Constraint-induced movement therapy (CIMT) involves restricting use of an unaffected limb while intensively training an affected limb for several hours per day. It is based on research showing that restricting use of a monkey's unaffected forelimb led to improved use of the affected limb. Studies in humans found that restricting an unaffected arm along with task-specific training of the affected arm improved function of that arm. The EXCITE trial, a large randomized controlled trial, provided strong evidence of CIMT's efficacy for improving arm function after stroke. While very effective, the intensive nature of CIMT presents challenges to implementation in clinical settings. Modified versions have aimed to address these issues.

1. Constraint-
Induced
Movement
Therapy (CIMT)

2. CIMT therapy is based on
research by Edward Taub,
Ph.D. and collaborators at
the University of Alabama.

3. Dr. Taub began with basic
research done with moneys in
which sensation was abolished
in one forelimb resulting in
somatosensory deafferentation.
After elimination of sensory
impulses monkeys did not use
the forelimb in the free situation
(problem is non-use).

5. REVERSING LEARNED NON-USE
• Restricting use of unaffected limb for
24 hours resulted in improved use of
affected limb.
• However reverted back to original
pattern of use once restriction
removed
• Restriction of use for longer period –
eg 1 week of 24 hour continuous
restriction – resulted in carry-over
once restriction removed. Limb use

6. • With addition of specific task
training, quality of limb activity
improved (not to “normal” but to
“very good”)
• (Taub, 1976, 1980)

7. TRANSFER TO HUMANS
• Initial studies looked only at the
constraint element
• Results were promising but
treatment effect small (Ostendorf
et al, 1981)
• Taub’s team implemented the
full protocol: constraint of
unaffected side and intensive

9. In 2006, the Extremity Constraint-
Induced Therapy Evaluation
(EXCITE) trial, were published and
showed statistically and clinically
relevant confirmation of the
efficacy of CIMT in patients with
post hemiparetic stroke.

10. EXCITE RCT (Wolf et al,
2006) Single-blind,
randomised multisite trial. 7
sites, 222 patients, 12 month
follow-up.

11. EXCITE trial
Restraint of the less impaired
upper extremity by donning a
protective safety mitt for 90% of
waking hours over a two-week
intervention period.
Subjects were also required to
participate in six hours/day (five

12. A large effect size for transfer of
treatment outcome to daily
activities is considered to be 0.8.
• Most studies of CI Therapy
were producing effect sizes of
between 2.1 to 4.0 (Taub, 2002)

13. Some researchers have
criticized this signature protocol
as being impractical in clinical
settings
Patient tolerance, mitt wearing
adherence, feasibility in clinics,
and reimbursement issues

14. In response to these critiques, a
number of “modified” versions
have arisen to address the
issues presented by the
signature form of CIMT.

15. CIMT protocols - Adult Criteria
• > 6 months post-stroke
• At least 10 degrees active wrist
and finger extension (from any start
position)
• Cognitive ability to engage in
treatment programme Protocol
• Constraint mitt worn 90%
waking hours
• 3 hours therapy a day, 5 days a

16. CIMT protocols - Children Criteria
• > 18 months old
• Ability to tolerate treatment
programme
• Enough activity to positively
participate in play
• Parents / carers who are able to
actively participate in programme and post-
treatment Protocol
• Non-removable cast worn for
duration (changed weekly)
• 3 hours therapy a day, 5 days a
week – play based

17. Repetitive task practice (RTP) is
continuous blocked practice of a
specific functional task, usually
for a period of 15–20 minutes.

18. Adaptive task practice (ATP), or
shaping, uses a step-wise
approximation method, breaking
down tasks into successive
manageable components to
improve overall proficiency

19. The present CI therapy
protocol, as applied in our
research and clinical settings,
consists of 3 main elements

20. 1) Repetitive, task-oriented
training of the more-impaired
UE for several hours a day for
10 or 15 consecutive
weekdays (depending on the
severity of the initial deficit)

21. 2) Applying a “transfer
package” of adherence-
enhancing behavioral
methods designed to transfer
gains made in the research
laboratory or clinical setting to
the patient’s real-world
environment;

22. 3) Constraining the patient to
use the more-impaired UE
during waking hours over the
course of treatment

24. Successful application of CIMT
is thought to induce a use
dependent
increase in cortical
reorganization of the areas of
the brain controlling the most
affected limb.

26. Boundaries of CIMT
• CIMT does not make movement
“normal”
• CIMT cannot restore motor
function to match unaffected side
• Effect of CIMT is determined by
severity of the initial impairment
• Taub (2007) – Retention rates
tend to be 70% at 6 months follow up.

27. CI therapy produces a
variable outcome that
depends on the severity of
the initial impairment.

28. Patients with higher function
have been found to retain their
treatment gains without
decrement for the two years that
they have been tested.

29. Patients with less higher
function do show a decrement of
~20% one year after treatment
and greater loss after two years.
This indicates that it might be
important to consider short
‘brush-up’ periods of training to
maintain the treatment gains in
these patients.

30. CIMT - expanding applications
• TBI
• Hemispherectomy (up to 10 years
post surgery)
• Congenital hemiparesis in adults
• Focal hand dystonia
• Nerve surgery
• Parkinson’s Disease
• MS
• Spinal cord injury
• Lower limb
• Speech