Constraint Induced Movement Therapy

Introduction

The term constraint-induced movement therapy (CIMT) describes a range of interventions aimed at reducing the impact of stroke on upper extremity (UL) function in some stroke survivors. [1] This is a Learned-Nonuse-based behavioral approach to neurorehabilitation. [2]

CIMT is often performed on individuals following a cerebrovascular accident (CVA), as 30-66% of CVA survivors experience some loss of function in the injured extremity. [3] In addition, traumatic brain injury (TBI) in people with cerebral palsy (CP) and Multiple sclerosis (MS). The aim of CIMT is to improve and increase the use of the more affected limb while limiting the use of the less affected arm.

The three main components of CIMT include:[1]

• Intensive treatment with repeated structured exercises on the more affected arm.
• Restraint of the less affected arm.
• Apply a range of behavioral techniques to transfer benefits from the clinical setting to the real world (i.e. make it work).

History

The term is derived from studies of nonhuman primates in which somatosensory afferents of a single forelimb were reduced, after which the animal was unable to use that limb. Originally developed by Dr. Edward Taub, who demonstrated monkeys with surgical afferent blockade (i.e., somatosensory) Repealed) Forelimbs stop using the affected limb. [4][5] By using failed attempts to deafferent the forelimb, monkeys develop compensatory methods to avoid using the affected limb, i.e. they effectively learn not to use the affected limb called learning Do not use. [4][5]

Indication

Participants who had suffered a stroke needed some hand function, high motivation, minimal cognitive impairment, adequate balance, and adequate walking ability while wearing a restraint device to be eligible for the CIMT intervention. [5]

The minimum exercise criteria for inclusion in treatment are:[2]

• 10° wrist extension
• 10° thumb abduction
• 10° finger extension

Clinical Intervention

• Participants spent 90 percent of their waking hours wearing the glove on the less affected arm.
• Perform 6-7 hours of repetitive task-oriented training with the affected arm daily.
• Run for 10 – 15 consecutive business days.

There are 3 major components;

1. Shaping is a training method in which motor tasks become progressively more difficult. [4] The shaping plan is individualized and consists of 10-15 tasks chosen primarily from a set of basic tasks. [4] Each task is typically performed in a set of 10-30 s trials. At the end of each set of 10 trials The task is to change. Change only one integer parameter at a time. It requires constant therapist involvement.
2. Task practice is repeated practice of a single functional task and takes approximately 15-20 minutes. [4] Provide breaks as needed. Give encouragement infrequently (i.e. every 5 minutes) and provide feedback at the end of the task along with how they did. [4] Requires fewer healers participate.
3. Behavioral technology packages are designed to transfer clinical benefits to everyday life. [4] Include a behavioral contract that identifies the tasks that actors will attempt to perform. Furthermore, this allows for the identification of obstacles and problem solving to overcome them obstacle. Daily management of a motor activity diary promotes adherence.

[6]

Although the short- and long-term benefits of CIMT have been described, it is known that most people perform everyday skills more proficiently with one upper extremity. Therefore, pre-stroke upper limb dominance may interfere with acquisition and Maintenance of upper body skills due to specific patterns of brain activation or the amount of use of the upper body during daily activities. Twenty-two chronic stroke survivors with mild to moderate motor impairments each underwent 5 sessions of individual home mCIMT with and without trunk restraint Study three hours a day for two weeks. In this study, participants were divided into a dominant group in which upper extremity paralysis was the dominant group (n=8) before stroke and a non-dominant group (n=14) for analysis. Ability to perform one-handed tasks as measured by Wolf Motor Functional testing (WMFT) and motor activity log (MAL), while the ability to perform bimanual tasks was measured using the Bilateral Activity Assessment Scale (BAAS).

The authors concluded that upper body dominance did not interfere with the acquisition of upper body skills after mCIMT. However, participants with dominant upper extremity paralysis showed a better ability to maintain unilateral gains. Sustain Bilateral Improvement Regardless of upper body dominance.

Key Evidence

Home based modified CIMT [7]

Purpose – To compare the 4-week CIMT home program (CMIThome) and the two-week CIMT Classic program (CIMTclassic)

Method

• n = 7 chronic CVA patients (pts) per group
• CIMT Family – Initial one day training including mentoring from family members. The training is then performed in the patient’s home. 2 hours of daily training in the patient’s home under the supervision of an instructor family member for 20 consecutive days. 60% restraint of the unaffected hand waking hours. A physical therapist visits the pt’s home once a week to monitor and adjust exercises. Pts received a total of 15 hours of professional physiological supervision.
• CMIT CLASSIC – THE ORIGINAL TECHNOLOGY – 6 hours of training per weekday with a physiotherapist for two weeks. Overall 60 hours of professional supervision.
• Outcome measures taken immediately after the intervention and up to six months after the intervention. Results include the Wolf Motor Function Test (WMFT) and Motor Activity Log (MAL).

Results – WMFT and MAL motor function improved significantly after 6/12 and at 6/12 in both groups Clinical Application – Home program may be feasible and effective and requires less therapist supervision and therefore cost effective. Future studies require larger sample sizes.

Restraint-induced exercise therapy versus dose-matched intervention for upper extremity dysfunction in adult stroke survivors: a systematic review of meta-analyses [8]

Objective: To summarize the existing literature and examine the effects of restraint-induced exercise therapy (CIMT) versus dose-matched control interventions on upper extremity (UL) dysfunction in adult stroke survivors.

METHODS: CINAHL Cochrane Library Embase NARIC/CIRRIE-Rehabdata PEDro PubMed Scopus and Web of Science were searched from inception to February 2011. Trial quality was described using the PEDro scale. The findings were summarized by meta-analysis.

RESULTS: For the 22 trials identified, the mean (SD) PEDro score was 6.4 (1.2). Meta-analysis showed that CIMT was superior to dose-matched interventions based on UL exercise capacity (15 trials n=432; standardized mean difference [SMD]=0.47 95% CI 0.27–0.66) and UL capacity (14 trials n=352; SMD=0.80 95% CI 0.57–1.02); functional independence measure score (6 trials n=182; mean difference [MD]=5.05 95% CI 2.23–7.87); and locomotor activity diary score (using Quantity: 12 trials n=318; MD=1.05 95% CI 0.85–1.24; Movement quality: 11 trials n=330; MD=0.89 95% CI 0.69–1.08）。

Conclusions: Compared with a control intervention of the same duration and dose, CIMT produced greater improvements in various measures of UL function in adult stroke survivors with residual upper extremity motion.

Constraint-induced movement therapy (CIMT): current perspectives and future directions [9]

Constraint-induced movement therapy (CIMT) has gained considerable popularity as a therapeutic technique for upper extremity rehabilitation in patients with mild to moderate stroke. While substantial evidence has emerged to support the question of its applicability, questions about the best and best options remain unanswered The most practical way. Following the establishment of so-called “signature” CIMT methods, characterized by intensive clinical/laboratory practice-based approaches, several distributed forms of training comparison methods address limitations in the literature extracted from A PEDro review is recommended. Efforts by researchers to improve methods and standardize protocols can greatly assist practicing clinicians in analyzing EBP and incorporating best practices into clinical practice. Establishing a standardized optimal model to replace the CIMT protocol will It also allows stroke guidelines to make clearer, more specific recommendations for CIMT.

Effect of modified restraint-induced exercise therapy on recovery of stroke-affected upper extremity function: a single-blind randomized parallel trial – comparing group versus individual interventions [10]

Objective – To determine the effectiveness of modified CIMT in group therapy compared with individual interventions in improving use and function of the paralyzed upper extremity during ADL.

Method

• n=36 patients with stroke >6 months ago were randomized into two intervention groups.
• The independent variable was implementing a group or individual pattern for 3 hours for 10 consecutive days.
• Dependent variables were assessed at baseline (pre-intervention assessment), end (post-intervention assessment) and 6 months after the intervention (follow-up) by exercise diaries and action research arm tests.

RESULTS – Both types of intervention increased upper extremity function and use, and these increases were higher in group therapy. The effects of the group therapy approach were maintained for 6 months after the intervention ended.

Clinical implications – Using a modified CIMT in a group setting may be more effective than individual interventions. Further studies with larger sample sizes would be useful.