Repetition and specific motor learning are key values for effectiveness in most therapy interventions after stroke. CIMT is one therapy intervention that is based on these values. (1)

The theory behind CIMT

CIMT is a neurorehabilitation approach for the paretic upper limb developed by Dr. Taub and his team. CIMT was first published in 1993 and is an acronym for constrained induced movement therapy. (1)

Improving upper limb function is a core element of stroke rehabilitation to reduce disability and enable independence in daily life.

After a stroke, patients tend to become unaware of their paretic upper limb and its potential function in daily life.
Improving arm use during everyday activities is vital to the quality of life and the main goal of CIMT. (2)

Background and how it works

The original version of CIMT was called “forced use therapy”. Taub’s concept included constraining the less affected arm for up to 90% during waking hours, followed by extensive task-oriented training of the affected arm up to 6 hours per day. Applying this method for 2 weeks (14 days) is meant to have a lasting impact on the daily use of the affected arm. (3,1)

CIMT and some other therapy methods such as mental practice and mirror therapy showed evidence that they are effective interventions for improving upper limb functions after stroke. (2)

However, research teams are still trying to maximize the patient’s outcome by optimizing therapy treatment.

One main obstacle in therapy is the transfer of function from therapy to daily life.
The quality of daily life only improves when the arm is used to accomplish everyday activities, but not through mere functional gain. (4)

Fundamental components

The main fundamental components of CIMT are:

  1. Intensive graded practice, repetitions and shaping practice (5)
  2. Constraining of the non-paretic upper limb or forced use of the paretic upper limb (1)
  3. Positive Reinforcement and Reward (6)
  4. Improving real-life functions (9)

Modified CIMT (mCIMT)

A feasible alternative to traditional CIMT is modified CIMT. It includes the same ideas as traditional CIMT but allows more flexibility. The primary difference is the lower level of intensity training.  One reason for modifying CIMT was to keep up patient compliance. Especially for the acute phase of stroke rehabilitation, modified CIMT enables an early start into CIMT. Follow up studies also show long term effects for up to one year. (3,7,8)

Over time, many forms of mCIMT were described in studies. By keeping the fundamental components, mCIMT has a meaningful impact on patient outcomes. The main variable factors are time, dosage and composition for therapy.
Furthermore, compared with traditional CIMT, modified CIMT may have a better outcome according to recent studies.  (1,3)

Learned non-use

Learned non-use is a phenomenon that was first described by Dr. Taub and his team. The underlying theory describes a spiral of function loss and unsuccessful movement attempts that lead to masked abilities and learned non-use.

Even though abilities and functions are present, they can or will not be used in daily life. Learned non-use can be measured by the difference between what a person can do, for example, in a therapy setting when required and what a person actually does spontaneous in daily life. (9)

By focusing on the single use of their paretic arm,  thought training overcoming this “learned non-use” is possible.

Can CIMT be something for every patient?

Yes and no.
Traditional CIMT has clear inclusion and exclusion criteria.
One important inclusion criterion for the traditional CIMT was a voluntary extension at the wrist and some minimal extension at the fingers. For safety reasons standing for at least 2 minutes with or without support should be possible. In addition, there are more general criteria including the mental state and general health of the patients. (1)

However, mCIMT includes a wider range of patients with more severe deficits.

New ways of CIMT

To gain higher patient compliance for mCIMT new ways of therapy were analyzed.
Gamification was introduced as a method to encourage continued engagement. For example, Wii-based movement therapy (deriving its name from the Nintendo Wii) was found to be effective as a strategy to boost motivation and compliance after stroke.
(10)

Another idea was to transfer the training from ambulatory care to the patient’s home. Home CIMT should encourage the use of the affected limb within the home environment. Evidence for this is still unclear. (11)

How I include CIMT into my therapy routine

For me as an OT in an early phase rehab setting, the principles of mCIMT are ever present. In stages were mCIMT is not possible yet, the ideas behind it can still be.
By creating positive learning moments were functions of the paretic limb are visible, learned non-use can be fought early.
Promoting the use of the affected limb, especially in everyday situations, can encourage spontaneous hand use.

I sometimes put a constraint like a washcloth, on the less affected hand while practicing repetitive tasks during therapy can promote the way for mCIMT later on.

One other thing that is really important to me in my therapy sessions is positive reinforcement. I sometimes feel like a cheerleader and the opponent player is “learned non-use”.

What are your thoughts on CIMT? Do you have experience with it?

Bibliography

  1. Kwakkel, G., Veerbeek, J. M., van Wegen, E. E. H., & Wolf, S. L. (2015). Constraint-induced movement therapy after stroke. The Lancet Neurology, 14(2), 224–234. https://doi.org/10.1016/S1474-4422(14)70160-7
  2. Pollock, A., Farmer, S. E., Brady, M. C., Langhorne, P., Mead, G. E., Mehrholz, J., & van Wijck, F. (2014). Interventions for improving upper limb function after stroke. Cochrane Database of Systematic Reviews, (11). https://doi.org/10.1002/14651858.CD010820.pub2
  3. Liu, X., Huai, J., Gao, J., Zhang, Y., & Yue, S. (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. https://doi.org/10.4103/1673-5374.215255
  4. Kelly, K. M., Borstad, A. L., Kline, D., & Gauthier, L. V. (2018). Improved quality of life following constraint-induced movement therapy is associated with gains in arm use, but not motor improvement. Topics in Stroke Rehabilitation, 25(7), 467–474. https://doi.org/10.1080/10749357.2018.1481605
  5. Abdullahi, A. (2018). Effects of Number of Repetitions and Number of Hours of Shaping Practice during Constraint-Induced Movement Therapy: A Randomized Controlled Trial. Neurology Research International, 2018, 1–9. https://doi.org/10.1155/2018/5496408
  6. Adcock, R. A., Thangavel, A., Whitfield-Gabrieli, S., Knutson, B., & Gabrieli, J. D. E. (2006). Reward-Motivated Learning: Mesolimbic Activation Precedes Memory Formation. Neuron, 50(3), 507–517. https://doi.org/10.1016/j.neuron.2006.03.036
  7. Shi, Y. X., Tian, J. H., Yang, K. H., & Zhao, Y. (2011). Modified Constraint-Induced Movement Therapy Versus Traditional Rehabilitation in Patients With Upper-Extremity Dysfunction After Stroke: A Systematic Review and Meta-Analysis. Archives of Physical Medicine and Rehabilitation, 92(6), 972–982. https://doi.org/10.1016/j.apmr.2010.12.036
  8. Takebayashi, T., Amano, S., Hanada, K., Umeji, A., Takahashi, K., Marumoto, K., … Domen, K. (2015). A one-year follow-up after modified constraint-induced movement therapy for chronic stroke patients with paretic arm: a prospective case series study. Topics in Stroke Rehabilitation, 22(1), 18–25. https://doi.org/10.1179/1074935714Z.0000000028
  9. Taub, E., Uswatte, G., Mark, V. W., & Morris, D. M. M. (2006). The learned nonuse phenomenon: implications for rehabilitation. Europa Medicophysica, 42(3), 241–56. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/17039223
  10. McNulty, P. A., Thompson-Butel, A. G., Faux, S. G., Lin, G., Katrak, P. H., Harris, L. R., & Shiner, C. T. (2015). The Efficacy of Wii-Based Movement Therapy for Upper Limb Rehabilitation in the Chronic Poststroke Period: A Randomized Controlled Trial. International Journal of Stroke, 10(8), 1253–1260. https://doi.org/10.1111/ijs.12594
  11. Barzel, A., Ketels, G., Stark, A., Tetzlaff, B., Daubmann, A., Wegscheider, K., … Scherer, M. (2015). Home-based constraint-induced movement therapy for patients with upper limb dysfunction after stroke (HOMECIMT): a cluster-randomised, controlled trial. The Lancet Neurology, 14(9), 893–902. https://doi.org/10.1016/S1474-4422(15)00147-7