Modified Constraint

Description

Modified restraint-induced exercise therapy (mCIMT) is an intervention used to improve function and mobility of the more affected upper extremity after stroke. It is used as an alternative to the limitations of exercise therapy caused by the original constraints.

The original CIMT involved the restraint of an individual’s less impaired upper extremity using safety gloves. During the 2-week intervention period, mittens were worn 90% of the time each day, along with 6 hours of task-specific training per day, 5 days per week. [1] CIMT is Intensive and sometimes difficult patients sometimes tire of wearing gloves [2] compromising adherence to the protocol. A survey showed that patients prefer longer durations, fewer sessions, or restrictive devices such as Mitten [3] Other barriers to implementing the original CIMT protocol include resource intensity and cost of the treatment protocol. The therapist has determined that time requirements make it difficult to create a challenging 6-hour schedule and interfere with other duties and other patients Caseload as a barrier to using the original CIMT protocol [4]. The modified CIMT (mCIMT) protocol was developed as an alternative to the intensive nature of CIMT and involves less time utilizing constraints over longer intervention periods [3].

Both mCIMT and CIMT aim to address learning disuse and motor decline in the upper extremity affected by post-stroke/CVA. [5] The patient/client is expected to use the more affected upper extremity for daily activities and the less affected upper extremity In the restrained state the patient performs gross motor tasks, fine motor tasks and ADL during the intervention. [5]

Components of mCIMT

Current evidence explores many different formants of mCIMT for stroke rehabilitation.

These protocols differ in practice and binding time; however, all share three basic components of therapeutic intervention derived from the original CIMT.

The three basic components used in each session of mCIMT are [6]:

1. Use gloves to restrain the less affected upper extremity.
2. Repetitive Task Practice.
3. Application of behavioural techniques
   • Shaping is considered the most important technique:
     • Shaping involves matching the difficulty of performing the task to the improvements made by the patient and providing encouraging feedback immediately after any gain in function [7].
     • The shaping task is determined by the therapist based on the following factors: the individual movement deficit of the specific joint, the joint motion that the therapist believes is most likely to be improved, and the patient’s preference for the specific task that produces said motion [8]. As plastic progresses The movement tasks are carried out in a systematic, quantified and parameterized manner for individual tasks for the patient. This makes the intervention time and meaningful to the patient/client, and positive – as feedback is always positive and encouraging is rarely negative [8].

The timing of mCIMT application varies in the literature. An earlier study described a structured session of functional task-specific exercises lasting 30 minutes with 5 hours of restriction on the less affected side, 5 days per week for 10 weeks [3]. 2011 meta-analysis and review of mCIMT Including a modified approach, intensive therapy limited to less than 6 hours per day, ranging from 30 minutes to 3 hours per day, with an intervention period of 2 to 10 weeks. [9]

A second comprehensive meta-analysis outlined three 30-minute sessions of mCIMT per week for 10 weeks. [6]

mCIMT includes a distributed practice program, while CIMT uses centralized practice. The mCIMT protocol involves reducing the therapist’s clinical time and providing patients with more time for home exercises using the more affected upper extremity functionally and in activities of daily living. [6]

Indications

According to Canadian best practice guidelines, mCIMT (similar to CIMT) therapy is recommended for post-stroke patients who have minimal sensory and cognitive deficits and are able to demonstrate at least 20° of active wrist extension and 10° of active finger extension. [10]

Outcome Measures

The most commonly used outcome measures along with mCIMT throughout the literature include the Fugl-Meyer assessment and the Functional Independence Measure (FIM) for disability and action research for motor function [9][11].

Other outcome measures used to quantify the progression of mCIMT interventions in individuals who have experienced stroke include:[11]

Measures of disability:

• Functional Independence Measure
• Barthel Index (BI)

Measures of arm motor function:

• Wolf Motor Function Test (Score Only) (WMFT)
• Action Research Arm Test (ARAT)
• Arm Motor Ability Test (AMAT)
• Emory Function Test (EMF)
• Assessment of Motor and Process Skills (AMPS)
• The Box and Block Test (BBT)

Measures of sensory arm motor function:

• Motor activity log (MAL)
• Amount of use (AoU)
• And quality of use (QoU)

Measures of arm motor impairment:

• Fugl Meyer Assessment (FMA)
• Chedoke McMaster Impaired Inventory (CMII)
• Hand strength

Measures of dexterity:

• Nine Hole Nail Test (NHPT) [low score indicates positive result]
• Grooved pegboard test (GPT)

Measures of quality of life:

• Stroke Impact Scale (SIS)

Evidence

Multiple studies have found that mCIMT improves function of the affected upper extremity after stroke. It was found that the mCIMT program can significantly improve disability, significantly improve upper limb function, and is an overall effective intervention for upper limb recovery after stroke [9][6]. A recent randomized controlled trial found that 4 weeks of mCIMT was effective in improving motor function and performance in ADLs. [12][13]. In addition, mCIMT has also been shown to be effective in improving balance and gait in post-stroke hemiplegic patients [14]. There are also studies showing Performing aerobic exercise prior to m-CIMT improves outcomes [15].

A single-blind randomized parallel study found that both individual and group mCIMT increased upper extremity function and use, with higher increases in group mCIMT [16].

Compared to raw CIMT, in particular meta-analysed evidence suggests that mCIMT is equally influential in promoting recovery of use and function of the affected limb after stroke. [9] Furthermore, the reduction in clinical time and resource usage involved in mCIMT makes it easier and Management by therapist and patient/client is more feasible [9]. This review examined the literature on the 10-week mCIMT regimen, showing that it is an effective treatment for promoting upper extremity recovery after stroke [9]. The resulting measure used (Fugl-Meyer’s UE ARAT Movement Log (MAL)) both showed positive improvements in upper extremity impairment and function in patients using the mCIMT protocol. In most of the studies analyzed, the mean magnitude of change in patients was greater than the MCID for the outcome measure used demonstrated that patients undergoing mCIMT had changes in UE function that were clinically meaningful compared to controls or no treatment [9].

A randomized controlled clinical trial specifically exploring the effects of mCIMT on acute subcortical infarcts found that it resulted in significant functional changes in timed movements and improved ipsilateral cortical excitability [17]. In addition, mCIMT has been found to significantly improve Functional use of the affected limb in chronic hemiplegic stroke patients, it is effective for upper limb hemiplegia compared with conventional treatment [18]. Furthermore, the effectiveness of UE recovery has been observed in all phases of post-stroke recovery [9] seeing this as It is important to note that although effectiveness has been shown by studies of all stages of post-stroke recovery, most evidence comes from studies of chronic stroke populations. This was determined to be moderate level of evidence [9]

A literature review combining findings from studies of restraint-induced exercise therapy (original restraint-induced exercise therapy and modified restraint-induced exercise therapy) in adult stroke patients found more encouraging results for mCIMT because it included a longer The training sessions allow enough time to adapt to new changes [19].