Constraint-induced movement therapy

Constraint-induced movement therapy (CI or CIMT) is a form of rehabilitation therapy that improves upper extremity function in stroke and other Central Nervous System damage victims by increasing the use of their affected upper limb.^[1]

The focus of CIMT is to combine restraint of the unaffected limb and intensive use of the affected limb. Constraint typically consists of placing a mitt on the unaffected hand or a sling or splint on the unaffected arm, forcing the use of the affected limb with the goal of promoting purposeful movements when performing functional tasks. The use of the affected limb is called shaping.^[2] Typically, CIMT involves restraining the unaffected arm in patients with hemiparetic stroke or hemiparetic cerebral palsy (HCP) for 90% of waking hours while engaging the affected limb in a range of everyday activities ^[2][3] However, studies have varied on hours of restraint per day and length of therapy. More specifically, CIMT involves the person performing supervised structured tasks with the affected limb 6 hours a day for 10 days over a 14 day period, in addition to wearing the restrictive mitt or sling for 90% of waking hours.^[4] One form of modified constraint induced movement therapy that has been found to be effective in improving motor control strategy during goal-directed reaching involved massed practice of the affected limb 2 hours a day for 10 days, in addition to wearing the restrictive mitt or sling for 6 hours a day for 2–3 weeks.^[5] Practitioners say that stroke victims disabled for many years have recovered the use of their limbs using CIMT. However, it has been shown that receiving CIMT early on (3–9 months post-stroke) will result in greater functional gains than receiving delayed treatment (15–21 months post-stroke).^[6] Through research, two key factors of CIMT have emerged that relate to the effectiveness of regaining function. First is that CIMT needs to include concentrated and repetitive practice of the affected limb. Second, the other arm or hand needs to be constrained at least 90 percent of waking hours.^[7]

As a result of the patient engaging in repetitive exercises with the affected limb, the brain grows new neural pathways. This change in the brain is referred to as cortical reorganization. One study by Deluca et al. showed that using Transcranial Magnetic Stimulation (TMS) that the excitable cortex of the affected cortex in adults patients with HCP doubled in size after 12 days of therapy.^[2] Recently, the possible benefits of cortical reorganization has led to studies of CIMT on children because neuroplasticity is even greater among children than adults.^[8] Particular interest is growing in CIMT for children who have cerebral palsy where one arm is more affected than the other.^[9]

CI was developed by Dr. Edward Taub of the University of Alabama at Birmingham. Taub argues that, after a stroke, the patient stops using the affected limb because they are discouraged by the difficulty.^[10] As a result, a process that Taub calls "learned non-use" sets in, furthering the deterioration. Learned non-use is a type of negative feedback. Individuals are unable to move their affected limb or the movements are inefficient and clumsy and in response to this a suppression of movement occurs. It is this process that CIMT seeks to reverse.The American Stroke Association has written that Taub's therapy is "at the forefront of a revolution" in what is regarded possible in terms of recovery for stroke survivors.^[1]

Constraint-induced movement therapy (CIMT) coupled with intensive and varied exercise training has proven to be effective in reducing spasticity and increasing function of the hemiplegic upper extremity in chronic stroke patients.^[11] Siebers, Oberg and Skargren conducted a study in 2010 involving patients between 6 months to 10 years post stroke. The unaffected upper limb of each subject was constrained using a restricting position belt for 90% of waking hours, 7 days a week, for 2 weeks and they were each assigned individualized, upper extremity exercise programs by a physiotherapist and occupational therapist to be completed 5 days a week in an outpatient rehabilitation clinic. Reduced spasticity and improved function were measured following the 2-week treatment block and improvements persisted 6 months later.^[11] Therefore, chronic hemiplegia can significantly benefit from CIMT with reductions in disuse complications, spasticity and improved function with increased use of the hemiplegic limb in activities of daily life.^[11]

See also

• Neuroplasticity
• Silver Spring Monkeys

References

1. ^ ^{a b} "Constraint-induced movement therapy", American Stroke Association
2. ^ ^{a b c} Deluca, S. C., Echols, K., Law, C. R., Ramey, S. L. (2006). "Pediatric constraint-induced therapy for children wih cerebral palsy: Randomized, controlled, crossover trial". Journal of Child Neurology 21: 931–940. doi:10.1177/08830738060210110401. 
3. ^ Sutcliffe, T. L., Logan, W. J., Fehlings, D. L. (2009). "Constraint-induced movement therapy is associated with increased contralateral cortical activity on functional magnetic resonance imaging". Journal of Child Neurology 24: 1230–1235. doi:10.1177/0883073809341268. 
4. ^ Taub, E; G Uswatte (1999). "Constraint-induced movement therapy: a new family of techniques with broad application to physical rehabilitation - a clinical review". Journal of Rehabilitation Research & Development 36 (3): 237–51. 
5. ^ Lin, K; C Wu, T Wei, C Lee, J Liu (2007). "Effects of modified constraint-induced movement therapy on reach-to-grasp movements and functional performance after chronic stroke: a randomized controlled study". Clinical Rehabilitation 21 (12): 1075–86. 
6. ^ Wolf, S; Carolee Winstein, J. Philip Miller, Edward Taub, Gitendra Uswatte, David Morris, Carol Giuliani, Kathye E. Light, Deborah Nichols-Larsen, (2006). "Effect of Constraint-Induced Movement Therapy on Upper Extremity Function 3 to 9 Months After Stroke". The Journal of the American Medical Association 296 (17): 2095–2104. doi:10.1001/jama.296.17.2095. 
7. ^ O'Sullivan, Susan B. (2007). Physical Therapy 5th Edition. Chapter 13: F.A. Davis Company. pp. 484–487. ISBN 0-8036-1247-8. 
8. ^ Pidcock, FS; Garcia T; Trovato MK; Schultz SC; Brady KD (2009). [URL: www.cinahl.com/cgi-bin/refsvc?jid=1485&accno=2010493933 "Pediatric constraint-induced movement therapy: a promising intervention for childhood hemiparesis"]. Topics in Stroke Rehabilitation 16 (5): 339–345. doi:10.1310/tsr1605-339. URL: www.cinahl.com/cgi-bin/refsvc?jid=1485&accno=2010493933. 
9. ^ Huang, H.; Fetters, L., Hale, J., McBride, A. (2009). "Bound for Success: A Systematic Review of Constraint-Induced Movement Therapy in Children With Cerebral Palsy Supports Improved Arm and Hand Use". Physical Therapy 89 (11): 1126–1141. doi:10.2522/ptj.20080111. 
10. ^ Taub, E.; Morris, D.M. (2001). "Constraint-Induced Movement Therapy to Enhance Recovery after Stroke". Current Atherosclerosis Reports 3 (4): 279–286. doi:10.1007/s11883-001-0020-0. 
11. ^ ^{a b c} Siebers, A; Oberg, Skargren (2010). "The effects of modified constraint-induced movement therapy on spasticity and motor function of the affected arm in patients with chronic stroke". Physiotherapy Canada 62 (4): 388–396.