Constraint-Induced Movement Therapy

Definition

Constraint-induced movement therapy (CIMT), which is also called CI therapy or forced-use therapy, is a rehabilitation treatment for patients who have had an ischemic stroke (characterized by narrowing or blockage of an artery in the brain) and suffer from muscular weakness on one side of the body (hemiparesis) or paralysis on one side (hemiplegia). It is also being tried as a therapy for children with cerebral palsy. As of 2005, CIMT is used to treat only the upper extremity—the arm or hand.

Purpose

CIMT has two major purposes. The first is the prevention of learned nonuse. Stroke patients who have lost part or all of the strength or function in one of their arms tend to stop using the affected limb and rely on the unaffected hand or arm. By forcing the patient to use the affected limb, CIMT reduces the risk of learned nonuse.

The second purpose of CIMT is to restore as high a level of functioning as possible to the affected hand or arm. Improvement of function not only helps the patient regain the ability to carry out some or all activities of daily life, it also lowers the patient's risk of developing a major depressive disorder, pain in the unused limb, or contractures, all of which are common sequelae of stroke.

Precautions

Some stroke patients should not attempt therapy with CIMT:

• Patients who lack motivation or are easily frustrated. CIMT is hard physical work, requiring up to six hours a day of exercises.
• Patients who are completely unable to bend and straighten the wrist and fingers of the affected arm.
• Patients who have lost so much of their memory after a stroke that they cannot follow two-step commands from the therapist.
• Patients who have had a severe hemorrhagic stroke (characterized by bleeding into the tissue of the brain from a ruptured blood vessel).

Another consideration for many patients is the high cost of CIMT. As of 2005, most insurance companies will not pay for this treatment. A week of CIMT therapy at the two major centers in the United States that offer it costs between $3,000 and $3,500, in addition to the costs of transportation, housing, and meals. The programs are expensive because of the many hours of time that the patient is actively working with physicians and physical therapists.

Description

The principle underlying CIMT was first demonstrated in 1917 by two scientists who were studying the recovery of laboratory monkeys whose brains had been surgically altered to produce hemiplegia. The scientists noted that the monkeys recovered more of the function in their paralyzed arms when their unaffected arms were restrained than they did when they were allowed free use of their unaffected arms. The researchers hypothesized that the parts of the animals' brains that control movement must have some capacity to be "rewired," that is, to develop new nerve pathways or even to increase the number of nerve cells in those areas of the brain. This capacity of the brain, which exists in humans as well as other mammals, is called plasticity. The first report of constraint-induced treatment of humans with hemiparesis or hemiplegia was published in 1981. As of the early 2000s, the researcher whose name is most frequently associated with CIMT is Dr. Edward Taub, a neuroscientist who directs a stroke therapy clinic at the University of Alabama at Birmingham. CIMT is presently used and studied in Germany, Scandinavia, and Thailand as well as in the United States.

CIMT consists of two steps, constraint and shaping. Constraint refers to placing the patient's unaffected arm in a sling or padded mitten to prevent using it. Shaping is a process in which the patient performs certain hand or arm movements over and over for several hours each day—in effect learning to use the arm or hand again. The specific movements used in shaping exercises are designed for each patient by a physical therapist. Later, the therapist will incorporate the movements that the patient is practicing into such activities of daily life as writing, picking up small objects, or managing buttons and other clothing fasteners.

Preparation

Preparation for CIMT requires a complete physical examination and an assessment by a neurologist to determine whether the patient can benefit from this form of therapy. Some patients may be given muscle relaxants or other medications prior to CIMT therapy.

Aftercare

Aftercare consists of a home exercise program to maintain the gains of the shaping exercises and to improve the patient's overall cardiovascular fitness. Patients return to the CIMT center after six months for a follow-up evaluation.

Complications

There are no reports of complications associated with CIMT as of the early 2000s.

Results

Results of CIMT therapy depend partly on the severity of the patient's stroke and the areas of the brain affected, and partly on the patient's compliance with the home exercise program. In addition, it is not yet known whether early use of CIMT (within the first 14 days after a stroke) has any advantages over later therapy (three months after the stroke). A group of researchers in Germany reported in 2005 that such differences as the timing of CIMT treatment, the patient's previous use of other types of post-stroke therapy, and the extent of the patient's sensory impairment did not affect outcome; in fact, almost all patients benefited from CIMT. Most researchers agree that more multicenter and long-term studies need to be done in order to answer such questions as whether the gains from this form of therapy are long-term or possibly permanent.

Health care team roles

In addition to physicians to monitor the patient's neurological symptoms and the side effects of any medications he or she may be taking, CIMT requires intensive participation by physical and occupational therapists. As the shaping exercises are tailored to each patient, the physical therapist must design movements that will benefit the patient, and later design ways to help the patient practice these movements in the context of his or her daily life. The therapist will also be involved in planning the patient's home exercise program.

KEY TERMS

Contracture— An abnormal persistent flexing or resistance to stretching of the muscles or tendons at a joint, usually caused by disorders of the muscle fibers or shortening of the muscles themselves.

Hemiparesis— Weakness or partial paralysis on one side of the body.

Hemiplegia— Paralysis on one side of the body.

Ischemic stroke— Stroke caused by narrowing or blocking of an artery to the brain, as distinguished from hemorrhagic strokes, characterized by bleeding from a ruptured blood vessel into the tissue of the brain. About 80 percent of strokes are ischemic strokes.

Learned nonuse— The tendency of stroke patients to stop trying to use a hand or arm weakened or partially paralyzed by a stroke and to rely instead on the unaffected limb.

Plasticity— The capacity of the nerve pathways in the brain to change their function, or to increase or decrease in number.

Sequela (plural, sequelae)— Any abnormal condition that results from a previous disease or disorder. Major depression and muscle disorders are common sequelae of stroke.

Shaping— A term that refers to the second part of CIMT treatment, in which the patient performs certain hand or arm movements repeatedly for lengthy periods of time.

Stroke— A blockage or rupture of a blood vessel leading to the brain, resulting in an inadequate supply of oxygen. A stroke may result in long-term impairment of balance, muscular strength, speech, memory, and emotional self-control.

Resources

BOOKS

"Cerebrovascular Disease," in The Merck Manual of Geriatrics, edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 2005.

"Rehabilitation for Some Specific Problems," in The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 2005.

PERIODICALS

Bonifer, N. M., K. M. Anderson, and D. B. Arciniegas. "Constraint-Induced Movement Therapy after Stroke: Efficacy for Patients with Minimal Upper-Extremity Motor Ability." Archives of Physical Medicine and Rehabilitation 86 (September 2005): 1867-1873.

Gordon, A. M., J. Charles, and S. L. Wolf. "Methods of Constraint-Induced Movement Therapy for Children with Hemiplegic Cerebral Palsy: Development of a Child-Friendly Intervention for Improving Upper-Extremity Function." Archives of Physical Medicine and Rehabilitation 86 (April 2005): 837-844.

Kononen, M., J. T. Kuikka, M. Husso-Saastamoinen, et al. "Increased Perfusion in Motor Areas after Constraint-Induced Movement Therapy in Chronic Stroke: A Single-Photon Emission Computerized Tomography Study." Journal of Cerebral Blood Flow and Metabolism 1 (June 2005).

Rijntjes, M., V. Hobbeling, F. Hamzei, et al. "Individual Factors in Constraint-Induced Movement Therapy after Stroke." Journal of Neurologic Rehabilitation 19 (September 2005): 238-249.

ORGANIZATIONS

American Stroke Association (ASA), National Center. 7272 Greenville Avenue, Dallas, TX 75231. (888) 478-7653. 〈http://www.strokeassociation.org〉.

Constraint-Induced Treatment Program, The Stroke Center, Washington University School of Medicine, Department of Neurology, 660 South Euclid Avenue, Box 8111, St. Louis, MO 63110-1093. Phone: (314) 454-7756. 〈http://www.neuro.wustl.edu/smart/citp.htm〉.

National Institute of Neurological Disorders and Stroke (NINDS). NIH Neurological Institute, P. O. Box 5801, Bethesda, MD 20824. (800) 352-9424 or (301) 496-5751. 〈http://www.ninds.nih.gov〉.

National Stroke Association (NSA). 9707 East Easter Lane, Building B, Englewood, CO 80127. (800) 787-6537. Fax: (303) 649-1328. 〈http://info.stroke.org〉.

Taub Therapy Clinic, University of Alabama at Birmingham (UAB). Center for Psychiatric Medicine, C-700, 1713 6th Avenue South, Birmingham, AL 35233. (866) 554-TAUB. 〈http://www.taubtherapy.com〉.

OTHER

Stroke Information Directory (SID). Online information resource about stroke, including treatments and clinical trials. 〈http://www.stroke-info.com〉.