Constraint Constraint Induced Induced

Movement Movement TherapyTherapy.

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

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

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

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

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

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

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

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

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

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

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

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

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.

CIMT protocol and components

Repetitive task oriented training1. Shaping2. Task practice

Shaping : it’s a training method based on behavioral

training

A motor or behavioral objective is approached in small

steps by successive approximations

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

6. Home practice

7. Home skill assignment

8. Daily schedule

Constraining use of less affected limb1. Use of mitt or any other method

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.

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)

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)

CIMT and plasticity

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).

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).

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

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

Cortical reorganization could be Cortical reorganization could be

a possible explanation for the a possible explanation for the

recoveryrecovery

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

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

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

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

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

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

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

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

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

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

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

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

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

Modified CIMT

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

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

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

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),

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),

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)

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

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

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

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

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

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

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

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.

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

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

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

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

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

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

Shortened CIMT..

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

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

Limited dose response to Constraint-Induced Movement Therapy in patients with chronic stroke

Lorie Richards et al.Clinical Rehabilitation 2006;

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

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

Stroke and CIMT..

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

Chronic stroke..

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

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

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

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.

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

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

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

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

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

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)

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)

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

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.

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

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

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).

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

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

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.

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

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

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

Balance or ambulation problems

Substantial use of the involved upper extremity in the life

situation

Major cognitive deficits, aphasia

Excessive pain, spasticity, ataxia,

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

The authors concluded that their results support the efficacy

of CI therapy for rehabilitating upper extremity motor function in

patients with chronic stroke

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

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

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

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)

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

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

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

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

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

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

Predictors of outcome..

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

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.

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

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

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

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)

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

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

Acute stroke..

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

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

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

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

Constraint-Induced Constraint-Induced Movement TherapyMovement Therapy

James C. Grotta, MD; Elizabeth A. Noser,Stroke. 2004

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.

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

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.

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

CIMT and cerebral palsy

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

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

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

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)

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

Effects of Constraint induced therapy on hand function in children with hemiplegic cerebral palsy Charles et al.

Pediatric physical therapy 2001;13:68 - 76

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

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

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

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

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

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)

Conclusions:

Forced use can be an effective rehabilitation technique in children with chronic hemiparesis

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

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.

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.

Results: AOU and QOM item improvements were significant, as

were changes in activities of daily living.

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.

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;

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

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

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

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

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

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;

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

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

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

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

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

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

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

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

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

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

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

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