Constraint-Induced Movement Therapy for Restoration of Upper-Limb Function: Introduction

Abstract

Constraint-induced movement therapy (CIMT) is a research-originated, behavioral approach to neurorehabilitation of limb function after neurologic damage. The intervention utilizes a combination of motor training elements and psychological concepts to facilitate increased use of the affected limb as well as improved movement quality and control. Importantly, CIMT is designed to achieve real-world improvements by behavioral methods, which facilitate the incorporation of regained abilities into the person’s spontaneous behavior. CIMT is composed of four primary elements: (1) repetitive, unilateral training procedures; (2) training by the behavioral technique termed shaping; (3) a set of behavioral techniques, termed the “transfer package,” that promote transfer of therapeutic gains to the life situation; and (4) constraining use of the more-affected hand by one of several techniques including restraint of the less-affected hand, discouragement for exclusive reliance on the less-affected hand for unimanual and bimanual tasks, and purposeful design of the CIMT treatment activities to encourage use of the more-affected hand. Evidence shows that CIMT improves the functional use and occupational performance of the more-affected upper extremity by reversing learned nonuse and facilitating use-dependent brain plasticity.

Before starting Constraint-Induced Movement Therapy, it was hard to remember to use my weaker hand for everyday things, but now I just use it without having to think about it.

Client

Appendices

The Case Study of Mrs. W

Keywords

Motor skills, neuronal plasticity, rehabilitation, stroke

Introduction

The theme of this case study is the use of constraint-induced movement therapy (CIMT) for upper extremity (UE) rehabilitation of an adult following stroke.

To better understand this case study we recommend review of the following key references:

• Taub E, Miller NE, Novack TA et al. (1993) Technique to improve chronic motor deficit after stroke. Arch Phys Med Rehabil 74:347–354

• Morris DM, Taub E, Mark VW (2006) Constraint-Induced Movement therapy: characterizing the intervention protocol. Euro Medicophys 42(3):257–268

• Taub E, Uswatte G, Mark VW et al (2013) Method for enhancing real-world use of more affected arm use in chronic stroke transfer package of Constraint-Induced Movement therapy. Stroke 44(5):1383–1388

• Gauthier LV, Taub E, Mark VW, et al (2009) Improvement after Constraint-Induced Movement therapy is independent of infarct location in chronic stroke patients . Stroke 40 (7):2468–2472

Overview of Content

The major goal of UE CIMT is to enable patients to make substantial gains in real-world spontaneous use of the more-affected arm and hand. This is achieved primarily by overcoming learned nonuse of the more-affected UE, but improvements in quality of movement also occur.

Background of the Clinical Case Study

Personal Information

Mrs. W is a 53-year-old African-American right-hand dominant woman. She is a high-school graduate and worked as a housekeeper prior to her stroke. She is divorced and lives in her own home where she is independent with her activities of daily living (ADLs).

Medical and Disability Status

She is status post right cerebral infarction sustained 1 year prior to her OT evaluation resulting in left-sided hemiparesis. Her past medical history includes hypertension, anemia, depression , and seasonal allergies.

Intervention

An assessment with Mrs. W determined that she had mild-to-moderate UE AROM (grade 2) of her left UE and that she demonstrated a deficit in use of the more-affected UE as measured by the MAL. Since she met the AROM criteria and appeared to display learned nonuse of her left UE, it was determined that it would be appropriate for her to participate in a grade-2 CIMT offered in an outpatient setting.

After pretreatment testing, she underwent a CIMT Protocol lasting 3.5 h, 5 days a week for 2 weeks. Treatment consisted of all four components of CIMT: intensive UE training, use of the training technique known as shaping that focused on improving motor ability of left UE, implementation of the adherence-enhancing transfer package that promoted gains in the clinical setting to be realized in her real-world environment, and techniques to constrain use of her more-affected UE, which included using a padded mitt which restrained use of the less affected UE. After treatment, Mrs. W was retested to determine changes in the functional use and motor ability of her left UE. She showed substantial improvement on the MAL, going from scores on the Amount Scale (AS) of 0.3 and How Well (HW) Scale of 0.7 pretreatment to scores on AS of 3.6 and HW of 3.7 at posttreatment; treatment changes of 3.3 and 3.0, respectively. Prior to CIMT, she used her arm for 10/29 items on the MAL and by the end of treatment she used it for 26/29 items. Her left UE motor ability also improved as measured by the Wolf Motor Function Test (WMFT); her median performance time decreased from 4.4 to 1.2 s and her mean functional ability score improved from 3.2 to 4.2. At 2 years following her treatment, she was found to have kept the gains that she made in CIMT in UE function and motor ability. She reports that she is using her hand for just about everything and that she is enjoying time with her grandchildren.

The Student’s Report

The following questions prompt the student to consider why CIMT was appropriate for Mrs. W. The listed references are resources for answering these questions.

• What is CIMT?

• What are the four components of CIMT?

• What is learned nonuse?

• What assessments are used for measuring changes in UE function after CIMT?

• Can a 2-week therapeutic rehabilitation intervention like CIMT result in structural changes in the brain?