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Constraint Induced Movement Therapy: The Therapeutic Use in Acquired Brain Injuries

Taryn Goodman & Fatima Hijazi

Department of Occupational Therapy

Clinical Neuroscience OTP 612

Dr. Conti & Dr. Yost

April 12, 2022

Author Note

Correspondence concerning this paper should be addressed to Taryn Goodman and Fatima

Hijazi, Department of Occupational Therapy, The University of Michigan Flint. Email:

taryng@umich.edu, hijazif@umich.edu.
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Abstract

The following paper will discuss Constraint Induced Movement Therapy (CIMT) as an

intervention for Acquired Brain Injuries. Included in this paper will be an in-depth introduction

to identify the therapeutic intervention and its effective use for patients with Hemiplegia because

of an acquired brain injury. A literature review will also be provided to further explain the

therapeutic use of constraint induced movement therapy specifically for this condition. A

detailed explanation of the various Central Nervous System structures and neurophysiology

underlying the intervention, and the criteria for intervention use including precautions and

contraindications that should be considered. The following paper will review the relationship

between constraint induced movement therapy and the concept of Repetitive Task Training

(RTT). Finally, an overview of concerns or extensions of the intervention that need further

research will be provided.

Keywords: Constraint induced movement therapy (CIMT), acquired brain injury,

hemiplegia, traumatic brain injury (TBI), non-traumatic brain injury, neurophysiology, repetitive

task training (RTT), motor activity log

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Introduction

What first comes to mind when the term Constraint Induced Movement Therapy (CIMT)

is used? A clear definition of the term is that it is a therapeutic intervention that involves the

restriction of an unaffected limb to improve performance of the affected limb through client

centered tasks and activities (Cimolin et al., 2012). Developed in the 1980’s, Dr. Edward Taub

studied the intervention of constraint induced movement therapy in primates with somatosensory

interruption in a single front limb. Through multiple attempts, the primates learned to

compensate using their affected limb by restricting use of the unaffected limb (Cimolin et al.,

2012). Constraint induced movement therapy consists of intense training of the affected limb to

help strengthen its function. This intervention is the newer technique relating to older techniques

that required patients to use their affected limb to perform activities (McDermott, 2016). This

form of therapy is typically administered by an occupational therapist or a physical therapist for

an average amount of thirteen hours a day over the course of a two-week period. Constraint

induced movement therapy can be practiced at a clinic, at home, or any other setting that is safe.

Occupational therapists and physical therapists can even minimize the intensity of this training

by decreasing the number of hours and increasing the number of weeks depending on the

severity of the condition and the client's needs (McDermott, 2016).

Much research suggests that constraint induced movement therapy is effective in

improving function and motor impairments in patients with upper extremity deficits following an

acquired brain injury. In a qualitative research study focusing on “Constraint-induced movement

therapy for children with acquired brain injury: didactical approach and functional change”,

health professionals including occupational therapists, physiotherapists and nurses were recruited

to administer CIMT on four children within the ages of 10-12 with acquired brain injuries. The
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health professionals utilized CIMT techniques for a time frame of six hours a day for ten days

over the course of two weeks. CIMT techniques included but were not limited to participants

wearing a sling on the unaffected limb while attending to tasks such as preparing meals, playing

board games, and painting. After completion of the two-week intervention, results showed

increased dexterity, motor control and function of the affected limb in all four children. Results

also showed increased improvement in independent performance of activities and attaining

personal goals (Schmidt et al., 2016).

Another study analyzed the effects of CIMT in children with brain injuries using

functional magnetic resonance imaging (fMRI). Participants included eighteen children between

the ages of 5 to 18 with hemiplegia because of an acquired brain injury (participants were

screened to determine eligibility prior to the study). Participants were then treated with CIMT for

ten weeks, seven days a week. Children were given restraining gloves to wear on their unaffected

hand for three hours a day while they underwent therapeutic training. Training included intense

activities such as memory card games, puzzles, using utensils to practice eating and drinking and

other activities of daily living. fMRI results showed that children had increased improvement in

mobility, and relearned task function in the affected limb at the end of the treatment sessions

(Rocca et al., 2013). As previous research has suggested that constraint induced movement

therapy has shown to be beneficial and effective for patients with hemiplegia because of an

acquired brain injury, it is also important to discuss the topic of acquired brain injuries and the

problems hemiplegia presents for individuals with this condition.

The condition of acquired brain injury can be broken down into two specific categories.

They are non-traumatic brain injury and traumatic brain injury (TBI). While non-traumatic brain

injuries occur from internal forces, traumatic brain injuries occur from external forces, both
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resulting in trauma to the brain's tissue. (Brain Injury Alliance of Colorado, 2022). TBI’s can

further be broken down into two subcategories. They include closed brain injury and penetrating

brain injury. As defined by Johns Hopkins Medicine, a closed brain injury occurs when the brain

becomes injured with no breakage of the skull or penetration to the brain. A penetrating injury is

defined as the opposite and is a result of penetration to the brain or an “open head injury”,

occurring due to breakage of the skull (Johns Hopkins Medicine, 2022). The following passages

will dive deeper into the various acquired brain injury conditions within each specific category

and subcategory, giving a brief overview of the condition and how it can result in the deficit of

hemiplegia.

As defined previously, non-traumatic brain injuries are understood to be an injury to the

brain without penetration or fracturing of the skull. This type of injury is caused from internal

forces within the body. The most common non traumatic brain injury is that of a stroke.

According to the CDC, about 87% of strokes are ischemic strokes, where proper blood flow of

the artery to the brain is blocked (CDC, 2022). When oxygen-rich blood is unable to nourish the

brain, brain tissue can become compromised and cells within the brain begin to die. Many

complications can arise as a result of a stroke, one of the main symptoms being hemiplegia

and/or hemiparesis. Individuals who suffer from a stroke can experience weakness independently

or simultaneously in the upper extremity, lower extremity, and/or facial muscles of one side of

their body (American Stroke Association, 2022). Stroke survivors face many difficult challenges

during rehabilitation as the result of the loss of coordination and balance, increased muscle

spasticity, and decreased movement precision.

Additionally, closed brain injuries are another type of acquired brain injury that a person

can obtain which are caused by external forces. Closed brain injuries are considered traumatic
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brain injuries due to bruising of brain tissue and damage of blood vessels as a result of rapid back

and forth movement or shaking of the brain within the cranial cavity (Stanford Medical Center,

2019). While closed brain injuries can range in severity, the most common type seen is a

concussion, typically because of a fall or motor vehicle accident. Concussions can occur as a

direct blow to the head but also because of a jolting body movement that creates enough force to

succussion the brain (Saling, 2020). A concussion can be extremely dangerous and lead to

extreme mental impairments and permanent disability. Some common signs and symptoms of a

concussion are memory loss, loss of balance control, the inability to concentrate, and the

inability to move one or more limbs (i.e., hemiplegia and/or hemiparesis).

Furthermore, the third identified acquired brain injury and second classification of TBI is

a penetrating brain injury. A TBI is considered penetrating when an object or external force

fractures the skull and damages the brain tissue. Although they are less common than closed

brain injuries, their prognosis is oftentimes much worse. Penetrating brain injuries are immensely

life threatening and the fourth leading cause of death within the United States (Alao et al., 2021).

In a survey conducted by the National Institute of Health, it was estimated that 1.9 million people

experience a skull fracture or penetrating brain injury annually (Vinas, 2020). Survivors of

penetrating brain injuries typically experience heavy blood loss from their head or ears due to the

impalement of an object puncturing the brain's dura mater. Consequently, this can lead to

cognitive impairments, sensory changes, as well as perpetual physical deficits (Mayo Clinic,

2021). Similarly to the previously listed acquired brain injury symptoms, individuals with

penetrating brain injuries also endure loss of balance, convulsions, confusion, slurred speech, and

the loss of motor ability and coordination in their limbs.

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While each type of acquired brain injury occurs differently with various characteristics of

trauma, they each have the commonality of prospective hemiplegia and/or hemiparesis. The

presence of hemiplegia for an individual who has obtained an acquired brain injury can be very

problematic for the individual's overall recovery, daily living needs, and activities associated

with independence and meaning. Hemiplegia can affect the upper extremity, lower extremity,

and even facial muscles. Weakness or paralysis is seen on the contralateral side of the body, i.e.,

the opposite side of the body from the area where the brain injury has occurred. Hemiplegia can

also be shown through other indicators beyond limb weakness. Other displays of hemiplegia

include but are not limited to poor balance, poor fine motor skills, difficulty grasping, and

muscle spasticity, leaving the muscles in a constant state of contraction (Eyvazzadeh, 2020). The

impacts of hemiplegia can affect an individual beyond just physical abilities as well. The

inability to utilize your limbs can directly influence emotional and behavioral effects for the

individual. Frustration, the feeling of isolation, anxiety and irritability are just a few outcomes

that can be seen. In the recent study “Psychological health of caregivers and association with

functional status of stroke patients”, caregivers' emotional state was assessed along with the

examination of rehabilitation outcomes for stroke survivors. The study contained 76 patients

with hemiplegia caused by stroke with severe physical disabilities. The findings concluded that

caregivers' with higher levels of anxiety and impaired emotional state were associated with the

severity of disability of the person they cared for. This also supported the notion that caregivers

experience high distress as a result of taking on physical and mental demands for the affected

individual, negatively influencing the functional recovery and response to rehabilitation for the

patient (Em et al., 2017).

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It should be noted that hemiplegia occurs because of an acquired brain injury due to the

physical influence it has on central nervous system structures, thus making CIMT a promising

intervention for those who suffer from it. To better understand why this intervention can play an

important role from a neurological and neurophysiological point of view, we will now discuss

the various cortical and subcortical structures involved in normal movement and abnormal

movement of the limbs, while considering neural and personal factors that may contribute to

CIMT intervention outcomes.

Central Nervous System Structures and Neurophysiology

Constraint induced movement therapy plays an important role in the neurological and

neurophysiological aspects of the human body. CIMT works to increase the size of the motor

homunculus (motor map of the brain) which promotes activation of cortical structures such as the

primary cortex (Abdullahi, 2018). To understand the neurological and neurophysiological basis

of CIMT, it is important to be able to identify the central nervous system structures that are

activated during normal movement. For over 150 years researchers and scientists have studied

the communication between the central nervous system and movement. It is important to note

that normal movement can be broken down into voluntary and involuntary movements

(Schwartz, 2016). Voluntary movements are described as movements that are controlled and

planned. Involuntary movements occur because of a response to reflexes or quick movements

that occur due to a stimulus response (Latash & Zatsiorsky, 2016). These involuntary responses

begin in the spinal cord and travel up to higher structures including the hindbrain, midbrain, and

other cortical structures (Schwartz, 2016).

All movements require muscles to be activated due to an impulse of the motor nerve

associated with the specific muscle. For these movements to occur motor neurons descend and
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ascend through common pathways found within the human body. The human body is made up of

multiple motor pathways; the corticospinal tract, reticulospinal tract, rubrospinal tract,

tectospinal tract, and the vestibulospinal tract. Each of these tracts play an important role in

assisting the motor neuron to travel from one associated area to the next (Ugawa, 2020). So,

what is the mechanism of normal motor movements you may ask? To start off, it is crucial to

keep in mind that the motor homunculus organizes movements in the cerebral cortex on the right

and left sides as follows; toes, knee, hip, trunk, shoulder, arm, elbow, wrist, hand, fingers, thumb

and so on and so forth; mapping out all parts of the body (Ugawa, 2020). Associated with the

motor homunculus, there are various cortical and subcortical structures involved. These include

the frontal lobe, primary motor cortex (M1), supplementary motor association, premotor

association, the cerebellum, basal ganglia, and the thalamus. Each of these structures serves as a

functional station to import and export movement. The frontal lobe contains the primary motor

cortex (M1) which functions to produce impulses that will generate movements. These

movements produced will occur on the opposite side of the body because opposite hemispheres

of the brain control opposite sides of the body. The supplementary motor association cortex and

the premotor association cortex are known as secondary motor cortices. The supplementary

motor association cortex oversees planning and coordinating complex movements. The premotor

association cortex works to control body orientation and directs sensory input of the movement.

Both cortices work together to relay information to the primary motor cortex and other motor

regions of the brainstem (Ugawa, 2020) (Kandel et al., 2014) (Schwerin et al., 2017). Another

important region for normal movement is the Cerebellum. The cerebellum plays a key role in

fine tuning movement and coordination. By generating motor commands, the cerebellum helps

coordinate the movement to be initiated (Sokolov et al., 2017). Along with the cerebellum, the
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Basal Ganglia, made up of nuclei is responsible for motor control as well as motor coordination.

It works together with the cerebellum to execute the function by receiving and delivering

information (Lanciego et al., 2012). A final structure that is crucial in normal movement is the

Thalamus, also known as the relay station. The thalamus’s main role is to reinforce movements

directed by the motor cortex. By receiving information from sensory nerves, the thalamus relays

the information to the cerebral cortex to process. Another important role that the thalamus is

involved in is sensory perception. The thalamus receives sensory information and passes it on to

structures throughout the body, not just the cerebral cortex (Ugawa, 2020) (Brain Made Simple,

2019).

Conversely, abnormal movements typically occur when there is damage or alteration to

any of the important cortical and subcortical structures previously identified in normal motor

movements. Damage can occur to these areas in various brain injury phenomena that include

convulsive seizures, axonic injury, vascular injury, traumatic injury, and inflammatory injury

(Hannawi et al., 2016). Abnormal movements can be both voluntary or involuntary and present

in mild and pronounced movement patterns. Abnormal movements are typically not seen as one

cohesive movement but instead can be sudden and jerky, slow and sustained, tremorous,

imprecise, and even uncontrolled in the presence of a muscle contraction. Abnormal movements

can be extremely impeding on an individual’s life and make daily living tasks difficult to

complete. Depending on what cortical and/or subcortical region is damaged can directly affect

what part of the motor movement is affected. We will now briefly explain the outcomes of

damage to each of the regions identified in normal motor movement and how they contribute to

abnormal motor movement.

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As previously mentioned, the frontal lobe is a vital part in initiating motor movements

and contains the primary motor cortex which is responsible for grading the amount of force

needed in a particular movement. When there is damage to the M1 area, there can be no

initiation of movement (paralysis/paresis) as well as uncontrolled force production within

movement on one side of the body. This contributes to abnormal movement seen in sudden and

jerky movement patterns. Similarly, the supplementary motor association area (SMA) is

responsible for planning sequential movements as well as bilateral coordination. When this area

is damaged, bilateral coordination is lost, making it difficult to initiate movement of the limbs

together in a controlled and organized manner. Abnormal movement of bilateral limbs can make

occupations like dressing, bathing, and cooking difficult. Next, we have the premotor association

cortex. When this area of the brain is damaged, we see deficits in fine motor control and

performing complex serial movements like walking and running. Since the PMA is also

responsible for body orientation and limb orientation towards a target, abnormal movements

associated with damage appear as difficulty to guide one's body in a coordinated manner towards

a particular target (Ugawa, 2020) (Kandel et al., 2014) (Schwerin et al., 2017). Next, we have the

cerebellum, previously described for its role in fine tuning of movement and coordination. When

the cerebellum is damaged, it affects one's ability to judge distances, resulting in the abnormal

movements of over or undershooting the strength and speed needed for completing tasks.

Damage to the cerebellum also affects the signaling of inhibitory and excitatory information to

muscles, resulting in the loss of coordination and balance (Denslow, 2022). Moreover, the basal

ganglia is another important structure that impacts abnormal movement patterns. Since the basal

ganglia is responsible for the activation and relaxation of agonist and antagonist muscles during

movement, damage to this area results in disruption of harmonious movement and muscles
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instead co-contract during initiated movements. This results in movements being abnormal and

are seen as abrupt, rapid, and uncontrolled (Flint Rehab, 2022). Finally, the thalamus is the last

important structure where damage may result in abnormal movement patterns. The role of the

thalamus is extremely important, as it is the relay station of sensory information to the motor

cortex. When the thalamus is damaged, it can result in movement disorders like hemiplegia and

spatial neglect. It can also affect one's ability to coordinate movements resulting in abnormal

movement patterns. This example can be seen while walking. A person with damage to the

thalamus will walk with a staggering, wide gait (Flint Rehab, 2022).

To recap, various cortical structures contribute to movement and if they are damaged,

abnormal motor movements can occur. There are many different intervention techniques that can

assist with the rehabilitation for abnormal movement, one of them being CIMT. To better

understand CIMT from a neuropsychological point of view, we must understand the concept of

neuroplasticity, which is an underlying mechanism for why CIMT can be beneficial. As defined

by the Oxford Dictionary, neuroplasticity is “the capacity of the nervous system to develop new

neuronal connections''. While the idea that the brain could change was present from the early

neuroscientist Santiago Ramón y Cajal, the idea that the brain could reorganize information and

function after traumatic events was not discovered until 1948 by Jerzy Konorski (Ackerman,

2022). There are two types of neuroplasticity, structural and functional. Through learning,

discovery, and repetition, permanent changes in synapses occur and recovery of function can be

obtained despite cortical and subcortical damages. This is a form of functional neuroplasticity, a

compensatory method that indirectly changes the nervous system and the reason why researchers

believe constraint induced movement therapy can be used as an intervention method for

individuals following acquired brain injury. In the systematic review “The neural basis of
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constraint-induced movement therapy”, brain structure and function were examined using

transcranial magnetic stimulation and brain imaging in post stroke patients participating in

CIMT. While participating in CIMT, transcranial magnetic stimulation showed an increase in

ipsilesional motor map size from baseline and a decrease of size in the contralesional motor map

following CIMT intervention, appearing to balance motor representation. Brain imaging also

reported changes for two patients with chronic stroke showing increased activation in the

contralesional hemisphere with gains in motor function after CIMT (Wittenberg et al., 2009).

This review concludes that the brain can undergo plasticity changes in structure and function

accompanied by motor function gains for post-stroke patients who have participated in CIMT as

an intervention method, thus supporting the concept of neuroplasticity and CIMT as a beneficial

intervention for individuals experiencing abnormal motor movement because of brain damage.

To better understand the intervention, it is important to note the neural mechanisms

involved. Many neurotransmitters play an important role in the treatment and recovery process.

Such neurotransmitters include but are not limited to; Glutamate, an excitatory neurotransmitter

found within the central nervous system (CNS); α-Amino-3-hydroxy-5-methyl-4-isoxazole

propionic acid receptor (AMPAR) and N-methyl-D-aspartic acid receptor (NR), which serve as

the ionotropic Glutamate receptors in the CNS. Ionotropic receptors can be better described as

ligand gated ion channels made up of proteins that play a role in the activation and deactivation

of ion channels (Hu et al., 2021) (Ni, 2021). In a recent study, researchers identified the effect of

CIMT on lab rats by comparing the results of AMPAR on the postsynaptic membrane. Within

the study, rats were divided into three groups: CIMT (middle cerebral artery occlusion surgery),

MCAO (middle cerebral artery occlusion surgery without CIMT), and a placebo group. For the

CIMT group, CIMT was started on the seventh day post-surgery. Based on the results achieved,
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CIMT was shown to improve motor function specifically in rats with cerebral ischemia. CIMT

also increased Glutamate ionotropic receptor (GluR2) and (NR) synapses and decreased

AMPARs that lacked GluR2 in the sensorimotor cortex in comparison to the MCAO and placebo

groups. Overall CIMT plays a vital role in reinforcing synaptic transmissions in the hippocampus

and sensorimotor cortex while also assisting to restore functional motor movement. (Hu et al.,

2021).

Lastly, various personal factors should be examined when understanding the

neurophysiology behind CIMT and how it can influence outcomes of this intervention. Such

factors include aging, physical activity, and nutrition. As individuals age their movements

become slower and more limited. Smith (2020) researched the effect of the neuromuscular

system related to aging in 28 young adults and 50 old adults. To do so, MEPs or motor evoked

potentials were measured once generated in motor cortices. Targeted limbs included the Vastus

Lateralis and the quadriceps. Results showed that the amount of power to produce a movement

decreased with age and was especially seen in knee extension. Increased fatigue was also

observed in older adults in comparison to younger adults. These results concluded that the most

common cause of decreased movement in aging is due to an increased atrophy in fast fibers. As

fast fibers decrease with age, movements tend to become slower, rigid, and harder to produce. It

is important to note that CIMT may be difficult for older adults as it requires intense training,

which leads to the importance of physical activity in neuromuscular function (Smith, 2020).

Physical activity is a vital component of movement as it pertains to increased health

benefits, neuromuscular function, and cognition. In 2022, a study in Ottawa was conducted that

focused on the “Evaluation of Afterschool Activity Programs’ (ASAP) Effect on Children’s

Physical Activity, Physical Health, and Fundamental Movement Skills (Crozier et al., 2022). 35
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students ages 5 to 12 years were recruited and enrolled in after school programs involving

physical activities for six months. Participants were assessed on multiple categories including

fundamental movement skills and physical fitness (7 days a week). After completion of the

training program and assessments, students showed an increase in body mass index (BMI) and

improvement in functional movement skills especially skills relating to object motor control.

These results provide further evidence that physical activity positively affects neuromuscular

function which is crucial for CIMT. CIMT requires some form of strength and motor control for

the individual to be able to train properly. Without these factors CIMT may not be as effective,

therefore the individual may see minimal changes in treatment of their condition or may require

longer periods of training (Crozier et al., 2022).

Additionally, nutrition serves as an important personal factor to consider when

understanding the neurophysiology behind CIMT and how it can influence outcomes of this

intervention. Maintaining a nutritious diet will allow for improvement in musculoskeletal health,

cognitive performance and decreases the risk of disease or injuries (Koehler & Drenowatz,

2019). Drenowatz and Greier (2018), studied the “Association of Sports Participation and Diet

with Motor Competence in Australian Middle School Students” (Drenowats & Greier, 2018). In

this study, participants recruited were 172 middle school students between the ages of 11 and 14

years. Students were assessed on anthropometric measures (BMI, body weight, height), motor

competence, dietary information, and club sports participation. Out of 172 students, 165

provided information on their nutrition and motor competence. As a result, girls showed lower

averages of food consumption such as meat and carbonated drinks and higher consumption of

vegetables and fruits. In terms of motor competence, girls also showed higher results than boys

(stand and reach, 20m sprint, balance, etc.). Overall, these results provided further information
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on the importance of healthy dietary lifestyles in development. As for nutrition and its impact on

CIMT, as stated before CIMT is composed of intense training for short time periods. Individuals

practicing healthy habits such as participating in physical activity and making healthy eating

decisions may benefit more from the intervention. The intervention alone is not enough to help

the individual regain function or improve function in their affected limb. It is important to keep

in mind that what goes into our body affects how our body develops and functions on the outside

as well (Drenowats & Greier, 2018).

Precautions and Contraindications

With all interventions, there comes precautions and contraindications that need to be

addressed. Based on previous research, this intervention has shown to be therapeutically

effective in hemipelagic patients with an acquired brain injury, however, there are personal and

environmental factors that need to be considered to ensure this intervention is best suited for the

patients safety and recovery. CIMT has been found to be the most beneficial and effective in

patients with conditions such as hemiplegia, stroke, cerebral palsy, and spinal cord injuries.

Patients who cannot participate in functional activities should be excluded from CIMT and

consider alternative treatment methods. This may include individuals who have skin burns or

contractures, as well as the inability to sustain high intensity training due to other underlying

conditions. Environmental factors can also contribute to discarding CIMT as an intervention

method. As previously mentioned, CIMT is administered for an average of 13 hours per day over

a two-week period. Since this intervention requires such an extensive amount of time to be

properly administered, resources including practitioner and patient availability, facility operation

hours, and lack of patient privacy may be limiting factors for the use of this method.
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There are other precautions and contraindications that also limit the use of this

intervention. Some precautions include ensuring that the patient and the facilitator are practicing

the therapeutic intervention safely. Safety plays an important key factor in the administration of

the intervention as it decreases the risk of causing more harm to the patient and minimizes the

risk of injury to the practitioner as well. Another precaution includes fall prevention and

implementing the use of universal falling practices regardless of the patient's fall risk. These

precautions involve the use of non-slip footwear, familiarizing the patient with the environment

where they will be performing tasks, and maintaining a shorter distance from the patient to assist

them if needed. If these precautions cannot be completed, a different method of intervention may

need to be considered. As for contraindications, many studies have discussed the potential risks

of CIMT, some of which focus on the psychological effects of the intervention. Since patients

are required to use their affected limb while restraining the unaffected limb, it may be difficult to

perform certain tasks that require bimanual coordination causing patients to become frustrated

and depressed. The mental health of the patient is crucial to the effectiveness of the treatment

meaning that CIMT may not be suitable for patients who show or have shown signs of emotional

distress at any time during the intervention or even prior to starting therapy (Cimoln et al., 2012).

Additionally, some studies state that the following intervention should be excluded due to limited

long term data following post treatment. As previously stated before, this intervention is the

newer technique relating to older techniques, and further research is needed to fully understand

the long-term effects it has on patients with various conditions (McDermott, 2016).

CIMT and Repetitive Task Training (RTT)

While there are many ways to conduct constraint induced movement therapy as an

intervention method, one method has been increasing in popularity with occupational and
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physical therapists is that of combining CIMT with the use of repetitive task training. Repetitive

task training or RTT, is the repetition of movements required to practice a specific motor task as

a form of rehabilitation (Thomas et al., 2017). Repetitive task training can be anything from

folding laundry, filling the dishwasher, reaching for items in cabinets or even simply lifting items

around the house. In a critical review of the interface of CIMT with RTT, researchers focused on

plasticity after stroke and restoration of body functions. Participants or patients of the study were

selected based on patient expectations; early post stroke and patients who would benefit the most

from this form of therapy to help minimize unreasonable expectations from developing. The

intervention consisted of two protocols, repetitive training, and constraining. During the

repetitive training phase of the study, patients were given an hour of independent training on

each working day for a time frame of three weeks (2-3 weeks of stroke). Based on clients ability,

the hour of RTT can be broken down into 30-minute or 15-minute training sessions to minimize

overloading the patient shortly after the stroke. Activities such as shaping and task practice were

involved in RTT. Shaping consists of modifying individual tasks with the affected arm to

increase task difficulty. Task practice consists of practicing specific functional tasks to improve

motor movement and impairment in the affected limb; for example, cutting, drinking, or eating.

As for the constraining part of the intervention, patients wore a mitten on the unaffected or less

affected hand 3 hours a day to force usage of the affected hand. Researchers found that the

following approach decreases compensatory strategies and increases restorative movements in

the affected hand. The interface with the RTT approach promoted growth proteins such as GAP

43 and MARCK (Myristoylated alanine-rich C-kinase substrate) 3 to 4 weeks post-stroke.

Recovery of neurological processes post-stroke was also found in participants after the

rehabilitation period (Nijland et al., 2013).

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Further Research

Although much research suggests that CIMT is an effective intervention for hemipelagic

patients that have an acquired brain injury (traumatic or non-traumatic), there is always room for

growth and further research. Much of the research available lacks information on the resources

present to practice CIMT. As more and more health professionals incorporate the intervention

into their treatments the demand for resources will also increase. Since this form of therapy is

newer than other therapeutic interventions it is important to have enough resources available for

health professionals to utilize across the world. Another concern of CIMT revolves around

further research relating to long term studies. Based on the studies provided and other studies not

presented in this document, there is not enough research on the long-term effectiveness of CIMT.

Majority of the studies available focus on the effect of CIMT during the treatment sessions or

shortly after treatment sessions have been completed. It would be beneficial for future

researchers to investigate how effective CIMT is over the course of months or even years after

completion of therapeutic training.

Lastly, although this intervention is administered by health professionals, it is considered

a slightly intense form of therapy, meaning that it requires high dose training in short periods of

time. It is not clearly understood whether the effects of this intervention are long lasting since

most treatment sessions usually last between two to three weeks. Health professionals should

always take into consideration the intensity of the training based on the client as each client is

unique. CIMT contains diverse outcomes from one individual to another depending on the

condition of the client, environmental factors, and personal client factors. Although this

intervention does contain some limitations and requires further research it presents patients with

many benefits as discussed previously.

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