Constraint-induced movement therapy

  • May 27, 2016

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.

Constraint-induced movement therapy forces the use of the affected side by restraining the unaffected side.

Constraint-induced movement therapy (CIMT) has really taken off in the past two years. Dr. Edwin Taub’s ideas of “learned non-use” and intensive use of the affected side have been at the forefront of a revolution in what it is possible for stroke survivors to recover.

Constraint-induced movement therapy (CIMT) was developed to overcome upper limb impairments after stroke and is the most investigated intervention for the rehabilitation of patients.

Types of constraint

The focus of CIMT is to combine restraint of the unaffected limb and intensive use of the affected limb. Types of restraints include a sling or triangular bandage, a splint, a sling combined with a resting hand splint, a half glove, and a mitt.

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.

Application of constraint-induced movement therapy

CIMT may be applicable to up to 75 percent of stroke patients, although the amount of improvement produced by CIMT appears to diminish as the initial motor ability of the patient decreases.

CIMT has been shown to be an effective means of stroke rehabilitation regardless of the level of initial motor ability, amount of chronicity, amount of prior therapy, side of hemiparesis, or infarct location.

This suggests that CIMT-induced plasticity may work irrespective of the pathways in the damaged motor network.

Although, due to the intensity of this treatment, patients who have suffered profound upper extremity paralysis from their condition are normally not eligible for constraint-induced upper extremity training.

A consistent exclusion criterion for CIMT has been the inability to perform voluntary wrist and finger extension in the involved hand.

The effects of constraint-induced movement therapy have been found to improve movements that not only remain stable for months after the completion of therapy, but translate well to improvements of everyday functional task.

This can be done by including the “transfer package” of CIMT during treatment, in which the physiotherapist applies various strategies to help the patient adhere to the requirements of CIMT outside the clinical setting.

These strategies may include :

  1. Monitoring, which requires patients to document their performance of target behaviours;
  2. Problem solving, in which patients create solutions and identify outcomes to potential obstacles; and
  3. Behavioural contracting, which involves getting patients to identify the components and methods of carrying out normal behaviors.

Limitations to implementation

Presently, constraint-induced movement therapy (CIMT) has not been incorporated as part of standard practice for the rehabilitation of the hemiplegic upper extremity. Concerns have been raised over the generalizability of the results obtained from research, as selection criteria for CIMT research has excluded patients with a moderate or more severe stroke, due to balance problems, serious cognitive deficits, and global aphasia, which may reduce understanding of safety instructions and interfere with a patient’s ability to communicate difficulties.

The cost of resources needed to conduct CIMT treatment protocol are high. Costs are generated due to the intensity of therapy required for CIMT, as participants typically receive up to 6 hours of one-on-one therapy at least 5 days per week for 2 weeks. CIMT can be prohibitively expensive for patients paying out-of-pocket or for publicly funded health care systems attempting to make this program available to all eligible stroke survivors.

Therapist apprehension directed at safety issues with constraint use, lack of facilities, the cost of providing one-on-one therapy sessions, and the opportunity costs associated with the therapist’s inability to see and treat other patients during that time has contributed to the resistance of adopting the CIMT protocol.

The patient’s ability to tolerate the intensity and duration of the therapy sessions is a limiting factor to protocol adoption. Stroke patients have commonly expressed the length of time wearing the constraint and time consuming hours of therapy as reasons they wish not to participate.

While the CIMT protocol results in improved function in its target population, it is unknown whether the combination of constraint and therapy is necessary to achieve the outcome seen or whether the benefit is due to exposure to high-intensity, task-specific activities focused on the use of the more affected limb.

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