Constraint-Induced Movement Therapy

(CIMT)

A literature review presented by:

Travis Breeding
Ernesto Jasso
Ashley Belcher

Derick Alkema
Jessica Alkema
Nate Augustine
 Learning Objectives:
Post-presentation the learner will be able to:

Describe Constraint-Induced Movement Therapy (CIMT) and its

uses
Define “Learned Non-Use”
Discuss the Hx of CIMT: (who originated it and how it was
originated)
Describe the basic components of CIMT
Describe admission requirements for CIMT
Discuss the various outcome measures used in CIMT (ie.Motor
Activity Log & Wolf Motor Function Test)
Discuss the differences between CIMT & Modified CIMT
Discuss the advantages/disadvantages of CIMT
 What is CIMT?
 Constraint-induced movement therapy
(CIMT) is based on research done by
Edward Taub, a behavioral neuroscientist
 Monkey deafferentation

 Teaches the brain to "rewire" itself

following a major injury such as stroke or
traumatic brain injury (neuroplasticity)

 Patients can "learn" to improve the motor

ability of the more affected parts of their
bodies and thus cease to rely exclusively or
primarily on the less affected parts.

 CIMT is the first rehabilitation modality to

show such progress and dramatically
changes how neurological injuries are
studied and treated

Taub et al. 2006

 What is CIMT?
 CIMT consists of three components
 Massing of repetitive, structured, practice-intensive therapy
in use of the more-affected arm
 restraint of the less-affected arm
 transfer program, which includes monitoring arm use in life
situations and problem solving to overcome perceived
barriers to using the extremity

Taub et al. 2006

 CIMT Patients
 CIMT is focused on three major patient populations:
 Stroke
 Cerebral Palsy (Pediatrics)
 TBI/Spinal Cord Injuries
 Learned Non-use
 Develops as a result of an upper motor neuron
lesion that depresses the central nervous system
and motor activity after a stroke

 The person learns to use the uninvolved or less

involved extremity more often to compensate for
lack of movement in the involved extremity
 Learn to NOT use the involved extremity

Taub, E., 2000

 Admission Criteria
 10 x 10 x 10
 10 degrees active wrist extension
 10 degrees active thumb abduction

 10 degrees active extension of any other two digits

on affected hand

Taub, E. et al., 1999

 CIMT Protocol
 Basic components include:
 Restraint of unaffected arm for 90% of waking
hours
 2 to 3 week period, 6 to 7 hours per day of intense
therapy on consecutive weekdays
 Repetitive training of more affected UE

 Behavioral agreement

 Treatment diary

Taub, E. et al., 1999

 How Much Therapist
Intervention is Necessary?

 “In people with ongoing limitation of arm

function after stroke, providing 6 hours of
therapist-guided task practice was equivalent
to 1 hour of direct therapy with 5 hours home
practice over 10 days.”
 “Gains after two weeks of intense practice
were not sustained at six months.”
Richards, L. et al., 2006
 The Extremity Constraint Induced Therapy
Evaluation Trial (EXCITE)
 Represents the first national, randomized, single-
blind study to systematically test a
neurorehabilitation therapy among patients with
the ability to initiate extension movements at the
wrist and fingers, and who experienced their first
stroke within 3 to 9 months prior to enrollment.

Wolf, S. & Miller, J., 2006

Schweighofer, N. et al, 2009
 The Extremity Constraint Induced Therapy
Evaluation Trial (EXCITE)
 Prospective, single-blind, randomized, multi-site clinical trial at
7 US academic institutions between January 2001 & January
2003.

 Compared effects of 2 week treatment of CIMT vs. customary

treatment on UE function

 222 people with predominantly ischemic strokes

 106 received CIMT & 116 customary treatment

 Outcomes were measured using:

 Wolf Motor Function Test (WMFT)
 Motor Activity Log (MAL)

Wolf, S. & Miller, J., 2006

 Outcome Measures
 Wolf Motor Function Test
 15 timed tasks: sequentially from simple to
complex
 2 strength tasks: Shoulder flexion & grip strength

 Motor Activity Log

 11 point Quality of Movement (QOM) scale
 11 point Amount of Use (AOU) scale
 Subjective, done by patient

Wolf, S. & Miller, J., 2006

 EXCITE Conclusion
 Among patient’s who had a stroke within the
previous 3 to 9 months, CIMT produced
statistically significant and clinically relevant
improvements in arm motor function that
persisted for at least 1 year.

Wolf, S. & Miller, J., 2006

 Modified CIMT
 Original CIMT is mentally challenging & can
result in poor compliance
Koyama et al., 2007

 Modified CIMT is now being implemented by

therapists to promote better compliance
 Less effective than traditional CIMT ?
 3 hours of treatment provides less improvement than 6
hours of treatment based on MAL units, however a
significant and relevant effect can be gained from 3
hours of daily training
Sterr et al., 2002
 Modified CIMT
In a 2008 study on modified CIMT by Stephen Page et al., the
magnitude of changes using modified CIMT were found to be
consistent with more intense constraint induced therapy protocols.
 Protocol: 30 minutes of 1 on 1 therapy,
3 days per week
 5 hours per day in restraint (weekdays)
 10 weeks
 *Outcome measures: Action Research
Arm Test (ARAT), Fugl-Meyer (FM),
and Motor Activity Log (MAL)
*Subjective and Objective Motor Gains
Page, S. et al., 2008

 What about neuroanatomical gains?

 Brain Mapping Measures
Newer Outcome Measures of CIMT Include:

 Voxel-Based Morphometry (VBM)

-Radiographical imaging device portrayed by pixels.
(MRI)
Gauthier et al. 2007

 Transcranial Magnetic Stimulation (TMS) also

provide brain mapping in CIMT studies.
Grotta et al., 2004
 Brain Activity
 A 2000 study by Taub showed brain activity
actually improves with CIMT treatment.

 “This finding offers hope to researchers who

believe it may be possible to stimulate or
manipulate brain areas to take over lost functions,
a process known as cortical reorganization,” says
Dr. Taub.

“A Rehab Revolution,” 2004

 Disadvantages to CIMT
 Requires enormous labor from both patient & medical staff

 Patient endures many hours of frustration

 Patients can suffer from muscle soreness resulting in stiffness and

discomfort in the involved upper extremity as well as skin lesions
and skin burns.

 Acute CIMT can be harmful by increasing the size of the lesion.

Grotta, J. et al., 2004

 Not beneficial for all stroke/BI patients

 Typically for patients with higher level of function

 Longer treatment = higher cost to patient

 Not reimbursable through insurance
 Advantages to CIMT
 Overall greater improvements in function vs. conventional
treatment
Gauthier, L. et al., 2008

 Highly researched and highly credible treatment approach

 Observed gray matter reorganization in primary motor and

sensory cortices and hippocampus by way of neuroplasticity
Gauthier, L. et al., 2008

 Increase societal participation (IADLS)

 Decrease in medical cost over lifetime

Taub et al., 2007
 Take Home Message
 Maybe it is time to change PT’s current
treatment model for patients with learned non-
use

 In order to do this, we need to furnish the

insurance industry with the long-term benefits
of CIMT
 References
 A Rehab Revolution. Stroke Connection Magazine, September/October 2004. Excerpt from the article.
Retrieved April 12, 2010 from http://www.strokeassociation.org/presenter.jhtml?
identifier=3029931#2006

 Brain Science #28: Edward Taub’s revolutionary approach to stoke rehabilitation. Pod Cast interview by
Dr. Ginger Campbell. http://brainscience podcast.wordpress.com/2008/01/11/brainscience-28-
edtaub/

 Gauthier, L. et al. Remodeling the brain: plastic structural brain changes produced by different motor
therapies after stroke. Stroke. 2008; 39:1520-1525.

 Grotta, J. et al. Constraint-induced movement therapy. Stroke. 2004; 35; 2699-2701.

 Hakkennes, S., Keating, J. Constraint –induced movement therapy following stroke: A systematic review
of randomised controlled trials. Australian Journal of Physiotherapy. 2008; 51:221-231.

 Page, S. et al. Modified constrain-induced therapy in chronic stroke: results of a single-blinded

randomized controlled trial. Physical Therapy. 2008; 88:333-340.

 Richards, L. et al. Limited dose response to Constraint-Induced Movement Therapy in patients with
chronic stroke. Clinical Rehabilitation 2006; 20: 1066-1074

 Schweighofer, N. et al, 2009. A functional threshold for long-term use of hand and arm function can be
determined: predictions from a computational model and supporting data from the Extremity
Constraint-Induced Therapy Evaluation (EXCITE) Trial. Physical Therapy. 2009 Dec;
 References Continued
 Sterr, A. et al. Longer versus shorter daily constraint-induced movement therapy of chronic
hemiparesis: and exploratory study. Archives of Physical Medicine & Rehabilitation. 2002;
83:1374-1377.

 Taub, E., Uswatte, G. Constraint-Induced Movement therapy: answers and questions after two
decades of research. Neurorehabilitation, 2006; 21(2): 93-5.

 Taub, E. et al. Constraint-induced movement therapy: a new family of techniques with broad
application to physical rehabilitation – a clinical review. Journal of Rehabilitation Res
Dev. 1999; 36:237-251.

 Taub, E. et al. Constraint induced manual therapy and massed practice. Stroke. 2000; 31:983-991.

 University of Alabama (UAB). (2007). Constraint-induced manual therapy. Retrieved

March 18, 2009 from http://www.health.uab.edu/16193/

 Wolf, S. et al. Effect of constraint-induced movement therapy on upper extremity function 3 to 9

months after stroke. Journal of the American Medical Association. 2006; 296:2095-2103.
 Review Learning Objectives
 Describe Constraint-Induced Movement Therapy (CIMT) and
its uses
 Define “Learned Non-Use”
 Discuss the Hx of CIMT: (who originated it and how it was
originated)
 Describe the basic components of CIMT therapy
 Describe admission requirements for CIMT therapy
 Discuss the various outcome measures used in CIMT (Motor
Activity Log & Wolf Motor Function Test)
 Discuss the differences between CIMT & Modified CIMT
 Discuss the advantages/disadvantages of CIMT