Constraint-Induced Movement Therapy (CIMT)

What is CIMT?

Constraint Induced Movement Therapy (CIMT) is a new treatment technique that claims to improve the arm motor ability and the functional use of a paretic arm - hand. CIMT forces the use of the affected side by restraining the unaffected side. Child with hemiplegic cerebral palsy can learn to improve the motor ability of the more affected parts of their bodies and thus cease to rely exclusively or primarily on the less affected parts.[1]

In the original concept, the less affected arm-hand was immobilized in a sling[2] [3], but soon an emphasis on intensive, repetitive training (massed practice) of the more affected arm- hand evolved. In the current application of the method, the patients wear a mitt on the less affected arm 90% of their waking hours and perform repetitive exercises with the more affected arm six to seven hours per day during two to three weeks [4] [5].
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History of CIMT

CIMT therapy is based on research by Edward Taub, Ph.D. and collaborators at the University of Alabama. The idea of CIMT therapy was developed due to the initial unsuccessful use of the affected limb. Dr. Taub hypothesize that the non-use was a learning mechanism and calls this behavior “Learned non-use”. [6]

The learned non-use phenomenon

It was observed that patients with hemiparesis did not use their affected extremity (hemi-neglecting) [7] . Taub and colleagues have investigated this phenomenon using basic research on monkeys. When one of the two forelimbs was deafferented, the animal stopped using the affected extremity. Taub et al concluded that the pattern with three-limb use, initially necessary after the spinal chock, was positively reinforced, whereas attempts to use the deafferented forelimb resulted in incoordination and failures [8]. It was postulated that the monkeys did not use the limb due to “learned non use”, or learned behaviour suppression. By immobilizing the intact arm for a period of consecutive days (1-2 weeks), the monkey started to reuse the deafferented forelimb again and “the learned non-use” was overcome [9]

Schemaa.JPG

Neurophysiologic basis for CIMT: The neurophysiologic mechanisms that are believed to underline treatment benefits of CIMT include overcoming learned nonuse and plastic brain reorganization. The brain changes itself when the affected extremity is involved intensively and repetitively for various activities [10]. The effect of CIMT is explained as

  • Cortical Reorganization
  • Dendrite branching
  • Redundancy Learned
  • Synaptic strength

CIMT patients

The patients eligible for CIMT are:

  • Cerebral palsy inform of hemiparesis
  • Stroke
  • TBI
  • Spinal cord injury
  • Multiple sclerosis

Components of CIMT

  • Restraint of the less affected arm.
  • Massing of repetitive, structured, practice, intensive therapy in use of the more affected arm.
  • Monitoring arm use in life situations and problem solving to overcome perceived barriers to using the extremity.
  • Behavioral agreement.
  • Treatment diary
ComponentsCIMT.JPG

Restraints

The restraints commonly used for CIMT includes[11]:

  • Sling
  • Plaster cast
  • Triangular bandage
  • Splint
  • Sling combined with a resting hand splint
  • Half glove
  • Mitt
Types CIMT.JPG

Requirements for participation in CIMT

It was stated by researchers [12] to simply, follow 10 x 10 x 10 eligibility criteria in selecting a patient for CIMT:

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

Also in order to CIMT be more beneficial, it was suggested that [13] :

  • Limited spasticity (0,1,1⁺) according to modified Ashworth scale.
  • Ability to move the affected arm 45 degrees of shoulder flexion and abduction, and 90 degrees of elbow flexion and extension.
  • Adequate balance.
  • Minimal cognitive dysfunction.

Models of CIMT

The treatment models are commonly explained in two methods:

1. Unmodified CIMT: Uses a variety of approaches that promote the affected limb for 90% of the individuals waking hours. Only activities involving toileting, hygiene and bathing are permitted. This is done by constraining or reducing the use of the unaffected extremity for 2-3 weeks. The most used Constraints of the upper extremity are that of a sling, mitts with Velcro or resting hand splints. [14] [15]

2. Modified CIMT: This is more pragmatic model. The program consists of 3 hour per day for 5 days/week, for a minimum of 4 successive weeks. In total there will be 20 treatment sessions totaling to 60 hours. The client is expected to use his/her affected extremity for a minimum of the five “top arm use hours” at home during each week day. [16]

Advantages to CIMT [17] [18]

  • Overall greater improvement in function than traditional treatment.
  • Highly researched and highly credible treatment approach.
  • There are brain activity and observed gray matter reorganization in primary motor, cortices and hippocampus.
  • Increase social participation.
  • Decrease in medical cost over lifetime.

Side effects

Few studies have reported harms associated with CIMT, such as burns, minor skin lesions and muscle soreness (stiffness and discomfort) in the affected upper extremity [19] . Shoulder pain in the acute phase after stroke has not been shown to increase after wearing a constraint. Patient endures many hours of frustration.[20]

Evidence

The evidence for early intervention

Early intervention is important because learning-induced brain plasticity at an early age seems to have a unique impact on brain development. Several researchers have demonstrated that activation and stimulation significantly affect neural activity in the sensory and motor cortex[21]. In young children, there are ongoing structural changes in the corticospinal system directed to hand function [22] . These observed changes are activity dependent[23] . In baby-CIMT, It can be benefit from advantage of the great plasticity of the young brain and recent knowledge of how to provide training with the aim of influencing future development of hand function[24] .

Evidence based practice of CIMT

Numerous studies show CIMT improves movement on the affected side. CIMT patients showed “large to very large” improvements in the functional use of their affected arm in their daily lives. Scores on a motor activity log (MAL) https://www.uab.edu/citherapy/images/pdf_files/CIT_Training_MAL_manual.pdf. in which survivors and caregivers noted how well and how much survivors used their impaired arm in daily living improved an average of 1.8 points for those undergoing CIMT. Those in the control group reported no change. In addition, CIMT patients were able to speed their completion of tasks in lab testing while the placebo patients were slower.

Gains in upper extremity function after constraint induced therapy have been reported in all stages after the onset of stroke[19] .

Chen et al. (2014)[25]: A systematic review and meta-analysis of forty-one RCTs, sixteen reviews, and two clinical guidelines that assessed the effectiveness of constraint induced movement therapy on upper extremity function in children with cerebral palsy.

El-Kafy et al. (2014)[26]: A RCT that examined the effectiveness of a mCIMT protocol in improving upper extremity function in children with congenital hemiplegic cerebral palsy.

Deluca et al. (2006)[27]: A randomized crossover trial of a new form of pediatric rehabilitation was conducted with 18 children with hemiparesis. Pediatric constraint-induced therapy produced significantly greater gains than conventional rehabilitation services.

Zafter et al. (2016)[28]: A RCT that examined the effectiveness of constraint induced movement therapy compared to bimanual therapy in upper motor function in children with hemiplegic cerebral palsy.

Gelkop et al. (2015)[29]: A matched-pair randomized trial that examined the effectiveness of mCIMT and Hand-Arm Bimanual Intensive Training (HABIT) protocols when provided in the school setting.
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  3. Taub E., Miller N. E., Novack T. A., Cook E. W., 3rd, Fleming W. C., Nepomuceno C. S., et al. (1993). Technique to improve chronic motor deficit after stroke. Arch Phys Med Rehabil, 74(4), 347-354.
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  8. Taub E, Bacon RC and Berman AJ (1965). Acquisition of a trace-conditioned avoidance response after deafferentation of the responding limb. J Comp Physiol Psychol (58) 275-279.
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  11. Charles, Jeanne; Gordon, Andrew M. (2005). "A Critical Review of Constraint-Induced Movement Therapy and Forced Use in Children with Hemiplegia". Neural Plasticity. 12 (2–3): 245–61; discussion 263–72.
  12. Taub, E. and Uswatte, G. (2006). Constraint-induced movement therapy: answers and questions after two decades of research. NeuroRehabilitation, 21(2), 93-95.
  13. Brogårdh, C.(2006). Constraint Induced Movement Therapy: influence of restraint and type of training on performance and on brain plasticity.
  14. Gauthier, L. V.; Taub, E.; Mark, V. W.; Perkins, C.; Uswatte, G. (2009). "Improvement After Constraint-Induced Movement Therapy is Independent of Infarct Location in Chronic Stroke Patients". Stroke. 40 (7): 2468–72.
  15. Page S, Levine P, Sisto SA, Bond Q and Johnston MV (2002). Stroke patients´ and therapists´ opinions of constraintinduced movement therapy. Clin Rehabil (16) 55-60.
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  17. Richards, L., Gonzalez Rothi LJ, Davis S, Wu SS, Nadeau SE.(2006) Limited dose response to Constraint-Induced Movement Therapy in patients with chronic stroke. Clinical Rehabilitation. 20: 1066-1074
  18. Sterr, A., Elbert T., Berthold I., Kolbel S and Rockstroh B.(2002). Longer versus shorter daily constraint-induced movement therapy of chronic hemiparesis: and exploratory study. Archives of Physical Medicine & Rehabilitation. 83:1374-1377.
  19. 19.0 19.1 Hakkennes S, Keating JL. (2005). Constraint-induced movement therapy following stroke: a systematic review of randomised controlled trials. Aust J Physiother. 51(4):221-31.
  20. Ploughman M, Corbett D.(2004). Can forced-use therapy be clinically applied after stroke? An exploratory randomized controlled trial. Arch Phys Med Rehabil. 85(9):1417-23.
  21. Nudo, R.J., Milliken GW, Jenkins WM, Merzenich MM.(1996). Use-dependent alterations of movement representations in primary motor cortex of adult squirrel monkeys. Journal of Neuroscience. 16:785-807.
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  23. Martin, J.H., S. Chakrabarty, and K.M. Friel, (2011). Harnessing activity-dependent plasticity to repair the damaged corticospinal tract in an animal model of cerebral palsy. Dev Med Child Neurol. 53 (4):9-13. 4.
  24. Friel, K.M., S. Chakrabarty, and J.H. Martin, (2013). Pathophysiological mechanisms of impaired limb use and repair strategies for motor systems after unilateral injury of the developing brain. Dev Med Child Neurol. 55 (4):27-31.
  25. Chen, Y., Pope, S., Tyler, D., & Warren, G. (2014). Effectiveness of constraint-induced movement therapy on upperextremity function in children with cerebral palsy: A systematic review and meta-analysis of randomized controlled trials. Clinical Rehabilitation, 28(10), 939-953.
  26. El-Kafy, M. A., Elshemy, S. A., & Alghamdi, M. S. (2014). Effect of constraint-induced therapy on upper limb functions: A randomized control trail. Scandinavian Journal of Occupational Therapy, 21, 11-23.
  27. Deluca, S. C.; Echols, K.; Law, C. R.; Ramey, S. L. (2006). "Intensive Pediatric Constraint-Induced Therapy for Children with Cerebral Palsy: Randomized, Controlled, Crossover Trial". Journal of Child Neurology. 21 (11): 931–8.
  28. Zafer, H., Amjad, I., Malik, A. N., & Shaukat, E. (2016). Effectiveness of constraint induced movement therapy as compared to bimanual therapy in upper motor function outcome in child with hemiplegic cerebral palsy. Pakistan Journal of Medical Sciences, 32(1), 181-184.
  29. Gelkop, N., Burshtein, D. G., Lahav, A., Brezner, A., AL-Oraibi, S., Ferre, C. L., & Gordon, A. M. (2015). Efficacy of constraint-induced movement therapy and bimanual training in children with hemiplegic cerebral palsy in an educational setting. Physical and Occupational Therapy in Pediatrics, 35(1), 24-39.