Veterans International-Cambodia

A Project of the International Center

Effectiveness of Constraint Induced

Movement Therapy (CIMT) in
Hemiplegic Stroke and Cerebral
Palsy (CP) on Upper Extremity
Presented by Song Sit
Senior PT
October 26th 2009 1
A stroke patient is wearing a sling on his unaffected hand
whilst holding a rail with his affected hand

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A stroke patient is wearing a mitt on her unaffected
hand whilst writing with her affected hand

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Child is wearing an uninvolved
Child is wearing a sling
cast

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Child is in a plaster cast
Outline Presentation
1. Objective outcome
2. History of CIMT
3. Learned non-used
4. Application of CIMT
5. The Shaping Method
6. The Repetitive Task Practice method
7. Effectiveness of CIMT on Stroke
8. Effectiveness of CIMT on Hemiplegic CP
9. Outcome measures
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Objective Outcome
1. PT will understand the benefits of CIMT in
patients with stroke and hemiplegic CP.
2. PT will understand how to apply CIMT in their
practice with patients with stroke and
hemiplegic CP.
3. PT will understand the benefits of using
outcome measures (MAL and PMAL) when
working with people with stroke and hemiplegic
CP.

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 History of Constraint Induced
Movement Therapy ( CIMT)

z Developed at the University of Alabama

Birmingham in the late 1970s to 1980s
(Edward Taub, Director, CIMT Research
Group).[18]

z Began with basic research done on monkeys

where somatic sensation was surgically abolished
in one arm (dorsal rhizotomy) resulting in
somatosensory deafferentation (desensitized).
[18,19]

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 History of Constraint Induced
Movement Therapy ( CIMT)
z After somatosensory desensitization, monkeys
did not use their affected arm. [19]

z Hypothesis - the non-use of the affected arm

was a learning mechanism, termed “learned
non-use”. [4]

z After restraining the good arm in a sling, the

monkey subsequently used its desensitized arm
to feed and move itself around. [3]
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 Learned Non-Use
z Learned non-use develops during the early
stages following a stroke.

z Stroke patients begin to compensate for difficult

activities by using the unaffected arm, delaying
recovery of function in affected arm. [8]

z CIMT is based on the theory “ learned non-use”.

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 Application of CIMT

z Restrain unaffected arm by wearing

a sling, mitt or plaster cast.[8,20,23]

z Shaping (adaptive task practice) and /or

Repetitive task practice on affected arm
under supervision of PT or caregiver with
time limit.[23]

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 Shaping
z Also called “ Adapted Task Practice”.[23]

z Form of operant or instrumental conditioning

characterized by repetition a defined movement.
It is graded to slowly increase in difficulty.[14,16,23]

z Patient is coached and encouraged by therapist.

Increase successful number of repetitions or
reduce the time to complete the task demand
with effort.[9]

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 Shaping
z The patient is rewarded and encouraged for
improvement but is never blamed (punished) for
failure.[12]
z A basic principle is to keep extending motor
capacity a small added amount beyond the
performance level already achieved.[12]
z Eg.
{ Pick up block and move them toward a pail, in a series of 10
trails in a minute. Then increase a series of 15 trails after pt
achieved 10 trails.
{ Build up block as a tower in 10 cubes in a minute then increase
to 10 cubes in 30 seconds.

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 Repetitive Task Practice
z Efforts to perform movement are usually
repeated.[23]
z Tasks become more challenging and function.[23]
{ Eg. Eating, combing hair, brushing teeth, setting a
table or folding towels etc.
z Progression: in successive periods of task
practice, the spatial requirements of the activity
or other parameters (such as duration) can be
changed to require more demanding control of
limb segments for task completion.[23]
z Feedback about overall performance is provided
at the end of the period.[23]

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 Effectiveness of CIMT on Stroke
1. After one week of CIMT, van Der Lee, et al (1999) showed good
improvement of function in the affected arm. On follow-up after one
year, the effectiveness of CIMT was still evident. This study showed
that CIMT showed clinically significant results for activities in daily
living. This would be relevant to people with stroke and sensory
disorder and hemineglect after 2 weeks of CIMT.[21]
{ CIMT Group (24h except driving, sleeping, dressing and toileting)
{ Worn resting splint at home
{ Sling on unaffected arm during Rx 6hs/d
{ Intensive training
{ Same intensive bimanual training based on Neuro-developmental
Treatment (NDT).

2. Miltmer WH, et al (1999) showed this intervention has shown general

applicability for chronic motor deficits stroke in Germany.[13]
z Worn sling 90% of waking time a day for 12 days.
z Shaping 7hs/d for 8 days

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 Effectiveness of CIMT on Stroke
3. Dromerick AW et al (2000) showed CIMT was possible for applying on
acute stroke (14 days after stroke).[5]
{ OT group
z ADL, Strength, ROM and positioning
z Duration: 2hs/d, 2weeks
{ CIMT
z Wore mitt 6hs/d on unaffected arm
z OT as above
z Duration same as above
4. Wolf SL et al, (2006) produced statistically significant and clinically
relevant improvement in arm motor function after 2weeks and this
improvement persisted for up to 1 year for patients who were recruited for
the study 3-9 months after stroke.[22]
{ CIMT
{ Mitt worn 90% of waking time for 2 weeks.
{ Shaping and repetitive task practice 6hs/d for 2 weeks and
30mins at home.
{ Usual and Customary Care
{ Collect report by phone ( no Rx, Mechanical Rx (Orthotics), OT
and PT Rx and outpatient Visit at home)
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 Effectiveness of CIMT on Stroke
5. Lin KC et al. (2007) showed CIMT improved functional use of the affected
arm and daily functioning, motor control strategy during goal-directed
reaching. Possible mechanism for the improved performance of stroke
patient undergoing CIMT to compare with traditional rehabilitation for 3
weeks.[9]
{ CIMT Group
{ Mitt worn 6hs of waking time for 3 weeks.
{ Intensive training 2hs a day for 3 weeks.
{ Traditional Rehabilitation Group
{ Muscle strength, balance, fine motor skill, weight bearing on hand
and functional tasks 2hs a day for 3 weeks.
6. Dahl AE et al. (2008) showed CIMT seems to be an effective and
possible method to improve motor function in the short term, and able to
maintain the improvement for 6 months in stroke but no long-term effect
was found. [2]
{ CIMT
z Six hours arm therapy for 10 consecutive weekdays, while
z Using mitten on the unaffected hand.
{ Traditional rehabilitation

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 Effectiveness of CIMT on Stroke
7. Lin KC et al. (2009) compared a modified CIT intervention with a
dose-matched control intervention. This study showed the effects
in specific outcomes including increased motor function, basic and
extended functional ability, and quality of life sub-acute stroke
when applying a modified CIT intervention.[11]
{ CIMT
z restraint of the less affected limb combined with intensive training
of the affected limb for 2 hours daily 5 days per week for 3 weeks
z and restraint of the less affected hand for 5 hours outside of the
rehabilitation training.
{ A dose-matched control intervention ( Control group)
z The same duration: restraint of the less affected hand for 5 hours
outside of the rehabilitation training

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 Effectiveness of CIMT on Stroke
8. Brogårdh C et al (2009) showed the long-term benefit of
constraint-induced group therapy. Hand function was
maintained over time and daily hand use had increased
compared to pre-treatment in chronic stroke with mild to
moderate impairments of hand function in 4 years follow
up.[1]

z 14 patients were applied CIMT ( Wore mitt for 80 -90%

of waking hour and Shaping for 6hs a day) for 2 weeks.
z After 2 weeks, Patients were divided into 2 groups for 3
more months.
1. One group wore the mitt with the same duration as
above
2. Other group received no further Rx

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 Effectiveness of CIMT on Stroke
9. Lin KC et al (2009) showed Bilateral Arm Training may
individually improve proximal UL motor impairment. On the
contrary, applying CIT may produce better functional gains for the
affected UL in subjects with mild to moderate chronic
hemiparesis.[10]
{ In the study of Effects of Constraint-Induced Therapy Versus
BAT on Motor Performance, Daily Functions, and Quality of
Life in Stroke Survivors.
{ Groups:
z CIMT,
z BAT
z And a control intervention of less specific but active
therapy.
{ Each group received intensive training for 2 hours a day, 5
days a week, for 3 weeks.

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 Effectiveness of CIMT on hemiplegic CP

1. Taub E at el (2004) showed great improvement in

functional ability and quality of life and sustained
improvement 6 months after Rx in motor function in the
young children with hemiparesis CP (7ms-8ys) in the
study.[17]
{ CIMT Group
z Plaster cast of the child’s less-affected 24h
z Shaping for 6 hours a day for 21 days
{ Conventional Group
z PT and OT mean time 2.2h a day for 21 days

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 Effectiveness of CIMT in hemiplegic CP
2. Gordom AM et al (2006) showed CIMT improved movement
efficiency and environmental functional limitations in children with
hemiplegic CP (4-13 years) of varying ages and that this efficacy
is not age-dependent.[7]
{ Divided into 2 groups
z One group (4-8 year-old)
z Other group (9-14 year-old)
{ Each group received
z Sling worn 6 hours a day for 2 weeks
z Without restraining unaffected arm and doing exercise at
home 1 hour a day and extend to 2 hours a day after 1
month to 6 month intervention
z Shaping and Repetitive task practice with time calculation

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 Effectiveness of CIMT on hemiplegic CP
3. Deluca SC et al (2006) showed pediatric constraint-
induced therapy produced significantly greater gains
than usual rehabilitation services (PT and OT).[6]
{ CIMT
z Bivalved cast for 24 hours
z Shaping method, bearing weight on the arm,
reaching, grasping etc.. for 6hours a day for 3
weeks.
{ Conventional PT and OT an average duration
2.2h a week then crossed over to CIMT group.

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Effectiveness of CIMT on hemiplegic CP
4. Nascimento LR et al (2009) showed that
although the studies have small sample sizes
and methodological differences, this is
evidence supports the effectiveness of CIMT
on hemiparesis CP children.[15]
5. Gordon AM et al are conducting a new research of a
randomized control trial to test the efficacy of
constraint-induced movement therapy and a new
treatment involving bimanual (Hand-Arm Bimanual
Intensive Therapy (HABIT) which is starting in July
2007 and will be completed in February 2011 .[24]

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 Outcome measure
z Motor Activity Log (MAL)
{ Structured subjective interview with self-reported grade of the
amount (how often) and quality (how well) of affected arm use
for 30-item questionnaire (e.g., open a drawer, use a fork for
eating) of 30 daily activities in a 0-5 point scale.[20]

{ The MAL is reliable and valid in subacute stroke (3 to 12

months post-stroke and had mild to moderate paresis of an
UL).[20]

{ It may be used to assess the real-world effects of upper

extremity neurorehabilitation and detect deficits in
spontaneous use of the hemiparetic arm in daily life.[20]

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Motor Activity log Form

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Motor Activity log Form con’t…

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 Outcome measure
zPediatric Motor Activity Log (PMAL)
{Adapted from the Motor Activity Log (MAL)
developed for adult patients with stroke.[17]
{The PMAL is a semi-structured interview
administered every other day to a child’s
principal caregiver.[17]
{It obtains orderly figures about 22 different arm-
hand functional activities typical of young
children and assess on how often and how well
a child performs these activities.[17]

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Pediatric Motor Activity Log Form

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Pediatric Motor Activity Log Form

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 Relevant Video Showing

zHemiplegic CP child with CIMT Video

zStroke with CIMT Video

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 References
1. Brogårdh C, Flansbjer UB & Lexell J. What is the long-term benefit of constraint-induced
movement therapy? A four-year follow-up. Clinical Rehabilitation. 2009;23 (5): 418-423.
2. Dahl AE, et al. Short- and long-term outcome of constraint-induced movement therapy after
stroke: a randomized controlled feasibility trial. Clinical Rehabilitation. 2008;22(5): 436-447.
3. Doidge 2007, p. 139.
4. Doidge 2007, p. 141.
5. Dromerick AW, Edwards DF & Hahn M. Does Application of Constraint Induced Movement
Therapy During Acute Rehabilitation Reduce Arm Impairment After Ischemic Stroke? Stroke.
2000;31;2984-2988.

6. Deluca SC, Echols K, Law CR & Ramey SL. Intensive Pediatric Constraint-Induced Therapy
for Children With Cerebral Palsy: Randomized, Controlled, Crossover Trial. J Child Neurol.
2006;21:931—938.
7. Gordon AM, Charles J and Wolf SL. Efficacy of Constraint-Induced Movement Therapy on
Involved Upper-Extremity Use in Children With Hemiplegic Cerebral Palsy Is Not Age-
Dependent. Pediatrics. 2006;117;e363-e373.
8. Grotta JC, et al. Constraint Induced Movement Therapy. Stroke.2004;35[suppl I]:2699-2701.

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 References
9. Lin KC, et al. Effects of modified constraint-induced movement therapy on reach-to-grasp
movements and functional performance after chronic stroke: a randomized controlled study.
Clin Rehabil. 2007;21:1075.
10. Lin KC, Chang YF, Wu CY & Chen YA. Effects of Constraint-Induced Therapy Versus Bilateral
Arm Training on Motor Performance, Daily Functions, and Quality of Life in Stroke Survivors.
Neurorehabilitation and Neural Repair. 2009;23(5): 441-448.
11. Lin KC, et al. Constraint-Induced Therapy Versus Dose-Matched Control Intervention to
Improve Motor Ability, Basic/Extended Daily Functions, and Quality of Life in Stroke.
Neurorehabilitation and Neural Repair. 2009;23(2):160-165.
12. Miltner W H.R, Bauder H, Sommer M, Dettmers C and Taub E. Effects of Constraint-Induced
Movement Therapy onPatients With Chronic Motor Deficits After Stroke: A Replication.
America Stroke Association. 1999;30;586-592.
13. Miltner W H.R, et al. Effective of Constraint-Induced Movement Therapy on Patient With
Chronic Motor Deficits After Stroke A Replication. Stroke. 1999;30:586-592.
14. Morgan WG. The shaping game:a teaching technique. Behav Ther. 1974;5:271–272.
15. Nascimento LR, Glória AE & Habib ES. Effects of constraint-induced movement therapy as a
rehabilitation strategy for the affected upper limb of children with hemiparesis: systematic
review of the literature. Rev Bras Fisioter, São Carlos. 2009;13(2):97-102.

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 References
16. Skinner BF.The Technology of Teaching. New York, NY: Appleton-Century-Crofts; 1968.
17. Taub E et al. Efficacy of constraint-induced movement therapy for children with cerebral palsy
with asymmetric motor impairment. Pediatrics. 2004; 113:305-312.
18. Taub E, Harger M, Grier HC, Hodos W. Some anatomical observations following chronic
dorsal rhizotomy in monkey. Neuroscience. 1980;5:389-401.
19. Taub E, Heitmann RD, Barro G. Alertness, level of activity, and purposive movement following
somatosensory deafferentation in monkeys. Ann N Y Acad Sci. 1977;29”0:348-365.
20. Uswatte G et al. The Motor Activity Log-28. Assessing daily use of the hemiparetic arm after
stroke. NEUROLOGY. 2006;67:1189-1194.
21. van der Lee JH, et al. Forced Use of the Upper Extremity in Chronic Stroke Patients:Results
From a Single-Blind Randomized Clinical Trial. Stroke.1999;30;2369- 2375.
22. Wolf SL, et al. Effective of Constraint- Induced Movement Therapy on Upper Extremity
Function 3 to 9 Months After Stroke: The EXCITE Randomized Clinical
Trail.JAMA.2006;296(17):2095-2104.
23. Wolf SL. Revisiting Constraint-Induced Movement Therapy: Are We Too Smitten With the
Mitten? Is All Nonuse “Learned”? And Other Quandaries. Phys Ther. 2007;87:1212-1223.
24. http://clinicaltrials.gov/ct2/show/NCT00305006

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 Thanks
Any Questions???????
Please………

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