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constraint induced movement therapy.pptx

Constraint-Induced Movement Therapy (CIMT) is designed to enhance motor function and the use of the affected arm in individuals with neurological conditions such as stroke and multiple sclerosis, based on the concept of overcoming 'learned non-use.' The therapy promotes intensive practice of the affected limb through the restriction of the less affected arm, demonstrating significant improvements in functional abilities and quality of life in patients. Recent studies highlight its effectiveness and potential benefits when combined with aerobic exercise prior to therapy.

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C CONSTRAINT INDUCED MOVEMENT THERAPY Dr. Quazi Ibtesaam Huma (MPT) Dr. Suvarna Ganvir (Phd, Prof & HOD) Dept. of Neurophysiotherapy DVVPF’s College of Physiotherapy
Content • Introduction • History of CIMT • Components of CIMT • Population for CIMT • Advantages of CIMT • Recent advances
Introduction CIMT is treatment technique that claims to improve the arm motor ability and the functional use of paretic hand
History of CIMT • CIMT is based on research by Edward Taub ,his hypothesize that the non use was a learning mechanism and calls this behavior “Learned non-use”. • It was observed that patients with hemiparesis did not use their affected extremity .
Taub and colleague investigated using basic on monkeys • One of the two forelimbs was deafferented, the animal stopped using the affected limb Taub et al concluded that the pattern of three limb use. • It was postulated that the monkeys did not use the limb due to learned non use phenomenon By immobilizing the intact arm for a period of consecutive days • The monkeys started to reuse the deafferented forelimb again and the learned non-use was overcome
Overcoming learned non use Learned non-use Masked recovery of limb use Increased motivation access function Positive Reinforcement Affected limb use Further practice More reinforcement Limb use in life situations
Mechanisms of CIMT Dendrite branching Cortical Re- organization Synaptic strength Redundancy Learned
Population for CIMT • Stroke • Traumatic Brain Injury • Spinal Cord Injury • Multiple Sclerosis • Cerebral Palsy • Brachial Plexus Injury
Advantages of CIMT • Overall greater improvement in function than traditional treatment. • Highly researched and credible treatment approach. • There are brain activity and observed gray matter reorganization in primary motor, cortices and hippocampus. • Increase social participation
Components Of CIMT Restraint from less affected arm Massing of repetitive, structured, practice, intensive therapy in use of the more affected arm. Monitoring arm use in life situation and problem solving to overcome perceived barriers to using the extremity. Behavioural agreement. Treatment Diary
Types of CIMT Traditional CIMT 90% use of Affected limb of the individuals waking hours Activities involving toileting, hygiene, bathing for 2-3 weeks Modified CIMT This is more pragmatic model which consists of goal directed therapy sessions. It consist of 3 hours per day for 5 days/week for minimum of 4 successive weeks
Restraining Tools for CIMT SLING SPLINT HALF GLOVES MITT TRIANGULA R BANDAGE PLASTER CAST
Minimal Requirement of hand function for CIMT at least 10° of extension in at least two additional digits at least 10° of thumb abduction/extension 10° of active wrist extension 20 degrees of active wrist extension, 10 degrees of active finger
Recent Advances • The EXCITE Trial: Retention of Improved Upper Extremity Function Among Stroke Survivors Receiving CI Movement Therapy.(2008) • The Extremity Constraint Induced Movement Therapy Evaluation (EXCITE) demonstrated that CIMT administered 3-9 months post-stroke, resulted in statistically significant and clinically relevant improvement in upper extremity function during the first year compared to those achieved by participants undergoing usual and customary care. • This study was the first randomized clinical trial to examine retention and improvements for the 24 month period following CIMT therapy in a subacute sample.
Higher functioning patients Lower functioning patients • The patient should extend the wrist at least 20° • The metacarpophalangeal and interphalangeal joints of each digit by at least 10° • 10° of active wrist extension, • at least 10° of thumb abduction/extension • at least 10° of extension in at least two additional digits
• Study design - single masked cross-over design, with participants undergoing adaptive randomization to balance ,gender, prestroke dominant side, side of stroke, and level of paretic arm function across sites. • CIMT was delivered up to 6 hours per day, 5 days per week for 2 weeks. • Subsequent evaluations were made after the two week period, and at 4, 8, and 12 months. • Because the control group was crossed over to receive CIMT after one year. • Primary outcome measures – Wolf Motor Function Test Motor Activity Log Secondary outcome measure - Stroke Impact Scale (SIS) were assessed at each of these time intervals, was administered only at baseline, 4, 12, 16 and 24 month evaluations.
• Result :There was no observed regression from the treatment effects observed at 12 months after treatment during the next 12 months for the primary outcome measures of WMFT and MAL. • In fact, the additional changes were in the direction of increased therapeutic effect. For the strength components of the WMFT the changes were significant (P < .05) Secondary outcome variables, including the SIS, exhibited a similar pattern. • Conclusion: Mild to moderately impaired patients who are 3-9 months post-stroke demonstrate substantial improvement in functional use of the paretic upper extremity and quality of life 2 years after receiving a 2-week CIMT intervention. Thus this intervention has persistent benefits.
Constraint-Induced Therapy Combined with Conventional Neurorehabilitation Techniques in Chronic Stroke Patients with Plegic Hands: A Case Series Arch Phys Med Rehabil. 2013 January ; 94(1): 86–94. • Objective—To determine in this pilot study whether the combination of CI therapy and conventional rehabilitation techniques can produce meaningful motor improvement in chronic stroke patients with initially fisted hands. In the past, limited success has been achieved using CI therapy alone for stroke patients with plegic hands. • Design—Case series • Setting—University hospital outpatient laboratory • Participants—Consecutive sample of 6 patients > 1 yr post-stroke with plegic hands
• Intervention - standard CI therapy protocol was modified so that it would be applicable to patients • Phase A: to use of orthotics/splints and adaptive equipment outside the laboratory. Device selection and instruction for individual subjects was conducted in six 2-hr sessions distributed over this period. The purpose of orthotics and splints was to maintain the fingers/wrist in better alignment to enhance the use of the arm and hand in activities of daily living (ADL). • Phase B: use of the Phase A devices was continued, and in addition CI was administered for 15 consecutive weekdays combined with neurodevelopmental treatment (NDT) techniques for managing tone and facilitating movement (e.g., tapping, weightbearing, placing and holding)23 well as use of ice baths and vibration. Treatment was carried out in 3-hour morning and afternoon sessions separated by a 1-hour lunch period. Rest breaks were provided as needed. Weight-bearing and stretching procedures were given for 1 hour at the beginning of each of the 2 daily sessions
• The use of both upper extremities was included in selected ADL practice. Some ADL practice focused on training the more-affected arm as a “helper” or gross assist during everyday activities (e.g., use of the more-affected hand to stabilize containers while the less affected hand opened the lids, opening cabinets using adaptive drawer straps, and holding a checkbook or receipts down while signing. • ADL practice also involved training in using the more-affected arm alone in the performance of more easily accomplished tasks, such as flipping a light switch and pushing open a door. • Main Outcome Measures—Motor Activity Log (MAL), accelerometry, Fugl-Meyer Motor Assessment (F-M) • Results— Patients exhibited a large improvement in spontaneous real-world use of the more affected arm.
Constraint-induced movement therapy in multiple sclerosis: Safety and three- dimensional kinematic analysis of upper limb activity. A randomized single-blind pilot study(2019) by Alessandro de Sire et al • OBJECTIVE: To evaluate safety and effectiveness of a 2-week CIMT protocol on upper limb activity of progressive MS patients through a three-dimensional (3D) kinematic analysis. • 2 groups: CIMT Group Control group • Outcome Measures: • clinical outcomes -hand grip strength, HGS, and 9 Hole Peg Test, 9HPT • 3D kinematic analysis (normalized jerk, number of movement units, going phase duration, mean velocity, endpoint error).
• Set of exercises that both groups have to perform: CIMT group with only one arm and control group bimanually 1 Brush hair to all wide (using the same comb) 2 Put a pen into a glass and remove it (using the pinch of the first/second finger) 3 Turn over 5 pages of a magazine 4 Turn over 5 playing cards and turn them again 5 Pile up 3 rubber shapes 6 Put water from a glass to another (using the same glass and same level of water) 7 Copy 2 geometric shapes 8 Open a box, remove the contained object then put it inside again 9 Get out a Compact Disk from its case 10 Screw off a bottle top, put it on the table then regain it and screw it again (bottle is full of water)
• CIMT group, that underwent a 2-week experimental protocol with the less affected limb blocked by a splint to prevent the use of the arm for 90% of waking hours; control group, performing the same rehabilitation exercises with the aid of both arms, without any block. • They were asked to complete the set twice per hour, for 5 hours per day, for 12 days (6 consecutive days/week), for a total of 120 sets of exercises per patient. • RESULTS: Ten MS patients, mean aged 51.0±7.7 years, were randomly allocated in the 2 groups. After treatment, no differences were found in the blocked arm. Furthermore, CIMT group showed significant improvements in clinical and kinematic parameters. • CONCLUSION: CIMT might be considered as a safe and effective treatment in in progressive MS patients, considering that the blocked limb did not worsen its performance.
Effect of aerobic exercise prior to modified constraint-induced movement therapy outcomes in individuals with chronic hemiparesis: a study protocol for a randomized clinical trial by Erika Shirley et al (2019) • Objective: To determine whether priming with moderate-high intensity aerobic exercise prior to m-CIMT will improve the manual dexterity of the paretic upper limb in individuals with chronic hemiparesis. • Sixty-two individuals with chronic hemiparesis will be randomized into two groups: 1) Aerobic exercise + m-CIMT 2) Stretching + m-CIMT. • m-CIMT includes 1) restraint of the nonparetic upper limb for 90% of waking hours, 2) intensive task-oriented training of the paretic upper limb for 3 h/day for 10 days and 3) behavior interventions for improving treatment adherence. Aerobic exercise will be conducted on a stationary bicycle at intervals of moderate to high intensity.
• Participants will be evaluated at baseline, 3, 30, and 90 days postintervention by the following instruments: • Motor Activity Log, Nottingham Sensory Assessment, Wolf Motor Function Test, Box and Block Test, Nine-Hole Peg Test, Stroke Specific Quality of Life Scale and three- dimensional kinematics using Three-dimensional Motion Analysis (3DMA) of three functional activities will be quantified using the optoelectronic ProReflex Motion Capture System
• Intervention: 1. CONTROL GROUP: exercise will consist of bilateral, intermittent, passive muscle stretching, 3 repetitions with 30-s duration and 60-s intervals between each repetition will be performed for each stretching exercise. 2. Stretches will be executed for the following muscle groups: hip flexors, knee extensors, ankle flexors, elbow flexors, wrist and fingers flexors. 3. iNTERVENTION GROUP: The protocol consists of intensive training for 3 h per day for 10 days (two weeks, excluding weekends) and Aerobic Exercises as per American Heart Association guidelines.
References • O Sullivan S.; Physical Rehabilitation;6th Edition. • Erika Shirley Moreira da Silva, Gabriela Lopes Santos, Aparecida Maria Catai, Alexandra Borstad, Natália Pereira Duarte Furtado, Isabela Arruda Verzola Aniceto and Thiago Luiz Russo, Effect of aerobic exercise prior to modified constraint-induced movement therapy outcomes in individuals with chronic hemiparesis: a study protocol for a randomized clinical trial; BMC Neurology (2019) 19:196. • Steven L. Wolf, Edward Taub; The EXCITE Trial: Retention of Improved Upper Extremity Function Among Stroke Survivors Receiving CI Movement Therapy; Lancet Neurol. 2008 January ; 7(1): 33–40 • Edward Taub, Gitendra Uswatte; Constraint-Induced Therapy Combined with Conventional Neurorehabilitation Techniques in Chronic Stroke Patients with Plegic Hands: A Case Series; Arch Phys Med Rehabil. 2013 January ; 94(1): 86–94.
• S. dos Anjos; Constraint-Induced Movement Therapy for Lower Extremity Function: Describing the LE-CIMT Protocol; October 7, 2019 • Taub E., Uswatte G. Constraint-induced movement therapy: A paradigm for translating advances in behavioral neuroscience into rehabilitation treatments. Handbook of neuroscience for the behavioral sciences (Vol. 2, pp. 1296-1319) 2009. • Richards L., Gonzalez Rothi LJ, Davis S.,Limited dose response to Constraint-Induced Movement Therapy in patients with chronic stroke. Clinical Rehabilitation. 20:1066-1074 2009. • Hakkennes S; Keating JL ,Constraint-induced movement therapy following stroke: A systematic review of randomised controlled trials. Australian Journal of Physiotherapy 51: 221–231,2005. • Taub E., Somatosensory deafferentation research with monkeys: implications for rehabilitation medicine, Behavioral Psychology in Rehabilitation Medicine, Clinical Applications, Baltimore:William and Wilkins 371-401 1980.
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