Constraint-Induced Movement Therapy: A Viable Option for Stroke Patients

The following article on Constraint-Induced Movement Therapy (along with Modified Constraint-Induced Movement Therapy) was guest-authored by Janet Meydam, OTR/L and Meredith Chandler, OTR/L. We want to give both of them a huge thanks for sharing their insight and research for this article.

According to the National Stroke Association, it is estimated that 9 out of 10 stroke survivors experience some form of paralysis. Occupational therapists who have been out in the field working with the adult population may be well-versed in “hemiparesis” and the functional deficits that it presents.

If we’re going for specifics, clinicians often confuse the two terms “hemiplegia” and “hemiparesis” or view them synonymously. “Hemi-“ refers to one side while “plegia” translates to heavy paralysis and “paresis” to slight paralysis or weakness (Chasa.org).

For both conditions, occupational therapy can apply a variety of interventions including modalities, therapeutic exercise, manual therapy techniques, splinting/bracing, and neurodevelopmental techniques (NDT) in order to improve functional use of the affected extremity and/or to prevent atrophy/breakdown of tissue.

One of the newer treatments gaining popularity is constraint-induced movement therapy (CIMT). This approach is relatively new compared to others and has experienced some controversy when presented as an alternative to traditional treatments for stroke rehabilitation, but research has shown promising results for stroke patients.

This article will provide you with an overview of what constraint-induced movement therapy is, the evidence supporting its effectiveness, and the primary treatment protocol used with adult stroke patients.

What is Constraint-Induced Movement Therapy?

Constraint-induced movement therapy is a therapeutic treatment protocol used with patients who have certain neurological conditions. These conditions, such as post-stroke (cerebrovascular accident), traumatic brain injury, multiple sclerosis, cerebral palsy, and others, have caused weakness or partial paralysis on one side of the body.

As a result, the unaffected side of the body displays a tendency to compensate for the affected side, causing the affected side to become more disabled than it actually is due to learned nonuse.

Constraint-induced movement therapy involves limiting the use of the unaffected side of the body so that the affected side is forced to attempt and participate in activity. Forced use helps the brain to reroute neural pathways around damaged areas so that movement can occur despite the neurological condition.

Below is a short video that explains and demonstrates CIMT for a stroke patient at Mary Free Bed Rehabilitation Hospital in Grand Rapids, Michigan.

 

Research Supporting CIMT

CIMT was introduced by Edward Taub, PhD and his group of researchers at the University of Alabama at Birmingham in the early 1990s. A study conducted by Taub, et. al. in 1993 compared the use of CIMT with chronic stroke patients to a comparison group of stroke patients who received intervention to improve attention to the affected limb.

The CIMT group showed substantially more improvement in use of the affected limb than the attention group. In addition, the CIMT group maintained functional gains over a follow up period of two years.

The attention group did not maintain gains achieved during the study period. Taub and his group have conducted numerous studies on the use of CIMT since this time, including a 1999 clinical review that supported the theory that CIMT facilitates reorganization of the brain to increase innervation of movement to the affected limb, and a multi-site randomized clinical trial that found significant improvements on all measures for patients 3 to 9 months post stroke who received CIMT (Wolf, et. al. 2006).

Dr. Taub and his group continue their research through the CI Therapy Research Group at the University of Alabama at Birmingham. You can read more about the group’s work and research studies currently underway here.

Other researchers have also obtained more recent results that support the use of CIMT with stroke patients. Kwakkel, et. al. (2015) found that use of less intensive, or modified, CIMT also improved functional use of the affected limb both immediately following treatment and at long term follow-up.

A Chinese study (Xi-hua, et. al., 2017), conducted a meta-analysis of 16 randomized controlled trials involving a total of 379 stroke patients who received CIMT and 359 control group patients. The results of this study showed significant mean differences on all measures used for the CIMT group.

Occupational therapy studies also support the effectiveness of CIMT for stroke patients. McCall, et. al. (2011) found that CIMT resulted in significant improvements on the Canadian Occupational Performance Measure for adults with a mean age of 82, even though the study group did not adhere to the 6 hours per day self-practice protocol.

A case study on a musician who had suffered a stroke 4 years prior (Earley et. al., 2010) found that modified CIMT paired with participation in meaningful occupations and activities resulted in improved function and a return to playing an instrument after therapy was completed.

Prerequisites and Protocols for CIMT

Patients who might be appropriate candidates for CIMT following stroke should have some active movement in the affected extremity. Recommendations for active movement in the forearm, wrist and hand include the ability to start from a resting position of forearm pronation and wrist flexion, 10 degrees active MCP and IP extension, and 20 degrees active wrist extension.

The basic components of Traditional CIMT treatment are as follows:

• The unaffected limb is placed in a protective mitt for 90% of waking hours. (Image source: https://www.odstockmedical.com)

• The affected limb is engaged in task-oriented training for several hours per day.
• Task-oriented training includes shaping, where optimal movement is achieved in small steps, and task practice, where functional activities are completed in a less structured manner.
• Treatment continues in this manner for 10-15 consecutive days.
• After daily treatment, the patient agrees to continue to use the affected limb at home, completed specific assigned functional tasks for 15-30 minutes per day and to focus overall on increasing use of the affected limb.
• Patients may be asked to keep a daily home diary and a motor activity log to document how much the affected limb is used and how the patient feels regarding use of the limb.
• A post-treatment home program is implemented after this phase of treatment that includes a list of 100 tasks for patients to choose from. Patients are instructed to perform 2-3 tasks for 10 minutes daily and to focus on overall use of the affected limb.
• Modified CIMT involves less restraint of the unaffected limb but continues to focus on task-oriented training.

When using CIMT as a part of occupational therapy treatment for stroke, it is important to incorporate meaningful, functional tasks as a part of task-oriented training. This will improve motivation and participation for the patient, which will in turn increase the amount of time and practice the patient puts into treatment.

Overall function will improve even more if meaningful activities are used to train the affected limb.

What is the Difference Between Traditional CIMT and Modified CIMT?

As stated above, traditional CIMT involved constraining the non-affected arm for up to 90% of a patient’s waking hours while intensely involving the affected arm in functional and rehabilitative tasks.

Modified constraint-induced movement therapy, however, is a less intensive form of CIMT, but echoes the repetition and consistency of using the affected arm just as you would in traditional CIMT (McDermott, 2016).

Basically, treatment requirements cuts the protocol duration in half (3 hours of intense treatment per day instead of 6-7 hours of treatment per day). The modified CIMT protocol was created because patients were having difficulty complying with the requirements of traditional CIMT (Breeding et al., n.d.).

Additional study groups began coming up with different variations of the treatment, in intensity, functional task choice, and duration and also labeled their approach modified CIMT. Thus, there is some confusion about the standardization of modified CIMT (Reiss et al., 2012).

Of course, the obvious question for clinicians and researchers was if modified CIMT was just as, if not more, effective than traditional CIMT. Reiss et al., (2012) recognized a handful of limitations as far as evidenced-based results regarding modified CIMT.

There are several studies out there that show that treatment is effective, but unfortunately each study ran into similar problems: small sample size, different duration requirements (hours, days, weeks), differences in stroke onset and administered treatment, and inconsistent task repetition. So if clinicians are looking for an empirical answer, it’s not there; however, this doesn’t mean that therapists should exclude CIMT or modified CIMT from their own interventions with stroke patients.

What Settings Are Stroke Patients Treated With CIMT In?

Settings where occupational therapists will see stroke patients include just about everywhere: acute care, subacute rehab, inpatient rehab, skilled nursing, transitional units, home health, and outpatient clinics.

Whether or not modified-CIMT can be applicable in those settings really depends on the patient and interdisciplinary teams.

What Else To Consider When Applying CIMT to Your Patient’s Plan of Care: 

Stroke Onset: Consider when the stroke actually occurred and how that could impact treatment. If the patient is only post-stroke by several days, they probably have other concerns that take greater priority over using their affected arm (i.e. being able to breathe, staying hydrated, regulating heart rate and blood pressure, accessing food, suppressing pain, etc.). A patient who has had a recent stroke may be emotionally compromised and not ready to handle a CIMT program, which could result in non-compliance and increased frustration. Lastly, if the stroke is new, there may be no way of telling what the hemiplegic extremity will look like until several weeks out.

Post-stroke Symptoms: Once again, patients will prioritize their symptoms and new limitations: vision, perception, emotional regulation, core instability, overall immobility and non-ambulation, irregular vitals, feeding precautions, and language changes. OTs need to acknowledge those limitations and let the patient voice their concerns and goals regarding their treatment. OT may be able to apply modified-CIMT around those concerns, but needs to be fair with the patient and recognize when to back off if necessary. Therapists should also note: involving the affected arm could hurt, especially if the patient has observable shoulder subluxation or atrophy (at any time post-stroke). Be prepared to accommodate for those symptoms by applying additional treatments: bracing, manual therapy, modalities, etc.

Treatment Duration: It is a sad reality that OTs are limited in their treatment times due to insurance reimbursement reasons. CIMT requires that the patient participate in repetitive, intense tasks for several hours per day and OTs are lucky to get 90 minutes with a patient per day. Therefore, CIMT protocols will need to be carried out by the patient OUTSIDE of treatment time and away from the therapist’s supervision. The patient could carry out the protocol independently or they could rely on other staff and/or family/caregivers for assistance.

Involvement of Other Staff Members: This is a concern for facilities such as hospitals, skilled nursing, and transitional units in which there are nursing staff and multiple disciplines that address the patient throughout the day. If therapy wants to see a CIMT protocol used throughout the day, but question whether or not the patient will initiate or continue the protocol independently, they may have to provide training to additional staff members.

Access to Functional Tasks: As previously mentioned, provide the patient with the functional tasks (that the patient enjoys or finds necessary) that can be conducted outside of therapy. If the patient is just sitting in a hospital bed for the remainder of the day, staring at the T.V. and not using the affected arm, then the protocol will be useless.

A Note About the Silver Spring Monkeys Experiments

During our researching and editing of this article, the origination of how Dr. Taub discovered CIMT with his Silver Spring monkey experiments came to light, and we felt it was important to highlight this history.

In 1981, Dr. Taub’s initial studies on CIMT using 17 wild-born macaque monkeys led to the first police raid in the U.S. against an animal researcher due to inhumane conditions and poor veterinary care. This resulted in Dr. Taub being charged with 17 counts of animal cruelty, and the team that uncovered the abuse formed the PETA organization shortly thereafter. You can learn more about these experiments here.

We felt this was important information to share so that we can all be aware of the history of CIMT. This kind of experimentation is heartbreaking and unfortunately all too common. I do believe that we should support organizations that fight for the rights and humane treatment of all animals.

Though CIMT has a dark history, the understanding gained through these experiments and Dr. Taub’s subsequent research can still be used to improve patients’ lives in modern times.

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In conclusion, CIMT remains controversial due to the limitations imposed on the unaffected limb and the intensity of treatment, causing some third-party payers to be reluctant to reimburse the amount of treatment required to complete the protocol.

Research, however, continues to strongly support the effectiveness of constraint-induced movement therapy and modified protocols have reduced the amount of constraint required, so views of the treatment are changing. If you work with adult stroke patients, CIMT and modified CIMT are worth considering as a part of your treatment toolbox.

 

References

Breeding, Jasso, Belcher, Alkema, Alkema, Augustine. (n.d.) Constraint-Induced Movement Therapy (CIMT)
www.csus.edu/indiv/m/mckeoughd/pt224/litreviewtopics/cimt.pps. Viewed on July 14, 2017.

Earley, D., Herlache, E. and Skelton, D. (2010). Use of Occupations and Activities in a Modified Constraint-Induced Movement Therapy Program: A Musician’s Triumphs Over Chronic Hemiparesis From Stroke. American Journal of Occupational Therapy 64:735-744. Retrieved 12 July 2018 from https://ajot.aota.org/article.aspx?articleid=1854529.

Hemiparesis. (2017). National Stroke Association. http://www.stroke.org/we-can-help/survivors/stroke-recovery/post-stroke-conditions/physical/hemiparesis. Viewed on July 8, 2017.

Hemiplegia, Hemiparesis, Hemiplegic Cerebral Palsy – What’s the difference? (2017). Child Hemiplegia and Stroke Association. http://chasa.org/hemiplegia-hemiparesis-hemiplegic-cerebral-palsy-whats-difference/. Viewed on July 8, 2017.

Kwakkel, G., et. al. (2015). Constraint-induced movement therapy after stroke. The Lancet – Neurology 14(2):224-234. Retrieved 12 July 2018 from https://www.thelancet.com/journals/laneur/article/PIIS1474-4422(14)70160-7/fulltext.

McCall, et. al. (2011). Modified Constraint-Induced Movement Therapy for Elderly Clients With Subacute Stroke. American Journal of Occupational Therapy 65:409-418. Retrieved 12 July 2018 from https://ajot.aota.org/article.aspx?articleid=1851487.

Mccc.edu. (2018). Constrain-Induce Movement Therapy (CIMT or CI). Mercer County Community College power point presentation. Retrieved 12 July 2018 from http://www.mccc.edu/~behrensb/documents/Constrain-InduceMovementTherapyCIMTorCI.pdf.

McDermott, A. (2016). Constraint-induced movement therapy. Heart and Stroke Foundation. https://www.strokengine.ca/intervention/constraint-induced-movement-therapy-upper-extremity/. Viewed on July 14, 2017.

Reiss, A.P., Wolf, S.L., Hammel, E.A., McLeod, E.L., & Williams, E.A. (2012). Constraint-Induced Movement Therapy (CIMT): Current Perspectives and Future Directions. Stroke Research and Treatment. doi:10.1155/2012/159391.

Taub, E., et. al. (1993). Technique to improve chronic motor deficit after stroke. Archives of Physical Medicine and Rehabilitation 74(4):347-354. Retrieved 12 July 2018 from https://www.ncbi.nlm.nih.gov/pubmed/8466415/.

Taub, E., Uswatte, G., Pidikiti, R. (1999) Constraint-Induced Movement Therapy: a new family of techniques with broad application to physical rehabilitation–a clinical review. Journal of Rehabilitation Research and Development 36(3):237-251. Retrieved 12 July 2018 from https://www.ncbi.nlm.nih.gov/pubmed/10659807.

Taub, E. (2012). The Behavior-Analytic Origins of Constraint-Induced Movement Therapy: An Example of Behavioral Neurorehabilitation. The Behavior Analyst 35(2):155-178. Retrieved 12 July 2018 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3501420/#bhan-35-02-03-Taub20.

Wolf, et. al. (2006). Effect of constraint-induced movement therapy on upper extremity function 3 to 9 months after stroke: The EXCITE randomized clinical trial. Journal of the American Medical Association 296(17):2095-2104. Retrieved 12 July 2018 from https://uncch.pure.elsevier.com/en/publications/effect-of-constraint-induced-movement-therapy-on-upper-extremity-.

Xi-hua, Liu, et. al. (2017). Constraint-induced movement therapy in treatment of acute and sub-acute stroke: a meta-analysis of 16 randomized controlled trials. Neural Regeneration Research 12(9):1443-1450. Retrieved 12 July 2018 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5649464/.