CIMT

1. CONSTRAINT INDUCED MOVEMENT
THERAPY(CIMT)
DR. MADHU

2. DEFINITION
 CIMT is a form of therapy that helps stroke and
CNS damage patients regain the use of affected
limbs by forcing the patient to use the affected
limb by restraining the unaffected one.
 The affected limb is then used intensively and as
a result of the patient engaging in repetitive
exercises with the affected limb, the brain grows
new neural pathways and movement and
function in the affected limb is proved.

3. CLINICAL USES
 CIMT has been used in
- Stroke
- TBI
- Cerebral palsy
- Focal hand dytonia

4. BASIS FOR CIMT
 Two different but linked mechanisms are
considered to be responsible for increased
use of the more affected extremities as a
result of CIMT.
1. Overcoming learned non use or
developmental disregard
2. Inducing use dependent cortical re-
organisation.

5. How it works
 The treatment is thought to work because it
overcomes a strong tendency not to use the
weaker arm(learned non-use) that develops
early after stroke.
 CIMT produces a large “rewiring” of the brain,
that is , after treatment more of the brain
works to move the weaker arm than before
the therapy.

6. Cortical re-organisation
 After CIMT, area surrounding the infract
(usually not used for hand control) get
recruited.
 These are synapses in the brain that are
previously not used for a particular function,
but have the potential for activation after the
usually dominant system has failed.
 Such neurons get utilized and , by repetition
and practice, can be set into constant use.

7. 1. Overcoming learned nonuse or
developmental disregard
CIMT is based on two fundamental principles-
(a) The constraint of the non affected limb
(b) Mass practice of activities with the affected limb
 Forced use of the affected limb through CIMT program,
removes the need for persistent prompting and may be a
more effective way of improving the outcome.
 CIMT attempts to change the contigencies of behavioural
reinforcement so that the learned non use or
developmental disregard of the more affected limb is
conditioned or lifted.

8.  Despite the conceptual difference in behavioural
adaptation (learned non use vs developmental
disregard) as a result of an acquired condition
(stroke) compared with the congenital
condition(CP), the components of CIMT program
including restraint and mass practice, aim to reverse
the behavioural suppress of movements in the
affected limb.
 The consequent increase in the use of the more
affected limb induces expansion of the contralateral
cortical area controlling movement of the more
affected limb and recruit new ipsilateral areas.
 This is proposed as the neural basis for the
permanent increase in use of affected limb
following CIMT.

9. 2. Inducing use of dependent cortical re-
organisation
CIMT improves motor function in the affected
extremity of patients with hemiplegia and results in
cortical changes in adults with stroke.
One of the mechanisms associated with improved
motor ability through CIMT is NEURO PLASTICITY.
CIMT produces functional changes in brain
meatbolism, blood flow and electric excitability.
These changes demonstrate that plastic changes of
the motor network occur as a neural basis of the
improvement subsequent to CIMT following brain
injury.

10. TYPES OF RESTRAINT
1. Holding a child’s arm
2. Glove or mitt
3. Forearm splints
4. Slings
5. Short arm casts
6. Long arm casts

11. COMPONENTS OF RETRAINING
PROGRAM
Classic constraint induced training defines two
types of training:
(a) Shaping or adaptive task practice
(b) Standard task practice

12. (a) Shaping or adaptive task practice
It derives its name from behavioural training technique.
It is a form of operant conditioning in which the probabilities of individual
determined behaviours are elicited through reinforcement(reward
or punishment).
Learner is passive in the process while performance is progressively
shaped as the behavioural objective (task goal) is approached in
small steps through reinforcement or reward(positive feedback).
Using this approach a motor objective(task goal) is approached in small
steps by successive approximations (part of the task), the task is
made more difficult in accordance with motor capability or the
speed of the performance is progressively increased.
Typically each functional activity or its part is practised for a set of 10trials
and explicit feedback is provided regarding the participants
performance with each trial.

13.  Shaping involved presenting intresting and useful
activities to the patient in ways that provide immediate,
frequent and repetitive rewards(primarily verbal praise,
smiles and supportive gestures) for the patients efforts
and increasingly functional use of the impaired
extremity.
 Tasks such as reaching, grasping, holding, manipulating
an object, bearing weight on the arm and making hand
gestures are derived into their small component skills
are worked on individually and later chained together to
comprise a target activity.
 When the patient demonstrates a new movement skill,
the therapist proceeds to shape this by increasing the
demands for more precision, strength, fluency,
automaticity and functional versatality.
 The therapist also incorporates everyday tasks(dressing,
eating, bathing and grooming) in the therapy sessions.

14. Shaping tasks are selected by considering-
 Family and patients goal
 Intrinsic motivating properties of an activity.
 Promotion of independence by acquisition of
appropriate self help skills.
 The movement that therapist believe has the
greatest potential for improvements.
When patents show signs of fatigue, frustration or
reduced interest, the therapist adopts the activities
but does not cease the therapy.Rest interval should
be given as needed. Intensive training is by far the
more important component of treatment
procedure.

15. (b) Standard task practice-
 It is less structured than shaping procedures.
 tasks are not set up to be carried out as individuals trials
of discrete movements.
 They involve functionally based activities performed
continuously fro a period of 15-20 minutes (setting the
table, wrapping a present).
 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 the limb segments for task
completion. Feedback about overall performance is
provided at the end of –min period.