraint induced therapy, editorial Euramedicophys2006;42:239 - 242
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Forced use refers to the restriction of a patient’s stronger limb to encourage focused and frequent use of the impaired limb during daily activities
CI therapy involves teaching a stroke patient to regain use of impaired arm by limiting use of the stronger arm and adding intense, structured, task specific training
Dawn M Aycock et al. what is CIT?; Journal Of Rehab Nurs, Aug 2004
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Constraint-Induced Movement TherapyConstraint-Induced Movement Therapy
Restraint Restraint of theof the
uninvolveduninvolvedUEUE
IntensiveIntensiveRehab TherapyRehab Therapy
of the of the involved UEinvolved UE
Hemiplegic stroke patientHemiplegic stroke patient
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Theoretical framework
CI therapy is the first rehabilitative approach which takes
into account not only remediation of motor dysfunction but
also the problem of learned non use deriving from
functional limitation
N Smania. Constraint induced therapy, editorial
Euramedicophys2006;42:239 - 242
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Concept of learned non use was first described by Taub after his research on monkeys in which the somatic sensations were surgically abolished from upper limb
These animals had motor deficit because of this sensory deprivation, but the strength was preserved and were able to perform movts under visual control
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However, deafferented monkeys did not use their insensate limb
Taub found that after a period of restraint of the unaffected limb, the monkeys began to use their affected limb in an effective and permanent way
Euramedicophys2006
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Taub hypothesized that Function suppression which is typical of the deafferented monkeys may be due to learned non use
He proposed that reversal of functional suppression could be attained by restraining the unaffected limb
This constitutes the core of CI therapyEuramedicophys2006
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WHO CAN BENEFIT Primary patient population thus far:
Chronic Stroke patients with mild to moderate UE hemiparesis.Populations being researched: Sub-Acute stroke patients with mild to moderate UE hemiparesis Acute stroke patients with mild to moderate UE hemiparesis
Pediatric patients with cerebral palsy
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CIMT inclusion criteria
Good trunk control Good standing balance Ability to extend at least 10 ° at MCP and IP joints and
at least 20 ° at wrist, abduct and extend thumb
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CIMT Exclusion Criteria
Exclusion criteria has been rather consistent:
Severely ’d AROM: Lack of ability to extend at least 10 ° at MCP and IP joints and at least 20 ° at wrist
Significant balance problems including walking at all times with an assistive device.
Serious cognitive deficits
Excessive spasticity
Serious, uncontrolled medical problems
Unwilling to wear restraining device 90% of day for 14 days.
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CIMT protocol and components
Repetitive task oriented training1. Shaping2. Task practice
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Shaping : it’s a training method based on behavioral
training
A motor or behavioral objective is approached in small
steps by successive approximations
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Adherence enhancing behavioral strategies
1. Administration of motor activity log
2. Home diary
3. Problem solving in real world approach
4. Behavioral contract
5. Caregiver contract
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6. Home practice
7. Home skill assignment
8. Daily schedule
Constraining use of less affected limb1. Use of mitt or any other method
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Limitations of traditional CIT Traditional CIT with one patient per therapist requires a lot of
resources and the six hours training protocol may be strenuous for the patients.
According to Page et al 2002, CIT considered unfeasible by clinicians due to patients’ concerns about the intensive schedule of treatment.
In addition, therapists are concerned about patients’ compliance, about safety issues and about clinical resources.
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Effects of CIT
Gains in upper extremity function after constraint induced therapy have been reported in all stages after the onset of stroke
(Wolf et al. 2002; Hakkennes and Keating 2005)
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2 possible mechanisms for the observed effects are believed to be
1. Overcoming the learned non-use of the more affected arm (i.e, increased use of the more affected arm) and
2. Use dependent cortical reorganisation
(Taub et al. 1999; Liepert et al. 2000; Morris and Taub 2001;Taub et al. 2002; Wolf et al. 2002)
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CIMT and plasticity
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Both strengthening and weakening of synaptic connexions have been proposed as learning mechanisms (Schweighofer et al. 2001;
Jörntell and Ekeroth 2003)
The mechanism of plasticity probably differs depending on the time course (Chen et al. 2002)
GABA seems to be the most important inhibitory neurotransmitter in the brain and evidence is strong that a reduction of GABAergic inhibition is crucial in mediating short-term plasticity changes (Chen et al. 2002).
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The major mechanism mediating long-term plasticity changes, by which learning and memory consolidation takes place in the brain, is probably LTP (long-term potentiation) (Kandel et al.
2000).
Other mechanisms regarding changes over longer time are axonal regeneration and sprouting (Carr and Shepherd 2000; Chen et al. 2002).
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Impairment of hand function is exacerbated by learned non-use and that this in turn leads to a loss of cortical representation of the upper limb
It is claimed that these processes can be reversed by two weeks of constraint of the unaffected limb combined with intensive practice in use of the paretic hand
Sunderland A, Tuke A 2005
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The principle of CIMT is to make use of the more affected limb
for 90% of the patient’s waking hours by constraining or
reducing the use of the less affected limb for 2 – 3 weeksSunderland A, Tuke A 2005
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Cortical reorganization could be Cortical reorganization could be
a possible explanation for the a possible explanation for the
recoveryrecovery
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Liepert J et al 1998 demonstrated that even in chronic stroke patients, reduced motor cortex representations of an affected body part can be enlarged and increased in level of excitability by an effective rehabilitation procedure
They studied a CNS correlate of therapy-induced recovery of function after nervous system damage in humans
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Before and 2 weeks after CIMT, motor cortex mapping was done using trans cranial magnetic stimulation
Motor-output areas of the abductor pollicis brevis muscle, motor evoked potential (MEP) amplitudes were studied
After CI therapy, motor performance improved substantially in all patients.
Increase of motor output area size and MEP amplitudes, indicating enhanced neuronal excitability in the damaged hemisphere for the target muscles
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As mentioned in the previous study, Lippert et al 1998 demonstrated treatment induced cortical plasticity occurred in stroke patients after CIMT
Levy et al 2001 demonstrated changes in the activation of the motor cortex after CIM therapy using fMRI
However, the brain areas of plastic change were not clearly identified
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So, in 2004,Yun Hi Kim et al studied the effects of short term
CIMT on plasticity of motor network and also to identify the
areas responsible for clinical improvement after CIMT using
functional MRI
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5 patients (4 stroke, 1 TBI)
Subjects had ability to extend wrist up to 20*, open at least 2
fingers and 10* movt at thumb
CIMT for 7 hours a day for 2 weeks
Outcome measures:
Fugl Meyer assessment scale, 9 hole peg test
Jebsen hand function test, f- MRI
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Results : Significant improvement of motor performance in the paretic
limb in all patients For 3 patients, new activation in the contralateral motor/
premotor cortices was observed after CIM therapy Increased activation of the ipsilateral motor cortex was
observed in the other patient
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Conclusion
Short term CIMT produced changes in the functional
organization of the motor network after brain injury, but Area
and pattern of reorganization is patient dependent
These plastic changes of the motor network might be
considered as the neural basis for the improvement after CIMT
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Sunderland A, Tuke A Neuropsychol Rehabil. 2005 May;15(2):81-96 said that the improvement in function following CIMT may be due to learning of compensatory movement strategies rather than reduction of basic motor impairment as such
Cortical changes detected by TMS or fMRI may reflect this compensatory motor skill learning rather than restoration of representations lost due to the infarct or non-use of the limb
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If future studies confirm this then the clinical implication is that
direct teaching of unimanual or bimanual compensatory
strategies might be a more productive approach than constraint
Lippert J in Cogn Behav Neurol. 2006 Mar;19(1):41-7, found
that therapy-associated changes of motor cortex excitability
mainly occur in the lesioned hemisphere
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To investigate motor cortex excitability in stroke patients and
explore excitability changes induced by an intense
physiotherapy
He studied 12 chronic stroke patients before and after
participation in 12 days of constraint-induced movement
therapy. TMS was applied to test intracortical inhibition (ICI),
intracortical facilitation, amplitudes of motor evoked potentials,
and motor thresholds
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Before therapy, a motor cortex disinhibition was found in the affected hemisphere
This disinhibition was stronger in patients with cortical lesions The amount of disinhibition was correlated with the degree of
spasticity After therapy, ICI changes were more pronounced in the
affected hemisphere compared with the unaffected side
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Motor function tests indicated an improvement in all patients
Motor cortical disinhibition is present in chronic stroke
Therapy-associated changes of motor cortex excitability mainly occur in the lesioned hemisphere
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Kononen M et al J Cereb Blood Flow Metab. 2005,with the help of a single-photon emission computerized tomography study found that Intensive movement therapy led to a change in the local cerebral perfusion in areas known to participate in movement planning and execution
These changes led the authors to conclude that these might be a sign of active reorganization processes after CIMT in the chronic state of stroke
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Modified CIMT
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A number of researchers have reported that, although promising, the clinical implementation of CIT is difficult
Blanton S in 1997 in a case study reported that the patient "grew tired of wearing the mitt and had difficulty with full adherence
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Page et al in 2002 in a survey found that > 60% of patients with stroke would not want to participate in CIT, preferring therapy lasting for more weeks with shorter activity sessions and/or fewer hours wearing the restrictive devices.
This survey also found that > 80% of physical and occupational therapists did not feel that this protocol was feasible within their clinical environments
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Because of the above limitations, even if CIT is shown efficacious, it may be difficult for clinical sites to actually implement the therapy
Edward Taub noted that "any technique that induces a patient to use an affected limb should be considered therapeutically efficacious.
With this framework in mind, "modified constraint-induced therapy" (mCIT) was developed
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Modifications of CIT To make CIT clinically adaptable with limited resources as
regards therapists, various modifications of the original concept have been attempted, for example:
Shortened CIT (Sterr et al. 2002a) (i.e 3 hours of training/day for two weeks);
Forced use therapy (FUT; restraint of the less affected arm but without specific shaping exercises for the affected arm) (van der Lee et al. 1999; Ploughman and Corbett 2004),
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Modified CIT (Page et al. 2001; Levin and Page 2004)(consisting of 3 hours of training per week for 10 weeks with the intact arm in restraint 5 hours/day for 5 days/week),
Automated delivery of constraint induced therapy (AutoCITE) i.e., a computerized form of CIT (Taub et al. 2005),
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Distributed CIT (3 hours of training per day distributed for 20 days) (Dettmers et al. 2005), and
Group CIT (with 2-3 patients per therapist) (Brogårdh and Sjölund 2006)
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Modified CIT (Page et al. 2001):
Like CIT, the goal of mCIT is to reintegrate more affected arm use during valued activities
And, like CIT, these increased use patterns are accomplished through two means, but over 10 weeks rather than two
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Patients attend half-hour therapy sessions 3 days a week in which they use the more affected arm for functional activities under the supervision of an OT/PT
A sling and/or mitt is worn on the less affected arm 5 days a week for 5 hours a day
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The mCIT schedule is advantageous because patients can work, and carry on other activities during the mCIT 10-week period
Patients can wear the sling and mitt during focused, five-hour time periods and obtain enough concentrated practice for motor changes to occur
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Automated delivery of constraint induced therapy (AutoCITE) i.e., a computerized form of CIT (Taub et al. 2005):
AutoCITE (automatedCI therapy extension) that automates the training portion ofCI therapy and is as efficacious as standard CI therapy
AutoCITE could potentially reduce the cost of the therapy by allowing participants to perform the training in the clinic with only partial therapist supervision
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The AutoCITE consists of a computer, 8 task devices arrayed in a cabinet on 4 work surfaces, and an attached chair
The computer provides simple 1-step instructions on a monitor that guides the participant through the entire treatment session
Completion of each instruction is verified by sensors built into
the device before the next instruction is given
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However, in these scenarios, subjects still must spend substantial time practicing (perhaps unsupervised), and the clinic or patient must invest in equipment to administer the programs.
Automated tasks may not transfer to subjects' home
environments depending on device programming, peripherals attached to the device, and patients' interests
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Although mCIT and AUTOCITE constitute an important development, some patients who would otherwise qualify for the therapy cannot attend clinical sessions due to limited transportation access, minimal familial support, or other challenges
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Stephen and Page 2006 have developed a modified constraint-induced therapy extension (mCITE). Through the program, patients use a personal computer camera
Then, at a predetermined time, subjects type in an address and "call" a computer at the rehabilitation hospital, where a therapist is seated.
3 days a week, the therapist interacts with the patient, providing instructions for therapy through a built-in camera microphone, direct supervision, and encouragement.
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The patient also practices home exercises assigned by the therapist for five hours/day, five days/week, making the program entirely home-based
Preliminary studies show that this program is as effective as CIT-based home practice strategies and as mCIT
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Constraint-induced movement
therapy in patients
with stroke: a pilot study on
effects of small group
training and of extended mitt use
Christina Brogardh, Bengt H
Sjolund
Clinical Rehabilitation 2006
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Purpose:
To evaluate constraint-induced movement therapy for
chronic stroke patients modified into group practice to limit
the demand on therapist resources
To explore whether extended mitt use alone may enhance
outcome
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Design: A combined case/control and randomized
controlled study with pre- and post-treatment measures by
blinded observers
Participants: 16 stroke patients on average 28.9 months
post stroke, with moderate motor impairments in the
contralateral upper limb
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Intervention: Constraint-induced therapy (mitt on the less
affected hand 90% of waking hours for 12 days) with 2-3
patients per therapist and 6 h of group training per day
After the training period, the patients were randomized
either to using the mitt at home every other day for two-
week periods for another three months (in total 21 days) or
to no further treatment
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Outcome measures: Modified Motor Assessment Scale,
Sollerman Hand Function Test, Two-Point Discrimination test
and Motor Activity Log
Conclusion: Constraint-induced group therapy, allowing
several patients per therapist, seems to be a feasible alternative
to improve upper limb motor function
The restraint alone, extended in time, did not enhance the
treatment effect
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Shortened CIMT..
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Taub et al. originally devised the patients wear a mitt on the less affected arm 90% of waking hours and perform exercises 6/7 h per day over 2/3 weeks with one therapist per patient
A one-to-one relation between patient and therapist 6 h per day for two weeks is not feasible with the present limitations of resources for stroke care
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The varying clinical benefit of constraint- induced therapy that
has been reported by different research groups could be
because the amount of training differs between the centers
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Limited dose response to Constraint-Induced Movement Therapy in patients with chronic stroke
Lorie Richards et al.Clinical Rehabilitation 2006;
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Purpose: To compare outcomes in motor skill, perceived
amount of use and ability of the paretic arm in daily
activities between traditional CIMT and shortened CIMT
Design: A secondary analysis of two previous randomized,
controlled, double-blind, parallel group studies
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39 patients
Outcome measures: The Wolf Motor Function Test ,Motor
Activity Log ,Quality of movement scales
Conclusion: These results suggest that 6 hours of
therapist-guided practice may not be necessary to facilitate
motor skill gains, but may influence patterns of use
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Stroke and CIMT..
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The first report of CIMT for hemiparesis in humans was by Ostendorf and Wolf in 1981
A large number of case reports and case series followed.
All of these reports were positive, reporting improvements in people with stroke
Most of the work was done on chronic stroke patients
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Chronic stroke..
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Edward Taub et al in stroke 1999 studied the effects of CIMT on
patients With Chronic Motor Deficits After Stroke
They took 15 chronic stroke patients and gave them CI therapy,
(sling for 90% of waking hours for 12 days) and training (by
shaping) of the more affected extremity for 7 hours on the 8
weekdays during that period
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Patients showed a significant and very large degree of
improvement from before to after treatment on a laboratory
motor test and on a test assessing amount of use of the affected
extremity in activities of daily living in the life setting ,with no
decrement in performance at 6-month follow-up
The results indicate that CI therapy is a powerful treatment for
improving the rehabilitation of movement of the affected upper
extremity in chronic stroke patients
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Side of hand dominance:
Subjects with paresis of the left, non dominant limb exhibited as
large a treatment effect as subjects with right hemiparesis
Time since stroke:
No difference in the motor improvement produced by CI therapy
for the patient population defined by the inclusion criteria of this
study
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However, the subjects in this study, including 4 patients with the
longest post event times (9, 9, 14, and 17 years) , all showed a
very substantial improvement in motor function
Thus, even very chronic stroke survivors are amenable to CI
therapy and do as well as individuals who are much closer in
time to the focal event.
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At the other end of the chronicity spectrum, it was found that the
2 subacute patients who suffered a stroke just 6 months before
the initiation of CI therapy received as much benefit from the
therapy as more-chronic patients
In the past, the effect of CI therapy has been mostly studied with
patients who are 1 year post stroke
However, the present results strongly suggest that CI therapy is
also effective for subacute patients
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Bonifer NM, Anderson KM, Arciniegas DB in their study in
APMR 2005, concluded that CIMT conferred significant
changes in objective measures in subjects with chronic
moderate-to-severe impairments after stroke and that
improvements in motor impairment scores remained stable 1
month after completion of formal treatment
Bonifer NM, Anderson KM, Arciniegas DB in their study in APMR 2005
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Tarkka IM, Pitkanen K, Sivenius J. in Am J Phys Med
Rehabilitation 2005 also observed similar results
Studied effectiveness of CIMT in improving motor abilities in
very chronic stroke subjects
Also assessed whether the obtained changes, if any, would
endure after the intervention program
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They found that following a 2 week therapy the motor abilities of
the affected arm improved significantly as measured by the
structured motor performance test and the obtained
improvements in the affected arm motor behaviour endured for
5 months after the therapy
Tarkka IM, Am J Phys Med Rehabilitation 2005
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Constraint-induced movement Constraint-induced movement therapy for people followingtherapy for people followingstroke in an outpatient settingstroke in an outpatient setting
Karen Porter, Lord S New Zealand Journal of Physiotherapy 2004
32(3) 111-119
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The studies have mostly been conducted on small samples
using CIMT variations that include:
A range of inclusion criteria;
Diverse CIMT treatment protocols; and
The use of non standardized outcome measures such as the
Motor Activity Log (MAL)
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The MAL has been used in previous CIMT studies both as the
part of the inclusion criteria and as an outcome measure (Sterr et
al. 2002, Page et al. 2001,Leipert et al 2000)
However the MAL is not used clinically and no specific evidence
has been found in the literature to establish its psychometric
properties (Blanton &Wolf 2000, Uswatte & Taub 1999)
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This study aimed to undertake a small trial of CIMT for
people with chronic stroke to:
1. Investigate the level of restraint use
2. Use standardized outcome measures to determine which
measures were more responsive to CIMT
3. Investigate the effect of CIMT on a small sample
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A convenience sample of 12 people with chronic stroke with
persisting upper limb disability post-stroke was selected
CIMT was undertaken involving two phases: a 14 day period of
restraint for the unaffected upper limb and a concurrent 10 day
period of intensive exercise for the affected upper limb
Pre and post-treatment scores on outcome measures
commonly used by physiotherapists were also recorded.
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The following measures were selected as primary outcomes to assess upper limb impairment and function:
The Fugl-Meyer Assessment (FM) The Motor Assessment Scale (MAS) The Nine-Hole Peg Test (NHPT) Grip Strength
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Secondary outcome measures included the Modified Ashworth Scale to assess muscle tone of elbow flexors
The MAL (Uswatte & Taub 1999,Taub et al. 1993), which was included as an outcome measure for this study so that the results could be compared with earlier work
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Overall the average hours of restraint use were low, although participant support for CIMT was very high.
The Motor Assessment Scale (MAS) was found to be the most responsive outcome measure.
Significant improvement in affected upper limb function at 3 months post-treatment on the MAS and in Grip Strength (p=0.001), but not on the Fugl-Meyer Assessment (p=0.052).
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This small study demonstrated that upper limb function was improved, despite low restraint use.
Large scale trials are required to verify the efficacy of CIMT, and also to determine its essential components
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A Placebo-Controlled Trial of A Placebo-Controlled Trial of Constraint-Induced Movement Constraint-Induced Movement Therapy for UpperTherapy for Upperextremity After Strokeextremity After Stroke
Edward Taub et al.Stroke 2006
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The authors state that a number of studies had reported positive
effects for CIMT, but no experiment had been done using a
placebo control group
A placebo-controlled trial of CI therapy in patients with mild to
moderate chronic (mean4.5 years after stroke) motor deficit
after stroke.
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The CI therapy group received intensive training (shaping) for 6
hours per day on 10 consecutive weekdays,
Restraint of the less affected extremity: 90% of waking hours, 2-
week treatment period,
Transfer to the life situation
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Placebo group recieved:
General fitness program
Strength, balance, and stamina training exercises,
Games that provided cognitive challenges,
Relaxation exercises for 6 hours per day for 10 consecutive
weekdays
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CI therapy (n=21) or placebo control group (n=20)
Exclusion criteria
Stroke experienced 1 year earlier, bilateral or brain stem stroke
Lack of ability to actively extend 10° at MCP and IP joints and 20° at
wrist
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Balance or ambulation problems
Substantial use of the involved upper extremity in the life
situation
Major cognitive deficits, aphasia
Excessive pain, spasticity, ataxia,
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After CI therapy, patients showed large (Wolf Motor Function
Test) to very large improvements in the functional use of their
more affected arm in their daily lives (Motor Activity Log)
The changes persisted over the 2 years tested
Placebo subjects showed no significant changes
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The authors concluded that their results support the efficacy
of CI therapy for rehabilitating upper extremity motor function in
patients with chronic stroke
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Application of Combined Application of Combined BotulinumToxin Type A and Modified BotulinumToxin Type A and Modified Constraint-Induced Movement Constraint-Induced Movement Therapy for an Individual With Therapy for an Individual With Chronic Upper-Extremity Spasticity Chronic Upper-Extremity Spasticity After StrokeAfter StrokeShu-Fen Sun, Chien-Wei Hsu
Physical Therapy . Volume 86 . Number 10 . October 2006
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Evidence indicates that the minimum motor criteria of patients
who show benefit from CIMT include at least 20 degrees of wrist
extension and 10 degrees of extension at each MCP and IP
joint of the affected upper extremity
Those people who do not meet these initial criteria may not
benefit from CIMT
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The purpose of this Case report was To describe the use of a
combination of Botulinum toxin type A (BtxA) and a modified
CIMT program for a patient with severe spasticity who was
unable to use his right upper extremity
The 52-year-old patient, who had a stroke 4 years ago, did not
meet the minimum motor criteria for CIMT benefit
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After receiving BtxA injections targeting the elbow, wrist, and
finger flexors, he completed a 4-week program of modified
CIMT followed by a 5-month home exercise program
Outcomes:
The patient exhibited improvement in muscle tone and in scores
on several upper-extremity function tests (MAS, MAL, Wolf
Motor Function Test, and Fugl-Meyer Assessment of Motor
Recovery)
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Test scores improved immediately following the 4-week
program and these increased scores were maintained at
the 6-month follow-u.
Conclusion: combined treatment of BtxA and modified
CIMT may have resulted in improved upper-extremity use
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Constraint-induced movement Constraint-induced movement therapy following stroke: A therapy following stroke: A systematic review of systematic review of randomised controlled trialsrandomised controlled trials
Sharon Hakkennes, Jennifer Keating
Australian Journal of Physiotherapy
2005
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Effects on function, quality of life, health care costs, and
patient/carer satisfaction of constraint-induced movement
therapy (CIMT) for upper limb hemiparesis following stroke
MEDLINE, CINAHL, EMBASE, Cochrane Library, PEDro and
OTseeker to March 2005
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Fourteen studies
Randomised or quasirandomised controlled trial including cross-
over designs or a systematic review of randomised controlled
trials
Participants were over 18 years
Reduced functional use of an upper extremity as a result of a
stroke
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Conclusions
The most common measures of upper limb function used in included
trials were the Action Research Arm Test, the Wolf Motor Function
Test and the Fugl-Meyer assessment
CIMT may improve upper limb function following stroke compared to
alternative and/or no treatment
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Little can be concluded about the effects of CIMT on quality of life,
independence with activities of daily living, and costs associated with
the intervention
It is unclear if there is an optimal CIMT protocol.
The findings of this review can be generalised to people with
preserved cognitive function, 10 degrees of active finger, and 20
degrees of active wrist extension
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Predictors of outcome..
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Active Finger Extension Predicts Active Finger Extension Predicts
Outcomes After Constraint-Induced Outcomes After Constraint-Induced
Movement Therapy for Individuals Movement Therapy for Individuals
With Hemiparesis After StrokeWith Hemiparesis After StrokeStacy L. Fritz, Kathye E. Light, Tara S. Patterson, Andrea L.
Behrman and Sandra B.
Stroke 2005
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Purpose: The goal of this study was to investigate the potential of 5
measures to predict functional CIMT outcomes
Methods: A convenience sample of 55 individuals, 6 months after
stroke, was recruited that met specific inclusion/ exclusion criteria
allowing for individuals whose upper extremity was mildly to severely
involved.
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They participated in CIMT 6 hours per day. Pretest, post-test,
and follow-up assessments were performed to assess the
outcomes for the Wolf Motor Function Test (WMFT)
The potential predictors were minimal motor criteria (active
extension of the wrist and 3 fingers), active finger
extension/grasp release, grip strength, Fugl–Meyer upper
extremity motor score, and the Frenchay score
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Conclusions: Finger extension was the only significant
predictor of WMFT outcomes
When using finger extension/grasp release as a predictor in the
regression equations, one can predict individual’s follow-up
scores for CIMT
This experiment provides the most comprehensive investigation
of predictors of CIMT outcomes to date
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Pain, Fatigue, and Intensity of Pain, Fatigue, and Intensity of
Practice in People With Stroke Who Practice in People With Stroke Who
Are Receiving Constraint-Induced Are Receiving Constraint-Induced
Movement TherapyMovement Therapy
Julie Underwood et al.
Physical Therapy September 2006
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Purpose: This study examined changes in pain and fatigue
status among people receiving CIMT
Subjects: Stroke
Received 2 weeks of CI therapy either 3 to 9 months after
stroke (sub acute therapy group, n=18) or 1 year later (chronic
therapy group, n=14)
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Methods: Pain, fatigue, and intensity of therapy were evaluated
The Wolf Motor Function Test (WMFT) and the pain scale of the
Fugl-Meyer Assessment for the upper extremity were
administered before and after training
Single-item measures for pain and fatigue were administered
twice daily during therapy
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Conclusion: For patients with stroke, the intensive practice
associated with CI therapy may be administered without
exacerbation of pain or fatigue, even early during the
recovery process
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Acute stroke..
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Does The Application Of Constraint-Does The Application Of Constraint-induced Movement Therapy During induced Movement Therapy During Acute Rehabilitation Reduce Arm Acute Rehabilitation Reduce Arm Impairment After Ischemic Stroke?Impairment After Ischemic Stroke?
Alexander W. Dromerick, Dorothy F. Edwards and Michele Hahn
Stroke 2000;31;2984-2988
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Purpose: whether a constraint-induced movement (CIM)
program could be implemented within 2 weeks after stroke and
whether CIM is more effective than traditional upper-extremity
(UE) therapies during this period
Design
prospective, randomized, controlled clinical trial
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23 patients
Outcome measures
Total action research arm test (ara) score after 14 days of
treatment
The Barthel index
Functional independence measure
All subjects received study treatment for 2 hours per day, 5
days per week, for 2 consecutive weeks
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Conclusion
CIM during acute stroke rehabilitation, could improve motor function
without increasing treatment time
emphasis on motor restoration might compromise compensatory
techniques and thus lead to excess disability
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Constraint-Induced Constraint-Induced Movement TherapyMovement Therapy
James C. Grotta, MD; Elizabeth A. Noser,Stroke. 2004
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Purpose : Test the feasibility and safety of carrying out a
larger efficacy trial in the acute stroke setting, as well as the
feasibility of correlating clinical outcome measures with
functional imaging
The patients had to have weakness in one arm and hand,
but at least 10° of preserved movement in the digits of their
hand.
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8 Patients were randomized to CIMT or standard of care
physical and occupational therapy for 2 weeks
CIMT group wore a mitten on the non-affected upper
extremity for 90% of waking hours
“shaping” of the affected upper extremity, using the
technique of successive approximations, was carried out for
3 hours a day
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The control group received treatment aimed at increasing functional
use of both hands, using compensatory techniques 3 hours a day for
2 week
Outcome measures :
Motor Activity Log
Grooved Pegboard Test (GPB),
upper extremity motor component of the Fugl-Meyer (FM) Test.
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In the CIMT group, a greater number of regions could
evoke a response in the contralateral affected hand both at
2 weeks and 3 months.
Conclusion, CIMT probably improves upper extremity
function in chronic stroke patients. If instituted in the first 2
weeks after stroke, it is probably not harmful and it may
accelerate recovery
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CIMT and cerebral palsy
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Pediatric CI therapy also called ACQUIREc therapy by some
UAB International Research Center
The word ACQUIRE exemplifies the overall goal of this treatment, to
acquire new skills and function for children participating in this
therapy while the subscript 'c' indicates the important component of
casting
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AAcquisition of new motor skills through;cquisition of new motor skills through;
CContinuous practice and shaping to ontinuous practice and shaping to
produce; produce;
QQuality movement of the; uality movement of the;
UUpper extremity through pper extremity through
IIntensive therapy andntensive therapy and
RReinforcement ineinforcement in
EEveryday patterns and placesveryday patterns and places
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CIM therapy is based on the hypothesis that in hemiplegia, disuse of
the affected arm can occur as a result to learned non use, because it
becomes more convenient to use the unaffected arm
Neuro imaging has shown a significantly increased cortical
representation of the affected hand after CIM therapyTaub et al,1999, 2002
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Unlike adults with hemiplegia who have had function before insult into
the central nervous system, children with hemiplegia have usually
never used their affected upper limb normally, so principle of learned
non use may not be applicable here
On the basis of Taub’s early work with deafferented monkeys, it has
been suggested that plasticity of the brain could be the basis for
rehabilitation with CIMT (Charles et al 2001)
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This theory is becoming widely used in adults with hemiplegia (Taub
et al,1999) and is now being developed for use with children
Crocker et al,1997 restrained the unaffected arm of 2 children aged 2
to 3 years in a splint during waking hours
The children were observed during normal therapy and free play
One child improved but the other did not tolerate the splint wearing
regime
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Effects of Constraint induced therapy on hand function in children with hemiplegic cerebral palsy Charles et al.
Pediatric physical therapy 2001;13:68 - 76
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3 children with hemiplegia aged 8 to 13 years were included
The unaffected arm was constrained in a sling for 6 hours a day for 2 weeks
Children were observed during functional and play activities while wearing a sling
It was observed that 2 of the three children improved their hand function
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Forced Use Treatment of Forced Use Treatment of Childhood HemiparesisChildhood Hemiparesis
John K. Willis, Ann Morello, Anita Davie, Janet C. Rice . J Am Pediatrics 2002;110;94- 96
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Objective:
to see whether the restraint of the unimpaired arm would improve
function of the paretic arm in children with chronic (>1 year)
hemiparesis
12 hemiparetic treatment children (age1–8 years) received a plaster
cast on the unimpaired arm for 1 month;
13 hemiparetic control children did not
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PDMS were performed at entry, then 1 month, 6 months, and 7
months after entry, both for controls and subject (PDMs - Peabody
Developmental Motor Scales)
Any noted change in functional ability was also elicited by parental
report.
The frequency of visits to physical and occupational therapy was
recorded
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Results: The 12 treatment (casted) children improved 12.6 PDMS
points after 1 month of casting;
the 13 control children improved 2.5 points.
Improved PDMS scores persisted 6 months later when 7 treatment
children returned
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Parental report corroborated improvement in casted children (22 of
22parents) and its persistence at follow-up (21 of 22 parents)
Receiving ongoing physical/occupational therapy did not seem to
account for these results: control children received more (2.1
visits/wk) than treatment children (1.4visits/wk)
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Conclusions:
Forced use can be an effective rehabilitation technique in children with chronic hemiparesis
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Constraint-induced movement Constraint-induced movement therapy for hemiplegic children with therapy for hemiplegic children with
acquired brain injuriesacquired brain injuries
Karman N, Maryles J, Baker RW, J Head Trauma Rehabil. 2003 May-
Jun;18(3):259-67
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ObjectiveObjective: :
To evaluate the feasibility and efficacy of constraint-induced
movement therapy (CIMT) for impaired upper extremity (UE) function
in children with acquired brain injury (ABI)
Design: Multiple case studies.
Setting: Inpatient pediatric rehabilitation.
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Participants:
Seven children consecutive ABI rehabilitation admissions with
hemiparesis were recruited without regard to injury etiology, or
cognitive capacities.
Main outcome measure:
The actual amount of use test (AAUT) was used to evaluate change
in UE function.
AAUT amount of use (AOU) and quality of movement (QOM) scales
were obtained at baseline and follow-up.
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Results: AOU and QOM item improvements were significant, as
were changes in activities of daily living.
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Conclusions: Stringent CIMT training, previously only implemented with
adults, can be used effectively with children when everyday elements of a child's life are integrated into adult protocols.
The use of child-friendly UE shaping exercises, "pushed into" activities by professional therapists as well as trained teachers,
paraprofessionals, and parents, was supported.
Larger controlled studies with additional outcome measures are indicated.
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Effects of constraint-induced Effects of constraint-induced movement therapy in young movement therapy in young children with hemiplegic children with hemiplegic cerebral palsycerebral palsy
Ann-Christin Eliasson; Lena Krumlinde-Sundholm; Karin Shaw; Chen Wang
Developmental Medicine and Child Neurology; Apr 2005; 47, 4;
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Objective:
To evaluate the effects of a modified version of CIMT on
bimanual hand use in children with hemiplegic cerebral
palsy and to make comparison with conventional pediatric
treatment
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21 children in CIMT group and 20 children in control group
were taken
Children in the CI therapy were expected to wear restraint
glove for 2 hours each day over a period of 2 months
Training was based on the principles of motor learning used
in play
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The Assisting Hand Assessment (AHA) was used was
evaluation of hand function
Assessment done at the beginning of the study, after 2
months (i.e. at the end of treatment) and 6 months after the
first assessment
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Children who received CI therapy improved their ability to
use their hemiplegic hand significantly more than the
children in the control group after 2 months, ie after
treatment and it remained so at 6 months
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Conclusion:
CI therapy seems to be an important agent for improving the
use of the hemiplegic hand
As the treatment was tailored to each child’s capacity and
interests, little frustration was experienced by the children
CI therapy could be a complement to other forms of
interventions, though larger RCTs and results related to the type
of lesions are needed to confirm evidence
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Modified constraint-induced Modified constraint-induced movement therapy for young children movement therapy for young children with hemiplegic cerebral palsy: a with hemiplegic cerebral palsy: a pilot studypilot study
C E Naylor; E BowerDevelopmental Medicine and Child Neurology;
Jun 2005; 47, 6;
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Objective:
To evaluate the effectiveness of modified CIMT in young
children with hemiplegia
ie to investigate whether a modification in the method of
restraint of the unaffected arm using a less invasive method
of restraint as in the other studies, was effective in
improving upper limb function
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Single case experimental design with children as their own controls
Total duration was 12 weeks
First 4 weeks, no hand treatment. During this period children were encouraged to play using both hands, emphasis on bilateral work, but no restraint
Next 4 weeks, modified CIMT one hour per day
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Followed by 4 weeks of no hand treatment again to measure the carry over
Constraint of the unaffected arm was done using gentle restraint ,with the therapist holding the child’s hand during play
Children were also encouraged verbally to use their affected arm
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9 children with congenital CP were involved in the study
Median age was 31 months
Changes in hand function evaluated by Quality of Upper Extremity Skills Test
Assessment was done at entry and then at 4 week intervals
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Statistically significant improvement s were seen in this
study after treatment
Conclusion:
Results of this pilot study suggests that this modification of
CIMT may be an effective way of treating young children
with hemiplegia
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Efficacy of CIMT on Involved Upper-Efficacy of CIMT on Involved Upper-Extremity Use in Children With Extremity Use in Children With Hemiplegic CP Is Not Age-DependentHemiplegic CP Is Not Age-Dependent
Andrew M. Gordon, Jeanne Charles, Steven L.
Pediatrics Volume 117, Number 3, March 2006
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Objectives:
To examine the relationship between efficacy of a child-
friendly form of CI therapy and age on involved upper-
extremity function
little is known about patient characteristics predicting
treatment efficacy, not all children may benefit from this
intervention
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20 children with hemiplegic CP age 4 to 13 years received CI
therapy and completed evaluations.
Children were divided into a “younger group” (age 4–8 years, n
12) and “older group” (age 9–13 years, n 8).
Children wore a sling on their noninvolved upper extremity for 6
hours per day for 10 of 12 consecutive days, during which time
they were engaged in play and functional activities
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Each child was evaluated by trained evaluators who were blinded to the fact that the children received treatment
The evaluations took place once before the intervention and at 1 week, 1 month, and 6 months after the intervention
Efficacy was examined at the movement efficiency (Jebsen-Taylor Test of Hand Function, subtest 8 of the Bruininks-Oseretsky Test of Motor Proficiency), environmental (caregiver frequency and quality of involved upper-limb use), and impairment (strength, tactile sensitivity, and muscle tone) levels
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Results.
Children in both age groups had significant improvements
in involved hand-movement efficiency and environmental
functional limitations, which were retained through the 6-
month posttest.
No differences in efficacy between younger and older
children
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Both hand severity and the children’s behavior during
testing (number of redirections), with the latter serving as a
reasonable correlate for attention during the intervention,
were related to changes in performance in the younger
group but not in the older group
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CONCLUSIONS.
Intensive practice associated with CI therapy can improve
movement efficiency and environmental functional
limitations among a carefully selected subgroup of children
with hemiplegic CP of varying ages and that this efficacy is
not age dependent
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