Constraint Induced Movement Therapy

CONSTRAINT INDUCED MOVEMENT THERAPY

Introduction

The foundations for this treatment approach are based on work completed by Dr. Edward Taub and his co-workers in the mid-1960s. It is a form of short-term, intensive rehabilitation therapy that improves upper extremity function in patients suffering from a stroke or other Central Nervous System complications by increasing the use of their affected upper limb and physically constraining the uninvolved or less affected arm.

CIMT is focused on the following patient populations:

Stroke, Cerebral Palsy, TBI /Spinal Cord Injuries and Multiple sclerosis.

Goals:

Purposeful movements when performing functional tasks.
Shaping the use of the affected limb.
Cortical Reorganization.
Teaches the brain to grow new neural pathways- Neuroplasticity.

Components Of CIMT:

Constraint of the unaffected limb
- Types of constraint: sling, glove, splint, plaster
Repetition, structured, intense practice of the affected UE,
1. Shaping: A training method in which a motor task is gradually made more difficult. Shaping programs are individualized consisting of 10-15 tasks selected based on movement goals, potential for improvement, patient preference.Each task is usually performed in a set of 10-30 sec trials with continuous feedback. It requires constant therapist involvement.
2. Task practice: It is a repetitive practice of individual functional tasks that takes roughly 15-30mins. Rest is provided as required. Encouragement is given on an infrequent basis (i.e. every 5 mins) with feedback at the end of task as well about how they performed. Requires less therapist involvement. The tasks should be challenging like folding towels, setting table, virtual reality).
Involved arm used in life situations and problem solving to overcome barriers.

How Does Modified CIMT Work?

LEARNED NON-USE: A conditioned suppression of movement that occurs when patient is initially unsuccessful at using affected extremity immediately post-injury and is reinforced by successful compensation with unaffected extremity.
Shortened rehab length of stay (LOS) forces therapists to focus on teaching compensatory techniques in order to maximize function for safe return home.
Areas of the cortex controlling movements of the affected limb shrink following stroke due to a combination of direct insult and learned nonuse.
Studies show that repeated forced use of impaired limb results in improved movement and enlargement of these areas.
Hence, it influences the brain to develop connectivity that improves motor function.

Protocols:

TRADITIONAL CIMT:

Type of constraint: cast
Total time of restraining: 90% of waking hours.
6hrs/day of intense therapy on consecutive weekdays.
2 to 3 week period.

MODIFIED CIMT:

To promote better compliance.
Type of constraint: glove or mitten.
30 mins of 1 to 1 therapy for 3 days a week;
5 hrs/day in restraint for 10 weeks.

Who Qualifies for Modified CIMT?

The individual needs to have a basic grasp/release to be eligible for the program.
They also need to be safe for mobility while having one hand in a cast.

Inclusion Criteria:

10 degrees active wrist extension.
10 degrees active thumb abduction.
10 degrees active extension of any other two digits of the affected hand.

Exclusion Criteria:

Medical condition requiring monitoring or intervention during the day (including administration of medication), unless responsible caregiver present.
Requires assistance to transfer or toilet, unless caregiver present.
Unable to tolerate half a day of activity (due to fatigue, pain, concentration, motivation)
Vision or hearing not sufficient to participate in self-rating scales.

Advantages:

Improved quality of hand use
New motor movements of the affected arm or hand
More spontaneous use of the affected arm or hand
Improved hand function such as fine motor and grasp
Increases daily/social participation
Decrease in medical cost over lifetime

Disadvantages:

Requires enormous labour from both patient & medical staff;
Patient endures many hours of frustration;
Not beneficial for all stroke or head injury patients. Typically for patients with higher level of function.
Acute CIMT can be harmful by increasing the size of the lesion;
Possible increase risk of injury to the involved arm and hand because the child is using the affected arm more but has decreased sensory awareness and motor control;
Patients can suffer from muscle soreness resulting in stiffness and discomfort in the involved upper extremity as well as skin lesions and skin burns.

Intervention:

Sensory stimulation: tactile strategies, limit visual distraction.
Focus on intensive shaping.
Caregiver education and home programming.
Progress HEP and task refinement;
Build on success, fade support.

Treatment Activities:

Selected to be developmentally appropriate, motivating and engaging.
Task analysis
Ideally follow child’s daily routine with focus on function.
May include:
- Play, ADL, IADL, Leisure activities, Strengthening, Weight-bearing, Sensory activities.

Bilateral activities (during the final phase of intervention)

Bilateral hand skills are crucial to typical daily functioning.
Constraint is removed during the last phase of treatment.
Number of days of bilateral treatment is age and skill-dependent.
Bilateral training begins immediately after cast is removed.
Involves same treatment intensity and therapy techniques.

THE EXTREMITY CONSTRAINT INDUCED THERAPY EVALUATION TRIAL (EXCITE)

Represents the first national, randomised, single-blind study at 7 US academic institutions to systematically test a neurorehabilitation therapy among patients with the ability to initiate extension movements at the wrist and fingers, and who experienced their first stroke within 3 to 9 months prior to enrolment.

Compared effects of 2 week treatment of CIMT vs. customary treatment on UE function.
222 people with predominantly ischaemic strokes; 106 received CIMT and 116 customary treatment.
Outcomes were measured using;

Wolf Motor Function Test
- 15 timed tasks: Sequentially from simplex to complex.
- 2 strength tasks: Shoulder flexion and grip strength.
Motor Activity Log
- 11 point Quality of Movement scale (QOM);
- 11 point Amount of Use (AOU) scale;
- Subjective, done by patient.

Conclusion:

Among patients who had a stroke within the previous 3 to 9 months, have shown significant increase in the daily use of their impaired limbs, and an increase in the speed at which they carried out activities after participating in CIMT.

References:

Taub, E. et al. Constraint-induced movement therapy: a new family of techniques with broad application to physical rehabilitation – a clinical review. Journal of Rehabilitation Res Dev. 1999;
Taub, E. et al. Constraint induced manual therapy and massed practice. Stroke. 2000; 31:983-991.
Richards, L. et al. Limited dose response to Constraint Induced Movement Therapy in patients with chronic stroke. Clinical Rehabilitation 2006; 20: 1066-1074.
Sterr, A. et al. Longer versus shorter daily constraint-induced movement therapy of chronic hemiparesis: and exploratory study. Archives of Physical Medicine & Rehabilitation. 2002; 83:1374-1377.
Wolf, S, et al. Effect of constraint- induced movement therapy on upper extremity function 3 to 9 months after stroke. Journal of the American Medical Association. 2006; 296:2095-2103.
A Rehab Revolution, Stroke Connection Magazine, September/ October 2004. Excerpt from the article.
Gauthier, L. et al. Remodelling the brain: plastic structural brain changes produced by different motor therapies after stroke. Stroke. 2008; 39:1520- 1525.
Grotta, J. et al. Constraint- induced movement therapy. Stroke. 2004; 35; 2699-2701.
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.
PEDIATRIC PHYSICAL THERAPY BY JAN S.TECKLIN FIFTH EDITION.