Constraint Induced Movement Therapy

What is CIMT?[edit | edit source]

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].

History of CIMT[edit | edit source]

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[edit | edit source]

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]

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[edit | edit source]

The patients eligible for CIMT are:

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

Components of CIMT[edit | edit source]

  • 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

Restraints[edit | edit source]

The restraints commonly used for CIMT includes[11]:

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

Requirements for participation in CIMT[edit | edit source]

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.
  1. A Rehab Revolution. Stroke Connection Magazine. December 23, 2010. Retrieved July 25, 2011.
  2. Wolf S., Lecraw D., Barton L., Jann B. (1989). Forced use of hemiplegic upper extremities to reverse the effect of learned nonuse among chronic stroke and head-injured patients. Exp. Neurol. 104 125–132
  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.
  4. E. Taub, S.L. Wolf. (1997). Constraint induced movement techniques to facilitate upper extremity use in stroke patients. Topics in Stroke Rehabilitation, 3, pp. 38–61
  5. Taub E, Uswatte G and Elbert T (2002). New treatments in neuro rehabilitation founded on basic research. Nature Reviews Neuroscience (3) 226-236.
  6. Taub E., Uswatte G.(2009). Constraint-induced movement therapy: A paradigm for translating advances in behavioral neuroscience into rehabilitation treatments. In: Berntson G., Cacioppo J., editors.Handbook of neuroscience for the behavioral sciences (Vol. 2, pp. 1296–1319) Hoboken, NJ: Wiley; 2009. (Eds.)
  7. Levin P and Page SJ (2004). Modified constraint-induced therapy: a promising restorative outpatient therapy. Top Stroke Rehabil (11) 1-10.
  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.
  9. Taub E (1980). Somatosensory deafferentation research with monkeys: implications for rehabilitation medicine. In Ince LP, ed. Behavioral Psychology in Rehabilitation Medicine, Clinical Applications, Baltimore: William and Wilkins 371- 401.
  10. Taub, E.& Uswatte G. (2000). Constraint induced manual therapy and massed practice. Stroke. 31:983-991.
  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.