Modified Constraint-Induced Movement Therapy for Stroke

Top Contributors - Alyssa Whelan, Nadia Kashetsky, Jessica Craig, Maura Leslie and Amrita Patro  

Description

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

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

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

Components of mCIMT

Current evidence explores many different formants of mCIMT for stroke rehabilitation.

These protocols differ in practice and constraint time; however, all protocols share three fundamental components of treatment intervention, which stem from the original CIMT.

The three fundamental components that are utilized in every session of mCIMT are [6] :

  • Restraint of the less impaired upper extremity, using a mitt.
  • Repetitive Task Practice
  • Application of behavioural techniques
    • Shaping is deemed the most important technique:
      • Shaping involves matching the difficulty of tasks performed to the improvements the patients makes, and providing encouraging feedback immediately after any gain in function[7].
      • Shaping tasks are determined by therapists based on: individual movement deficits at specific joints, joint movements that, in the theapists opinion, has the most potential for improvement, and patient preference of specific tasks that would produce the movements above[8]. With shaping, progression of movement tasks is made in a systematic, quantified, and parametric way on tasks that are individualized for the patient. This makes the intervention time specific and meaningful to the patient/client, as well as positive - as feedback is always positive and encouraging, very rarely negative [8].

The timing of the applied mCIMT varies in the literature. Early studies described structured sessions of functional, task-specific practice that lasts 30 minutes, with 5 hours of constraint of the less affected side, for 5 days a week for 10 weeks [3]. While, a 2011 meta-analysis and review of mCIMT included modified approaches with less than 6 hours of constrain a day, intensive therapy that ranged from 30 minutes to 3 hours a day, and intervention periods ranging from 2 to 10 weeks.[9]

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

mCIMT includes a distributed practice schedule, whereas CIMT employs massed practice. mCIMT protocols include less clinical treatment time with therapists, providing the patients with an increased amount of time to be spent on home-based practice using the more affected upper extremity functionally and during activities of daily living. [6]

Indications

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

Outcome Measures

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

Other outcome measures used to quantify progress of the mCIMT intervention for individuals who have experienced stroke include: [11]

Measures of disability:

Measures of arm motor function:

  • Wolf Motor Function Test (only score) (WMFT)
  • Action Research Arm Test (ARAT)
  • Arm Motor Ability Test (AMAT)
  • Emory Function Test (EMF)
  • Assessment of Motor and Process Skills (AMPS)

Measures of perceived arm motor function:

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

Measures of arm motor impairment:

Measures of dexterity:

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

Measures of quality of life:

  • Stroke Impact Scale (SIS)

Evidence

Several studies have found that mCIMT improves function in the affected upper limb after stroke. mCIMT protocols were found to significantly improve disability, significantly improve upper extremity function, and is an overall effective intervention for upper extremity recovery post-stroke [9][6]. Recent randomized controlled trials have found that 4 weeks of mCIMT is effective in improving motor function and performance of ADLS.[12][13].Furthermore, mCIMT has also been shown to be effective in improving balance and gait in hemi-paretic patients after stroke[14].

A single-blind, randomized parallel study found that both individual and group mCIMT increases the function and use of the upper extremity, with the increases being higher with the group mCIMT[15].

In comparison to the original CIMT specifically, meta-analytic evidence suggests that mCIMT is just as influential and in promoting use and functional recovery of an affected limb post-stroke.[9] Moreover, the decrease in clinical time and use of resources involved in mCIMT makes it easier and more feasible to manage for both the therapist and patient/client[9]. This review examined the literature on the 10 week, mCIMT protocol, and showed that it is an effective treatment for the promotion of recovery in the upper extremity post stroke[9]. The outcome measures used (UE of the Fugl-Meyer, ARAT, Motor Activity Log (MAL)) all demonstrated a positive improvement for patients using the mCIMT protocol in regard to upper extremity impairment and function. In the majority of studies analyzed, the average degree of change for patients was greater than the MCID of the outcome measures used, indicating that the patients who received mCIMT saw a change in UE function that is clinically meaningful, compared to control or no-therapy groups [9].

A randomized controlled clinical trial explored the effect of mCIMT on acute subcortical infarctions specifically and found it resulted in significant functional changes in timed movement, and improved ipsilesional cortical excitability [16]. Additionally, mCIMT has been found to significantly improve functional use of the affected limb in chronic hemi-paretic stroke patients and it is effective for upper extremity hemiparesis in comparison to conventional treatment[17].Furthermore, effectiveness of UE recovery was observed across all stages of recovery post-stroke[9] Seeing this, it is important to note that even though effectiveness was shown through studies in all stages of post-stroke recovery, the majority of evidence comes from research on chronic stroke population. This was determined to be indicated by an intermediate level of evidence [9]

Resources

Categories:
Neurology

Queen's University Neuromotor Function Project

References

  1. Reiss AP, Wolf SL, Hammel EA, McLeod EL, Williams EA. Constraint-induced movement therapy (CIMT): Current perspectives and future directions. Stroke Res Treat. 2012;2012. https://doi.org/10.1155/2012/159391 
  2. Blanton S, Wolf SL. An application of upper-extremity constraint-induced movement therapy in a patient with subacute stroke. Phys Ther. 1999;79(9):847–53. PMID:10479785
  3. 3.0 3.1 3.2 Page SJ, Sisto SA, Levine P, McGrath RE. Efficacy of Modified Constraint-Induced Movement Therapy in Chronic Stroke: A Single-Blinded Randomized Controlled Trial. Arch Phys Med Rehabil. 2004;85(1):14–8. https://doi.org/10.1016/S0003-9993(03)00481-7
  4. Viana R, Teasell R. Barriers to the Implementation of Constraint-Induced Movement Therapy Into Practice. Top Stroke Rehabil [Internet]. 2012;19(2):104–14.https://doi.org/10.1310/tsr1902-104
  5. 5.0 5.1 Herlache E, Pasant A, Earley D, Johnson C, Ewend J, Schwab C, et al. Improving Upper Extremity Function: Through a Home-Based Modified Constraint-Induced Movement Therapy Program. OT Pract. 2012;17(18):14–18,20. https://doi.org/10.1016/S1474-4422(15)00147-7    
  6. 6.0 6.1 6.2 6.3 Fleet A, Page SJ, MacKay-Lyons M, Boe SG. Modified Constraint-Induced Movement Therapy for Upper Extremity Recovery Post Stroke: What Is the Evidence? Top Stroke Rehabil [Internet]. 2014;21(4):319–31. https://doi.org/10.1310/tsr2104-319    
  7. 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. NeuroRehabilitation [Internet]. 2006;21(2):147–56. Available from: PMID:16917161
  8. 8.0 8.1 Taub E, Uswatte G, King DK, Morris D, Crago JE, Chatterjee A. A placebo-controlled trial of constraint-induced movement therapy for upper extremity after stroke. Stroke. 2006;37(4):1045–9.https://doi.org/10.1161/01.STR.0000206463.66461.97
  9. 9.0 9.1 9.2 9.3 9.4 9.5 9.6 9.7 9.8 Shi YX, Tian JH, Yang KH, Zhao Y. Modified constraint-induced movement therapy versus traditional rehabilitation in patients with upper-extremity dysfunction after stroke: A systematic review and meta-analysis. Arch Phys Med Rehabil [Internet]. 2011;92(6):972–82. Available from: http://dx.doi.org/10.1016/j.apmr.2010.12.036
  10. Hebert D, Lindsay MP, McIntyre A, Kirton A, Rumney PG, Bagg S, et al. Canadian stroke best practice recommendations: Stroke rehabilitation practice guidelines, update 2015. Int J Stroke. 2016;11(4):459–84. DOI:10.1177/1747493016643553 
  11. 11.0 11.1 Sirtori V, Corbetta D, Moja L, Gatti R. Constraint-induced movement therapy for upper extremities in stroke patients. Cochrane database Syst Rev [Internet]. 2009;(4):CD004433. Available from: PMID: 26446577
  12. Yadav RK, Sharma R, Borah D, Kothari SY. Efficacy of modified constraint induced movement therapy in the treatment of hemiparetic upper limb in stroke patients: A randomized controlled trial. J Clin Diagnostic Res [Internet]. 2016;10(11):YC01-YC05. http://doi.org/10.7860/JCDR/2016/23468.8899
  13. Ju Y, Yoon I-J. The effects of modified constraint-induced movement therapy and mirror therapy on upper extremity function and its influence on activities of daily living. J Phys Ther Sci [Internet]. 2018;30(1):77–81. Available from: PMID: 29410571
  14. Fuzaro AC, Guerreiro CT, Galetti FC, Jucá RBVM, Araujo JE de. Modified constraint-induced movement therapy and modified forced-use therapy for stroke patients are both effective to promote balance and gait improvements. Brazilian J Phys Ther [Internet]. 2012;16(2):157–65. PMID: 22378476 
  15. Doussoulin A, Rivas C, Rivas R, Saiz J. Effects of modified constraint-induced movement therapy in the recovery of upper extremity function affected by stroke: a single-blind randomized parallel trial-comparing group versus individual intervention. Int J Rehabil Res [Internet]. 2017;1. PMID: 28957983
  16. C. Y, W. W, Y. Z, Y. W, W. H, S. L, et al. The effects of modified constraint-induced movement therapy in acute subcortical cerebral infarction. Front Hum Neurosci [Internet]. 2017;11. doi:http://doi.org/10.3389/fnhum.2017.00265
  17. Sethy D, Bajpai P, Kujur ES, Mohakud K, Sahoo S. Effectiveness of Modified Constraint Induced Movement Therapy and Bilateral Arm Training on Upper Extremity Function after Chronic Stroke : A Comparative Study. Open J Ther Rehabil [Internet]. 2016;4(February):1–9. http://dx.doi.org/10.4236/ojtr.2016.41001