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 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 . Overcoming learned non use Mechanisms of CIMT 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 Types of CIMT Restraining Tools for CIMT Minimal Requirement of hand function for CIMT 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. 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

1. C
CONSTRAINT INDUCED
MOVEMENT THERAPY
Dr. Quazi Ibtesaam Huma (MPT)
Dr. Suvarna Ganvir (Phd, Prof &
HOD)
Dept. of Neurophysiotherapy
DVVPF’s College of Physiotherapy

2. Content
• Introduction
• History of CIMT
• Components of CIMT
• Population for CIMT
• Advantages of CIMT
• Recent advances

3. Introduction
CIMT is treatment
technique that claims
to improve the arm
motor ability and the
functional use of
paretic hand

4. 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 .

5. 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

6. 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

7. Mechanisms of CIMT
Dendrite
branching
Cortical Re-
organization
Synaptic
strength
Redundancy
Learned

8. Population for CIMT
• Stroke
• Traumatic Brain Injury
• Spinal Cord Injury
• Multiple Sclerosis
• Cerebral Palsy
• Brachial Plexus Injury

9. 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

10. 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

12. 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

13. Restraining Tools for CIMT
SLING
SPLINT
HALF
GLOVES
MITT
TRIANGULA
R BANDAGE
PLASTER
CAST

14. 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

15. 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.

16. 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

17. • 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.

18. • 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.

19. 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

20. • 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

21. • 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.

22. 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).

23. • 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)

24. • 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.

25. 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.

26. • 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

27. • 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.

28. 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.

29. • 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.

30. THANK-YOU