Constraint-Induced Movement Therapy (CIMT): Difference between revisions

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What is Constraint-Induced Movement Therapy or CIMT?[edit | edit source]

Constraint-Induced Movement Therapy (CIMT), also known as CI is a “rehabilitative strategy” aimed at improving functional use of an affected extremity. It uses principles of mass practice while restraining the neurologically stronger limb.[1]It is a behavioural approach to neurorehabilitation, making use of simple behavioural techniques – shaping being a predominant theme.[2]

CIMT has been described as including the essential components of rehabilitation following neurological injury, which comprise of:[2]

  1. Repetition – task orientated in manner.
  2. Constraining of patients, so as to induce use of the impaired limb or function.
  3. Application of a “package of behavioural methods” (pg 1, para 1) which allow the transference of skills learned in the clinical settings to that of the real-world environment.

While initially developed for the stroke population, it is also being used in populations affected by cerebral palsy, traumatic brain injury, phantom limb pain, focal hand dystonia in musicians and multiple sclerosis.[3]

CIMT therapy is based on research by psychologist, Dr. Edward Taub and collaborators at the University of Alabama. Dr. Taub demonstrated that monkeys with a surgical de-afferentation (i.e. where somatic sensation was abolished) of a forelimb, ceased using the affected extremity. Through failed attempts to use the de-afferented forelimb, the monkeys developed compensation methods to avoid using the affected limb, that is, they effectively learned not to use their affected extremity. Dr. Taub hypothesized that the non-use was a learning mechanism and calls this behavior “Learned non-use”. [4][5][6]

In the original concept, the less affected arm-hand was immobilized in a sling[7][8], but soon an emphasis on intensive, repetitive training (massed practice) of the more affected arm-hand evolved. In the current application of the method, the patients wear a mitt on the less-affected arm 90% of their waking hours and perform repetitive exercises with the more affected arm six to seven hours per day during two to three weeks [9][10].

The Learned Non-Use Phenomenon[edit | edit source]

It was observed that patients with hemiparesis did not use their affected extremity (hemi-neglecting) [11] . Taub and colleagues have investigated this phenomenon using basic research on monkeys. When one of the two forelimbs was deafferented, the animal stopped using the affected extremity. Taub et al concluded that the pattern with three-limb use, initially necessary after the spinal chock, was positively reinforced, whereas attempts to use the deafferented forelimb resulted in incoordination and failures [12]. It was postulated that the monkeys did not use the limb due to “learned non use”, or learned behaviour suppression. By immobilizing the intact arm for a period of consecutive days (1-2 weeks), the monkey started to reuse the deafferented forelimb again and “the learned non-use” was overcome [13]


Neurophysiologic basis for CIMT: The neurophysiologic mechanisms that are believed to underline treatment benefits of CIMT include overcoming learned nonuse and plastic brain reorganization. The brain changes itself when the affected extremity is involved intensively and repetitively for various activities [14]. The effect of CIMT is explained as

  • Cortical Reorganization
  • Dendrite branching
  • Redundancy Learned
  • Synaptic strength

The patients eligible for CIMT are:

  • Restraint of the less affected arm.
  • Massing of repetitive, structured, practice, intensive therapy in use of the more affected arm.
  • Monitoring arm use in life situations and problem-solving to overcome perceived barriers to using the extremity.
  • Behavioural agreement.
  • Treatment diary

The restraints commonly used for CIMT includes[15]:

  • Sling
  • Plaster cast
  • Triangular bandage
  • Splint
  • Sling combined with a resting hand splint
  • Half glove
  • Mitt

Requirements for Participation in CIMT[edit | edit source]

It was stated by researchers [16] to simply, follow 10 x 10 x 10 eligibility criteria in selecting a patient for CIMT:

  • 10 degrees active wrist extension on the affected hand
  • 10 degrees active thumb abduction on the affected hand
  • 10 degrees active extension of any other two digits on the affected hand

Also in order to CIMT be more beneficial, it was suggested that [17] :

  • Limited spasticity (0,1,1⁺) according to modified Ashworth scale.
  • Ability to move the affected arm 45 degrees of shoulder flexion and abduction, and 90 degrees of elbow flexion and extension.
  • Adequate balance.
  • Minimal cognitive dysfunction.

The treatment models are commonly explained in two methods:

1. Unmodified CIMT: Uses a variety of approaches that promote the affected limb for 90% of the individuals waking hours. Only activities involving toileting, hygiene and bathing are permitted. This is done by constraining or reducing the use of the unaffected extremity for 2-3 weeks. The most used Constraints of the upper extremity are that of a sling, mitts with Velcro or resting hand splints. [18][19]

2. Modified CIMT: This is more pragmatic model. The program consists of 3 hour per day for 5 days/week, for a minimum of 4 successive weeks. In total there will be 20 treatment sessions totaling to 60 hours. The client is expected to use his/her affected extremity for a minimum of the five “top arm use hours” at home during each week day. [20]

  • Overall greater improvement in function than traditional treatment.
  • Highly researched and highly credible treatment approach.
  • There are brain activity and observed gray matter reorganization in primary motor, cortices and hippocampus.
  • Increase social participation.
  • Decrease in medical cost over lifetime.

Few studies have reported harms associated with CIMT, such as burns, minor skin lesions and muscle soreness (stiffness and discomfort) in the affected upper extremity [23] . Shoulder pain in the acute phase after stroke has not been shown to increase after wearing a constraint. Patient endures many hours of frustration.[24]

The Evidence for Early Intervention[edit | edit source]

Early intervention is important because learning-induced brain plasticity at an early age seems to have a unique impact on brain development. Several researchers have demonstrated that activation and stimulation significantly affect neural activity in the sensory and motor cortex[25]. In young children, there are ongoing structural changes in the corticospinal system directed to hand function [26] . These observed changes are activity dependent[27] . In baby-CIMT, It can be benefit from advantage of the great plasticity of the young brain and recent knowledge of how to provide training with the aim of influencing future development of hand function[28] .

Evidence Based Practice of CIMT[edit | edit source]

Numerous studies show CIMT improves movement on the affected side. CIMT patients showed “large to very large” improvements in the functional use of their affected arm in their daily lives. Scores on a motor activity log (MAL). in which survivors and caregivers noted how well and how much survivors used their impaired arm in daily living improved an average of 1.8 points for those undergoing CIMT. Those in the control group reported no change. In addition, CIMT patients were able to speed their completion of tasks in lab testing while the placebo patients were slower.

Gains in upper extremity function after constraint-induced therapy have been reported in all stages after the onset of stroke[23] .

Chen et al. (2014)[29]: A systematic review and meta-analysis of forty-one RCTs, sixteen reviews, and two clinical guidelines that assessed the effectiveness of constraint induced movement therapy on upper extremity function in children with cerebral palsy.

El-Kafy et al. (2014)[30]: A RCT that examined the effectiveness of a mCIMT protocol in improving upper extremity function in children with congenital hemiplegic cerebral palsy.

Deluca et al. (2006)[31]: A randomized crossover trial of a new form of pediatric rehabilitation was conducted with 18 children with hemiparesis. Pediatric constraint-induced therapy produced significantly greater gains than conventional rehabilitation services.

Zafter et al. (2016)[32]: A RCT that examined the effectiveness of constraint induced movement therapy compared to bimanual therapy in upper motor function in children with hemiplegic cerebral palsy.

Gelkop et al. (2015)[33]: A matched-pair randomized trial that examined the effectiveness of mCIMT and Hand-Arm Bimanual Intensive Training (HABIT) protocols when provided in the school setting.

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  29. Chen, Y., Pope, S., Tyler, D., & Warren, G. (2014). Effectiveness of constraint-induced movement therapy on upperextremity function in children with cerebral palsy: A systematic review and meta-analysis of randomized controlled trials. Clinical Rehabilitation, 28(10), 939-953.
  30. El-Kafy, M. A., Elshemy, S. A., & Alghamdi, M. S. (2014). Effect of constraint-induced therapy on upper limb functions: A randomized control trail. Scandinavian Journal of Occupational Therapy, 21, 11-23.
  31. Deluca, S. C.; Echols, K.; Law, C. R.; Ramey, S. L. (2006). “Intensive Pediatric Constraint-Induced Therapy for Children with Cerebral Palsy: Randomized, Controlled, Crossover Trial”. Journal of Child Neurology. 21 (11): 931–8.
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  33. Gelkop, N., Burshtein, D. G., Lahav, A., Brezner, A., AL-Oraibi, S., Ferre, C. L., & Gordon, A. M. (2015). Efficacy of constraint-induced movement therapy and bimanual training in children with hemiplegic cerebral palsy in an educational setting. Physical and Occupational Therapy in Pediatrics, 35(1), 24-39.

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