Constraint Induced Movement Therapy.

Therapy

Stroke is one the leading causes of disability In 1999, more than 1,100,000 stroke survivors reported difficulty with functional activities
American 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.

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 patients 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

Constraint-Induced Movement Therapy

Restraint of the uninvolved UE

Intensive Rehab Therapy of the involved UE

Hemiplegic 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 therapy
Euramedicophys2006

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

1. 2.

Repetitive task oriented training Shaping Task practice

Shaping : its a training method based on behavioral training

A motor or behavioral objective is approached in small steps by successive approximations

Adherence enhancing behavioral strategies Administration of motor activity log Home diary Problem solving in real world approach Behavioral contract Caregiver contract

1. 2. 3. 4. 5.

6.
7. 8.

Home practice Home skill assignment Daily schedule

1.

Constraining use of less affected limb 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)

1.

2.

2 possible mechanisms for the observed effects are believed to be Overcoming the learned non-use of the more affected arm (i.e, increased use of the more affected arm) and 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;
Jrntell 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 patients waking hours by constraining or reducing the use of the less affected limb for 2 3 weeks
Sunderland A, Tuke A 2005

Cortical reorganization could be a possible explanation for the recovery

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 therapyinduced 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 nonuse 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 therapyassociated changes of motor cortex excitability mainly occur in the lesioned

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

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.

in 2002 in a survey found that >

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) (Brogrdh and Sjlund 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

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 constraintinduced therapy that has been reported by different research groups could be because the amount of training differs between the centers

Limited dose response to ConstraintInduced 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, doubleblind, 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

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

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

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 therapy for people following stroke 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
2002, Page et al. 2001,Leipert et al 2000) (Sterr et al.

However the MAL is not used clinically and no specific evidence has been found in the literature to establish its psychometric

This study aimed to undertake a small trial of CIMT for people with chronic stroke to:

1. 2.

Investigate the level of restraint use Use standardized outcome measures to determine which measures were more responsive to CIMT

3.

Investigate the effect of CIMT on a small

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

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

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 Constraint-Induced Movement Therapy for Upper extremity 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

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 BotulinumToxin Type A and Modified Constraint-Induced Movement Therapy for an Individual With Chronic Upper-Extremity Spasticity After Stroke Sun, Chien-Wei Hsu Shu-Fen
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

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

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 therapy following stroke: A systematic review of randomised 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

Predictors of outcome..

Active Finger Extension Predicts Outcomes After Constraint-Induced Movement Therapy for Individuals With Hemiparesis After Stroke
Stacy 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, FuglMeyer upper

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 individuals follow-up scores for CIMT This experiment provides the most comprehensive investigation of predictors of CIMT outcomes to date

Pain, Fatigue, and Intensity of Practice in People With Stroke Who Are Receiving Constraint-Induced Movement 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

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

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 Constraintinduced Movement Therapy During Acute Rehabilitation Reduce Arm 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 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

Outcome measures

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 Movement 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 nonaffected upper extremity for 90% of waking hours

shaping of the affected upper extremity, using the technique of successive approximations, was carried out for 3

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 FuglMeyer (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

Acquisition of new motor skills through; Continuous practice and shaping to produce; Quality movement of the; Upper extremity through Intensive therapy and Reinforcement in

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 therapy

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 Taubs early work with deafferented monkeys, it has been suggested that

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

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 Childhood 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 (age18 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

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

Constraint-induced movement therapy for hemiplegic children with acquired brain injuries

Karman N, Maryles J, Baker RW, J Head Trauma Rehabil. 2003 MayJun;18(3):259-67

Objective: 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.

Effects of constraint-induced movement therapy in young children with hemiplegic cerebral palsy
Ann-Christin Eliasson; Lena KrumlindeSundholm; 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 childs 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 movement therapy for young children with hemiplegic cerebral palsy: a pilot study
C E Naylor; E Bower

Developmental 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 childs 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 UpperExtremity Use in Children With Hemiplegic 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 upperextremity 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 48 years, n 12) and older group (age 913 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

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 BruininksOseretsky Test of Motor Proficiency), environmental (caregiver frequency and quality of involved upper-limb use), and

Results. Children in both age groups had significant improvements in involved handmovement 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 childrens 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