Constraint-induced movement therapy

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Constraint-induced movement therapy
Specialty Neurology

Constraint-induced movement therapy (CI, CIT, or CIMT) is a form of rehabilitation therapy that improves upper extremity function in stroke and other central nervous system damage patients by increasing the use of their affected upper limb. [1] Due to its high duration of treatment, the therapy has been found to frequently be infeasible when attempts have been made to apply it to clinical situations, and both patients and treating clinicians have reported poor compliance and concerns with patient safety. [2] [3] In the United States, the high duration of the therapy has also made the therapy not able to get reimbursed in most clinical environments.

Contents

However, distributed or "modified" CIT protocols have enjoyed similar efficacy to CIMT, [4] have been able to be administered in outpatient clinical environments, and have enjoyed high success rates internationally.

Types of constraint

The focus of CIMT is to combine restraint of the unaffected limb and intensive use of the affected limb. Types of restraints include a sling or triangular bandage, a splint, [5] a sling combined with a resting hand splint, a half glove, and a mitt. [6] Determination of the type of restraint used for therapy depends on the required level of safety vs. intensity of therapy. Some restraints restrict the wearer from using their hand and wrist, though allow use of their non-involved upper extremity for protection by extension of their arm in case of loss of balance or falls. [7] However, restraints that allow some use of the non-involved extremity will result in less intensive practice because the non-involved arm can still be used to complete tasks. [8] Constraint typically consists of placing a mitt on the unaffected hand or a sling or splint on the unaffected arm, forcing the use of the affected limb with the goal of promoting purposeful movements when performing functional tasks. The use of the affected limb is called shaping. [9]

Duration and timing of "traditional" versus "modified" CI therapy programs

Traditionally, CIMT involves restraining the unaffected arm in patients with hemiparetic stroke or hemiparetic cerebral palsy (HCP) for 90% of waking hours while engaging the affected limb in a range of everyday activities [9] [10] However, given concerns with compliance (both among patients and clinicians), reimbursement, and patient safety, studies have varied on hours of restraint per day and length of therapy. More specifically, CIMT involves the person performing supervised structured tasks with the affected limb 6 hours a day for 10 days over a 14-day period, in addition to wearing the restrictive mitt or sling for 90% of waking hours. [11]

Alternatively, modified constraint induced movement therapy protocols have been found to be equally effective as "traditional" CI therapy protocols. [4] [12] The most established, commonly used, and evidence based form of modified CI therapy that has been found to be effective in improving motor control asks patients to attend goal directed therapy sessions lasting a half hour per day, on 3 days/week over a 10-week period. Concurrently, patients wear a mitt on the less affected limb for 5 hours/weekday during the same 10-week period. [4] In addition to providing more practice with the affected limb than "traditional" CI therapy over the 10-week period, the regimen is in greater accord with outpatient therapy regimens around the world, is less costly, and the efficacy has been shown to be comparable to a more intensive CI therapy schedule.[ citation needed ]

Practitioners say that stroke survivors disabled for many years have recovered the use of their limbs using CIMT. However, it has been shown that receiving CIMT early on (3–9 months post-stroke) will result in greater functional gains than receiving delayed treatment (15–21 months post-stroke), [13] with no benefits associated with its administration acutely (< 3 months post stroke). However, modified CI therapy protocols have shown larger treatment effects when administered in the acute phase. [14]

Mechanism of change

CIMT was developed by Edward Taub of the University of Alabama at Birmingham. Taub argues that, after a stroke, the patient stops using the affected limb because they are discouraged by the difficulty. [8] As a result, a process that Taub calls "learned non-use" sets in, furthering the deterioration. Learned non-use is a type of negative feedback. Individuals are unable to move their affected limb or the movements are inefficient and clumsy and in response to this a suppression of movement occurs. It is this process that CIMT seeks to reverse. The American Stroke Association has written that Taub's therapy is "at the forefront of a revolution" in what is regarded possible in terms of recovery for stroke survivors. [1]

As a result of the patient engaging in repetitive exercises with the affected limb, the brain grows new neural pathways. This change in the brain is referred to as cortical reorganization or neuroplasticity. One study by Deluca et al. showed that using transcranial magnetic stimulation (TMS) that the excitable cortex of the affected cortex in adults patients with HCP doubled in size after 12 days of therapy. [9] Recently, the possible benefits of cortical reorganization has led to studies of CIMT on children because neuroplasticity is even greater among children than adults. [15] Particular interest is growing in CIMT for children who have cerebral palsy where one arm is more affected than the other. [16]

As with adults, however, the plausibility of administering CIMT in pediatric models is low except in specialized, for profit, clinics, due to its intensive parameters, and it has been noted that compliance is especially low in most community-dwelling children. [17]

Application of constraint-induced movement therapy

Both CIMT and modified CIMT may be applicable to up to 20–25 percent of stroke patients, [18] and the amount of improvement produced by either regimen appears to diminish as the initial motor ability of the patient decreases. [11] [19] Both CIMT and modified CI therapy has been shown to be an effective means of stroke rehabilitation regardless of the level of initial motor ability, amount of chronicity, amount of prior therapy, side of hemiparesis, or infarct location. [20] [21] [22] This suggests that plasticity may work irrespective of the pathways in the damaged motor network. [21] Although, due to the duration of this treatment, patients who have had profound upper extremity paralysis from their condition are normally not eligible for constraint-induced upper extremity training. [20] [22] [23] [24] A consistent exclusion criterion for CIMT and modified CI therapy has been the inability to perform voluntary wrist and finger extension in the involved hand. [20] [22] [23] [24] As stated above, this criterion typically limits the population eligible for this family of therapies to 20–25% of the entire stroke population. [18]

CIAT (Constraint Induced Aphasia Therapy) is an adaptation of CIMT for people with Aphasia. It can be used for clients with either expressive or receptive aphasia. Like CIMT, treatment is intensive and usually occurs over a ten-day period for several hours per day. In CIAT, patient must use verbal communication without gestures or pointing in order communicate. The constraints are placed on the use of gestures with the aim of improving verbal communication. Also like CIMT, CIAT has been shown to not be feasible in most clinical environments due to its parameters and distributed protocols are now being investigated. [25]

Both constraint-induced movement therapy (CIMT) and modified CI therapy coupled with intensive and varied exercise training has proven to be effective in reducing spasticity and increasing function of the hemiplegic upper extremity in chronic stroke patients. [26] [27] [28]

The effects of constraint-induced movement therapy and its modified versions have been found to improve movements that not only remain stable for months after the completion of therapy, but translate well to improvements of everyday functional task. [29]

Limitations to implementation

As stated earlier, the "traditional" form of constraint-induced movement therapy (CIMT) has not been incorporated as part of standard practice for the rehabilitation of the hemiplegic upper extremity. [30] Most notably, concerns have been cited over the reimbursement, intensity, and both patient and clinician compliance with the therapy, [2] [3] especially in light of equally-effective, less intense alternative forms. [4] Concerns have also been raised over the generalizability of the results obtained from research, as selection criteria for CIMT research has excluded patients with a moderate or more severe stroke, due to balance problems, serious cognitive deficits, and global aphasia, which may reduce understanding of safety instructions and interfere with a patient's ability to communicate difficulties. [31]

The cost of resources needed to conduct CIMT treatment protocol are high. Costs are generated due to the intensity of therapy required for CIMT, as participants typically receive up to 6 hours of one-on-one therapy at least 5 days per week for 2 weeks. [31] CIMT can be prohibitively expensive for patients paying out-of-pocket or for publicly funded health care systems attempting to make this program available to all eligible stroke survivors. [30]

Therapist apprehension directed at safety issues with constraint use, lack of facilities, the cost of providing one-on-one therapy sessions, and the opportunity costs associated with the therapist's inability to see and treat other patients during that time has contributed to the resistance of adopting the CIMT protocol. [30] [31]

The patient's ability to tolerate the intensity and duration of the therapy sessions is a limiting factor to protocol adoption. Stroke patients have commonly expressed the length of time wearing the constraint and time-consuming hours of therapy as reasons they wish not to participate. [31]

While the CIMT protocol results in improved function in its target population, it is unknown whether the combination of constraint and therapy is necessary to achieve the outcome seen or whether the benefit is due to exposure to high-intensity, task-specific activities focused on the use of the more affected limb. [30] [31] Additionally, the therapy only appears to work on stroke survivors with some initial movement in their wrists and fingers; about 25% of the entire population of stroke survivors.

See also

Related Research Articles

<span class="mw-page-title-main">Expressive aphasia</span> Language disorder involving inability to produce language

Expressive aphasia, also known as Broca's aphasia, is a type of aphasia characterized by partial loss of the ability to produce language, although comprehension generally remains intact. A person with expressive aphasia will exhibit effortful speech. Speech generally includes important content words but leaves out function words that have more grammatical significance than physical meaning, such as prepositions and articles. This is known as "telegraphic speech". The person's intended message may still be understood, but their sentence will not be grammatically correct. In very severe forms of expressive aphasia, a person may only speak using single word utterances. Typically, comprehension is mildly to moderately impaired in expressive aphasia due to difficulty understanding complex grammar.

Hemiparesis, or unilateral paresis, is weakness of one entire side of the body. Hemiplegia is, in its most severe form, complete paralysis of half of the body. Hemiparesis and hemiplegia can be caused by different medical conditions, including congenital causes, trauma, tumors, or stroke.

<span class="mw-page-title-main">Complex regional pain syndrome</span> Array of painful conditions in humans

Complex regional pain syndrome (CRPS) is any of several painful conditions that are characterized by a continuing regional pain that is seemingly disproportionate in time or degree to the usual course of any known trauma or other lesion. Usually starting in a limb, it manifests as pain, swelling, limited range of motion, and/or changes to the skin and bones. It may initially affect one limb and then spread throughout the body; 35% of affected people report symptoms throughout their whole bodies. Two types exist: reflex sympathetic dystrophy (RSD) and causalgia. Having both types is possible.

Spasticity is a feature of altered skeletal muscle performance with a combination of paralysis, increased tendon reflex activity, and hypertonia. It is also colloquially referred to as an unusual "tightness", stiffness, or "pull" of muscles.

<span class="mw-page-title-main">Ischemia</span> Restriction in blood supply to tissues

Ischemia or ischaemia is a restriction in blood supply to any tissue, muscle group, or organ of the body, causing a shortage of oxygen that is needed for cellular metabolism. Ischemia is generally caused by problems with blood vessels, with resultant damage to or dysfunction of tissue i.e. hypoxia and microvascular dysfunction. It also implies local hypoxia in a part of a body resulting from constriction. Ischemia causes not only insufficiency of oxygen, but also reduced availability of nutrients and inadequate removal of metabolic wastes. Ischemia can be partial or total blockage. The inadequate delivery of oxygenated blood to the organs must be resolved either by treating the cause of the inadequate delivery or reducing the oxygen demand of the system that needs it. For example, patients with myocardial ischemia have a decreased blood flow to the heart and are prescribed with medications that reduce chronotrophy and ionotrophy to meet the new level of blood delivery supplied by the stenosed vasculature so that it is adequate.

<span class="mw-page-title-main">Kinesiology</span> Study of human body movement

Kinesiology is the scientific study of human body movement. Kinesiology addresses physiological, anatomical, biomechanical, pathological, neuropsychological principles and mechanisms of movement. Applications of kinesiology to human health include biomechanics and orthopedics; strength and conditioning; sport psychology; motor control; skill acquisition and motor learning; methods of rehabilitation, such as physical and occupational therapy; and sport and exercise physiology. Studies of human and animal motion include measures from motion tracking systems, electrophysiology of muscle and brain activity, various methods for monitoring physiological function, and other behavioral and cognitive research techniques.

The primary goals of stroke management are to reduce brain injury and promote maximum patient recovery. Rapid detection and appropriate emergency medical care are essential for optimizing health outcomes. When available, patients are admitted to an acute stroke unit for treatment. These units specialize in providing medical and surgical care aimed at stabilizing the patient's medical status. Standardized assessments are also performed to aid in the development of an appropriate care plan. Current research suggests that stroke units may be effective in reducing in-hospital fatality rates and the length of hospital stays.

<span class="mw-page-title-main">Mirror therapy</span> Treatment for some kinds of pain

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Phantom pain is a perception that an individual experiences relating to a limb or an organ that is not physically part of the body, either because it was removed or was never there in the first place. However, phantom limb sensations can also occur following nerve avulsion or spinal cord injury.

Monoplegia is paralysis of a single limb, usually an arm. Common symptoms associated with monoplegic patients are weakness, numbness, and pain in the affected limb. Monoplegia is a type of paralysis that falls under hemiplegia. While hemiplegia is paralysis of half of the body, monoplegia is localized to a single limb or to a specific region of the body. Monoplegia of the upper limb is sometimes referred to as brachial monoplegia, and that of the lower limb is called crural monoplegia. Monoplegia in the lower extremities is not as common of an occurrence as in the upper extremities. Monoparesis is a similar, but less severe, condition because one limb is very weak, not paralyzed. For more information, see paresis.

<span class="mw-page-title-main">Silver Spring monkeys</span> Macaques used in neuroplasticity research; subjects of an animal-cruelty court case

The Silver Spring monkeys were 17 wild-born macaque monkeys from the Philippines who were kept in the Institute for Behavioral Research in Silver Spring, Maryland. From 1981 until 1991, they became what one writer called the most famous lab animals in history, as a result of a battle between animal researchers, animal advocates, politicians, and the courts over whether to use them in research or release them to a sanctuary. Within the scientific community, the monkeys became known for their use in experiments into neuroplasticity—the ability of the adult primate brain to reorganize itself.

<span class="mw-page-title-main">Edward Taub</span> American neuroscientist, born 1931

Edward Taub is a behavioral neuroscientist on the faculty at the University of Alabama at Birmingham. He is best known for his involvement in the Silver Spring monkeys case, for making discoveries in the area of neuroplasticity, and developing constraint-induced movement therapy; a family of techniques which helps the rehabilitation of people who have developed learned non-use as a result of suffering neurological injuries from a stroke or other cause.

Learned non-use of a limb is a learning phenomenon whereby movement is suppressed initially due to adverse reactions and failure of any activity attempted with the affected limb, which then results in the suppression of behavior. Continuation of this response results in persisting tendency and consequently, the individual never learns that the limb may have become potentially useful. By constraining the less-affected limb there is a change in motivation, which overcomes the learned nonuse of the more-affected limb.

<span class="mw-page-title-main">Management of cerebral palsy</span>

Over time, the approach to cerebral palsy management has shifted away from narrow attempts to fix individual physical problems – such as spasticity in a particular limb – to making such treatments part of a larger goal of maximizing the person's independence and community engagement. Much of childhood therapy is aimed at improving gait and walking. Approximately 60% of people with CP are able to walk independently or with aids at adulthood. However, the evidence base for the effectiveness of intervention programs reflecting the philosophy of independence has not yet caught up: effective interventions for body structures and functions have a strong evidence base, but evidence is lacking for effective interventions targeted toward participation, environment, or personal factors. There is also no good evidence to show that an intervention that is effective at the body-specific level will result in an improvement at the activity level, or vice versa. Although such cross-over benefit might happen, not enough high-quality studies have been done to demonstrate it.

Rehabilitation robotics is a field of research dedicated to understanding and augmenting rehabilitation through the application of robotic devices. Rehabilitation robotics includes development of robotic devices tailored for assisting different sensorimotor functions(e.g. arm, hand, leg, ankle), development of different schemes of assisting therapeutic training, and assessment of sensorimotor performance of patient; here, robots are used mainly as therapy aids instead of assistive devices. Rehabilitation using robotics is generally well tolerated by patients, and has been found to be an effective adjunct to therapy in individuals with motor impairments, especially due to stroke.

Sensory stimulation therapy (SST) is an experimental therapy that aims to use neural plasticity mechanisms to aid in the recovery of somatosensory function after stroke or cognitive ageing. Stroke and cognitive ageing are well known sources of cognitive loss, the former by neuronal death, the latter by weakening of neural connections. SST stimulates a specific sense at a specific frequency. Research suggests that this technique may reverse cognitive ageing by up to 30 years, and may selectively improve or impair two point discrimination thresholds.

<span class="mw-page-title-main">Spastic hemiplegia</span> Medical condition

Spastic hemiplegia is a neuromuscular condition of spasticity that results in the muscles on one side of the body being in a constant state of contraction. It is the "one-sided version" of spastic diplegia. It falls under the mobility impairment umbrella of cerebral palsy. About 20–30% of people with cerebral palsy have spastic hemiplegia. Due to brain or nerve damage, the brain is constantly sending action potentials to the neuromuscular junctions on the affected side of the body. Similar to strokes, damage on the left side of the brain affects the right side of the body and damage on the right side of the brain affects the left side of the body. Other side can be effected for lesser extent. The affected side of the body is rigid, weak and has low functional abilities. In most cases, the upper extremity is much more affected than the lower extremity. This could be due to preference of hand usage during early development. If both arms are affected, the condition is referred to as double hemiplegia. Some patients with spastic hemiplegia only experience minor impairments, where in severe cases one side of the body could be completely paralyzed. The severity of spastic hemiplegia is dependent upon the degree of the brain or nerve damage.

<span class="mw-page-title-main">Restorative neurology</span>

Restorative neurology is a branch of neurology dedicated to improving functions of the impaired nervous system through selective structural or functional modification of abnormal neurocontrol according to underlying mechanisms and clinically unrecognized residual functions. When impaired, the body naturally reconstructs new neurological pathways and redirects activity. The field of restorative neurology works to accentuate these new pathways and primarily focuses on the theory of the plasticity of an impaired nervous system. Its main goal is to take a broken down and disordered nervous system and return it to a state of normal function. Certain treatment strategies are used to augment instead of fully replace any performance of surviving and also improving the potential of motor neuron functions. This rehabilitation of motor neurons allows patients a therapeutic approach to recovery opposed to physical structural reconstruction. It is applied in a wide range of disorders of the nervous system, including upper motor neuron dysfunctions like spinal cord injury, cerebral palsy, multiple sclerosis and acquired brain injury including stroke, and neuromuscular diseases as well as for control of pain and spasticity. Instead of applying a reconstructive neurobiological approach, i.e. structural modifications, restorative neurology relies on improving residual function. While subspecialties like neurosurgery and pharmacology exist and are useful in diagnosing and treating conditions of the nervous system, restorative neurology takes a pathophysiological approach. Instead of heavily relying on neurochemistry or perhaps an anatomical discipline, restorative neurology encompasses many fields and blends them together.

<span class="mw-page-title-main">Peter G. Levine</span> American medical researcher (1960–2022)

Peter G. Levine was an American medical researcher, science educator, and authority on stroke recovery. He published articles in peer-reviewed journals on brain plasticity as it relates to stroke, with emphasis on modified constraint induced therapy, cortical reorganization, telerehabilitation, electrical stimulation, electromyography-triggered stimulation, mental practice, cortical plasticity, acquired brain injury, spasticity, sensation recovery, evidence-based practice, outcome measures, and others. His articles have been widely cited by the medical community. His 2013 book Stronger After Stroke is regarded as an authoritative guide for patients and therapists dealing with stroke and it has received numerous positive reviews, and has been translated into Indonesian, Japanese, and Korean. His seminars throughout the United States were described by one reviewer as "funny, entertaining, engaging, dynamic, well organized, passionate and lighthearted." Levine was a trainer of stroke-specific outcome measures for The Ohio State University; B.R.A.I.N. Lab. He was a researcher and co-director at the Neuromotor Recovery and Rehabilitation Laboratory at the University of Cincinnati College of Medicine. Before that, he was a researcher at the Human Performance & Motion Analysis Laboratory, which is the research arm of the Kessler Institute for Rehabilitation.

Fugl-Meyer Assessment (FMA) scale is an index to assess the sensorimotor impairment in individuals who have had stroke. This scale was first proposed by Axel Fugl-Meyer and his colleagues as a standardized assessment test for post-stroke recovery in their paper titled The post-stroke hemiplegic patient: A method for evaluation of physical performance. It is now widely used for clinical assessment of motor function. The Fugl-Meyer Assessment score has been tested several times, and is found to have excellent consistency, responsivity and good accuracy. The maximum possible score in Fugl-Meyer scale is 226, which corresponds to full sensory-motor recovery. The minimal clinically important difference of Fugl-Meyer assessment scale is 6 for lower limb in chronic stroke and 9-10 for upper limb in sub-acute stroke.

References

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  28. ↑ Sun, Shu-Fen; Hsu, Chien-Wei; Sun, Hsien-Pin; Hwang, Chiao-Wen; Yang, Chia-Lin; Wang, Jue-Long (2010-01-01). "Combined botulinum toxin type A with modified constraint-induced movement therapy for chronic stroke patients with upper extremity spasticity: a randomized controlled study". Neurorehabilitation and Neural Repair. 24 (1): 34–41. doi:10.1177/1545968309341060. ISSN   1552-6844. PMID   19729582. S2CID   39490453.
  29. ↑ Miltner WH, Bauder H, Sommer M, Dettmers C, Taub E (March 1999). "Effects of constraint-induced movement therapy on patients with chronic motor deficits after stroke: a replication". Stroke. 30 (3): 586–92. doi: 10.1161/01.STR.30.3.586 . PMID   10066856.
  30. 1 2 3 4 Teasell, Robert; Viana, Ricardo (2012). "Barriers to the Implementation of Constraint-Induced Movement Therapy into Practice". Topics in Stroke Rehabilitation. 19 (2): 104–14. doi:10.1310/tsr1902-104. PMID   22436358. S2CID   23526903.
  31. 1 2 3 4 5 Sterr, Annette; Saunders, Amy (2006). "CI therapy distribution: Theory, evidence and practice". NeuroRehabilitation. 21 (2): 97–105. doi:10.3233/NRE-2006-21202. PMID   16917157.
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