Constraint-Induced Movement Therapy and its Application to Physical and Occupational Therapy

Nicole M. Boyko, PT/s

Background Information

730,000 strokes/yr 50% patients have motor deficits 30-66% of patients are unable to use

affected UE for ADLS following stroke

What is Constraint-Induced Movement Therapy?

A technique in which the patient uses concentrated, repeated practice of the affected extremity in order to facilitate movement– Shaping: a behavioral technique in which quality of movement is

improved progressively in small steps Family of techniques includes:

– Restraining of less affected UE in hand splint and/or sling while subsequently shaping the hemiplegic UE

– Wearing glove/mitt on less affected hand while shaping hemiplegic hand

– Shaping of hemiplegic UE or LE without restraint of unaffected side

– Intense PT of hemiplegic side 5 hrs/day x 10 week days without restraint of unaffected side (pts asked not to use unaffected side)

Rationale “Learned nonuse”: a conditioned suppression of

mvmt that occurs when pt is initially unsuccessful at using affected extremity immediately post-injury and is reinforced by successful compensation with unaffected extremity.

Shortened rehab LOS forces therapists to focus on teaching compensatory techniques in order to maximize fxn for safe return to home

Areas of the cortex controlling movements of the affected limb shrink following stroke due to a combination of direct insult and learned nonuse

Preliminary studies show that repeated forced use of impaired limb results in improved mvmt and enlargement of these areas.

Current Research

EXCITE (Extremity Constraint Induced Therapy Evaluation)– 5 yr NIH supported trial

– Sites: U of Alabama at Birmingham, Emory U, UNC/Wake Forest School of Medicine, UCLA, UFL at Gainesville, Ohio State

– Protocol: less affected UE restrained in sling for 90% of waking hours x 2 wks; training of most affected UE 6 hrs/day with 1 hr rest x 10 weekdays

Diagnoses for which CI is being researched: CVA (UE and LE), SCI (LE only), hip fx/replacement, focal hand dystonia in musicians, cerebral palsy in children

Availability of CIMT

Taub training clinic opened at UAB in Aug 2001

Provides 2-3 wks CIMT for UE primarily for patients post stroke

Medicare does not cover– Private pay: 2 wks: $6700, 3 wks: $12, 700

CI therapy research labs offer CIMT for strokes, SCI, hip Fx, CP and hand dystonia for free to qualifying pts at select locations

Blanton and Wolf (1999)

Literature Review

Subjects/Methods– 61 y/o African-American female 4 mo s/p ischemic

lacunar infarct of (L) post limb of internal capsule– Fxnl status: (I) ADLs, amb device, no voluntary

use of (R) UE– Received CIMT using mitt on (L) UE for 90%

waking hrs x 14 days– Practice performing ADLS with (R) UE in clinic 6

hrs/day x 10 days with 1-2 hrs/day rest

Blanton and Wolf (1999)

Literature Review

Measures – Taken before, after, 3 mo f/u– Wolf Motor Function Test (14 timed, 2 strength)– Motor Activity Log (30 ADLS)

Results– Improved on all items on WMFT– Prior to Rx, using (R) UE for 1/30 tasks on MAL– After Rx, using (R) UE 50% as much on 25/30– Upon 3 mo f/u, using (R) UE for 30/30 tasks

Taub et al (1999)

Literature Review

Subjects/Methods– 4 patients in CIMT grp, 5 in placebo group– Inclusion criteria: 20º wrist ext, 10º finger ext– Exp grp:CIMT with unaffected UE in resting hand

splint for 90% of waking hrs x 14 days• Sling also used during 6 hrs/day of Rx x 10 days in

performing activities such as eating, throwing a ball, playing board games, writing, sweeping

– Placebo: told they had greater capacity to use affected UE and instructed in passive ex

Taub et al. (1999)

Literature Review

Measures: WMFT, MAL, Arm Motor Ability Test

Results– Experimental grp showed significant increases on

WMFT and AMAT while controls showed no change or a decline

– Experimental grp showed a very large significant increase in real-world affected extremity use as measured by MAL which persisted at 2 yr f/u. Controls showed no change or a decline.

Liepert et al. (2000)

Literature Review Purpose: to use CIMT as a model to assess

therapy-induced plasticity in stroke patients

Subjects/Methods– 10 men and 3 women with chronic hemiplegia post

stroke– Inclusion criteria same as previous Taub study– CIMT with unaffected UE in resting hand splint for

90% waking hrs x 12 days– Sling also applied to unaffected UE in clinic for 6

hrs/day of Rx for 8 days to increase quality of mvmt and use of affected UE

Liepert et al. (2000)

Literature Review

Measures: MAL, transcranial magnetic stimulation mapping of motor output, motor threshold, and amplitude weighted center of activation sites (CoG)

Results– 1 day post Rx, 37.5% more activity in affected

hemisphere was noted– Increased cortical representation area in affected

hemisphere– Increase in ADLs persisting at 6 mo f/u

Conclusions

CIMT has been proven effective in subacute and chronic stroke for all but the 25% of pts with most severely impaired extremity fxn

CIMT may reverse the “learned nonuse” behavior by making pts more willing to use the affected extremity in functional ADLs

CIMT seems to result in cortical reorganization which represents the pts actual potential for recovery of fxn in the affected extremities

Questions for Acute Care Practitioners to Ponder

Can compensatory skills be taught without jeopardizing spontaneous recovery of the affected side?

How can resources best be allotted to promote recovery of hemiplegic limbs?

How can we best bridge the gap b/t therapeutic gains in the clinic and fxnl (I) in the real world?

Questions?