Induced Movement Therapy Research Articles

Constraint - Induced Movement Therapy: Determinants and Correlates of Duration of Adherence to Restraint use Among Stroke Survivors with Hemiparesis

Background: Constraint-Induced Movement Therapy (CIMT) was developed to improve purposeful movement of the stroke-affected extremity by restrictingthe use of the unaffected extremity. The two main components of CIMT are the training of the more-impaired arm to perform functional tasks, and the restraint of the less-impaired arm. One challenge that the application of CIMT faces is in ensuring adherence to the use of restraint. Purpose: There is a need to determine the factors that may influence adherence, as this would allow CIMT to be delivered more effectively, and prevent situations where unrealistic expectations are placed on stroke–affected individuals. Methods: Thirty stroke survivors with hemiparesis who met the inclusion criteria were consecutively recruited from the physiotherapy out-patient clinics, using a purposive sampling technique. A structured questionnaire was used to obtain information on clinical and socio-demographic parameters. The participants were given a restraint and an adherence time log-book, to make a daily record during the period they wore the restraint. The adherence time logbook was collected at the end of every week of the 3-week study. Motor function and functional use of the upper limb were measured using Motricity Index and Motor Activity Log respectively. Data was analysed using mean and standard deviations, independent t-test and Spearman rho; p was significant at 0.05. Results: Gender (p=0.73) and side affected/handedness (p=0.79) had no significant influence on the percentage duration of adherence to restraint use (DARU). The influence of socio-economic status was seen, with the participants of middle socio-economic status adhering for longer duration (p=0.02). Age had weak and no significant correlation with percentage DARU (p=0.55). There was significantly fair correlation between motor function/functional use at any stage (p=0.55) and the corresponding percentage duration of adherence to restraint use, except the functional use in the first week (p=0.44). Conclusion: Socio-economic status should be considered when applying CIMT.

THE EFFECT OF COMBINATION OF CONSTRAINT INDUCED MOVEMENT THERAPY WITH BIMANUAL INTENSIVE THERAPY ON UPPER LIMB FUNCTION OF CHILDREN WITH HEMIPLEGIC CEREBRAL PALSY

Introduction: Constraint- Induced Movement Therapy (CIMT) and bimanual approach (BIM training) are a promising treatment for upper limb function improvement in children with spastic hemiplegia. CIMT involved restraint of non-involved upper extremity and intensive practice with involved upper extremity. BIM training is complementary to other treatments of upper extremity and improves bimanual coordination using structured task practice embedded in bimanual play and functional activities. This study was aimed to evaluate the influence of combination of CIMT with BIM training on fine motor skills of children with hemiplegic cerebral palsy. Materials and Methods: In this study, twenty five children with hemiplegic cerebral palsy aged 5-10 years participated and randomly assigned into two intervention and control groups. Children in Control group received current occupational therapy intervention. Subjects in intervention group received a combination of CIMT and BIM training in addition to current occupational therapy. Each session was started with restraint on non-involved upper extremity and practicing with involved upper extremity for three hours. This was followed with BIM training for another three hours. This process lasted for 10 out of 12 consecutive days. Upper limb function and muscle tone were assessed by Jebsen-Taylor test of hand function and modified Ashwort scale, respectively. Results: Upper limb function in intervention group significantly improved (P 0.05). Conclusion: Our findings suggest that combination of constraint induced movement therapy and bimanual intensive therapy improved upper limb Function in the hemiplegic cerebral palsy children. Keywords: Upper extremity function, Constraint induced movement therapy, Bimanual training, Hemiplegia

Effects of Modified Constraint-induced Movement Therapy on Hand Dexterity, Grip Strength and Activities of Daily Living of Children with Cerebral Palsy: a Randomized Control Trial

[Purpose] This study investigated hand function and activities of daily living (ADL) changes in children with hemiplegic cerebral palsy (CP) using modified constraint induced movement therapy (mCIMT). [Subjects] Twenty children with CP were randomly allocated into mCIMT (n = 10) and control (CON) (n = 10) groups. [Methods] Two expert physical therapists provided the mCIMT and CON groups with traditional rehabilitation therapy in 30-minute sessions, semi-weekly, for 10 weeks. The mCIMT training was provided only to mCIMT group semiweekly for 10 weeks at 60 minutes per session. The CON group received traditional therapy only. Before and after the 10 weeks of intervention, hand function and ADL evaluations were performed, and the obtained data were analyzed. [Results] The mCIMT and CON groups showed significant differences in hand dexterity and grip strength on the affected side and ADL self-care subtest scores. [Conclusion] The results are not generalizable to all children with CP because of the small number of subjects. Detailed and diverse investigations should be performed by considering the number and characteristics of subjects and the limitations influencing the mCIMT training period.

Modified Constraint Induced Movement Therapy enhanced by a Neuro-Development Treatment-based therapeutic handling protocol: Two case studies

Modified Constraint Induced Movement Therapy (CIMT) and Neuro-Developmental Treatment (NDT) are both intervention strategies that focus on active practice to optimize function. CIMT involves constraint of the less involved upper extremity during function and NDT includes facilitation of optimal postural control and symmetry to enhance the ability to complete a given motor function. The purpose of this article is to describe an intervention protocol for children with hemiplegia that integrates key NDT and CIMT principles. Two children participated in a modified CIMT (mCIMT)/NDT program 2 hours a day for two months. The children wore a constraint on the less involved arm and participated in guided play with early intervention members and parents. Play was individualized to developmental level and incorporated principles of NDT. Function was measured pre- and post-intervention using the PDMS-2, QUEST, ACQUIRE Therapy Motor Patterns, and ACQUIRE Functional Activities. Both children demonstrated motor skill acquisition, improved quality of functional use, and increased frequency of bilateral hand use. Parents found the protocol challenging but manageable in their daily routines. The inclusion of NDT principles within a mCIMT protocol may be an effective intervention to maximize functional motor skill acquisition in children with hemiplegia. Additional research is warranted to support this intervention.

Plasticity in Cortical Motor Upper-Limb Representation Following Stroke and Rehabilitation: Two Longitudinal Multi-Joint fMRI Case-Studies

Motor dysfunction and recovery following stroke and rehabilitation are associated with primary motor cortex plasticity. To better track these effects we studied two patients with sub-acute sub-cortical stroke causing hemiparesis, who underwent an effective behavioral treatment termed Constraint Induced Movement Therapy (CIMT). The therapy involves 2 weeks of intensive motor training of the hemiparetic limb coupled with immobilization of the unaffected limb. The study included a longitudinal series of clinical evaluations and fMRI scans, before and after the treatment. The fMRI task included wrist, elbow, or ankle movements. Activity in the M1 upper-limb region of control subjects was stable, strictly contralateral, and similar in amplitude for elbow and wrist movements. These findings reflect the well-known contralateral motor control and support the idea of overlapping representations of adjacent joints in M1. In both patients, pre-CIMT activation patterns in M1 were tested twice and did not change significantly, were contralateral, and included elbow-wrist differences. Following CIMT, the clinical condition of both patients improved and three fMRI-explored prototypes were found: First, cluster position remained constant; Second, ipsilateral activity appeared in the unaffected hemispheres during hemiparetic movements; Third, patient-specific elbow-wrist inter and intra hemispheric differences were modified. All effects were long-lasting. We suggest that overlapping representations of adjacent joints contributed to the cortical plasticity observed following CIMT. Our findings should be confirmed by studying larger groups of homogeneous patients. Nevertheless, this study introduces multi-joint imaging studies and shows that it is both possible and valuable to carry it out in stroke patients.

Protocolo modificado de la terapia del movimiento inducido por restricción para un hospital de atención a crónicos y larga estancia

Introduction Constraint-induced movement therapy is one of the few therapies for upper limb rehabilitation that has been scientifically proven to have an impact on daily life activities. The purpose of this clinical trial is check whether the modification of the original protocol of constraint- induced movement therapy improves the eligibility restrictions of the original protocol and maintains the benefits. Material and methods We performed a comparative study on a sample of 32 patients who had suffered a stroke. They were randomly divided into an experimental group and a control group to determine if a modification of the original protocol of constraint-induced movement therapy has a significant impact on improvement in daily living activities within the overall treatment of patients admitted to a chronic care, long stay, hospital, that is, the Hospital “Pare Jofre” of the city of Valencia. The technique was compared with the traditional treatment of occupational therapy. Results Eligibility is increased from 1.6% to 26.22%. We observed functional improvement in activities of daily living with statistical significance (Mann-Whitney U Test: 0.001) and a significant difference in levels of dependence between the experimental and control group. It has been observed that patients receiving the technique have lower levels of dependency (Chi-square 0.038) and statistically significant differences for activities of daily life, such as eating, dressing, personal hygiene, showering, use of toilet, transfers and movements from one place to another, so we can say that the benefits of the original protocol are maintained. Conclusions Eligibility is increased with this modified protocol and it has better results in activities of daily living, such as feeding, dressing, hygiene, bathroom, use of the toilet and transfers.

An ecological approach of Constraint Induced Movement Therapy for 2–3-year-old children: A randomized control trial

The aim was to evaluate the effect of Eco-CIMT in young children with unilateral cerebral palsy in a randomized controlled crossover design. The training was implemented within the regular pediatric services, provided by the child's parents and/or preschool teacher and supervised by the child's regular therapist. Twenty-five children (mean age 28.8 months [SD 11.2], 72% male) participated. Assisting Hand Assessment (AHA) was used as the outcome measure. The Eco-CIMT was provided for 2h a day over a period of two months. Children were randomized into two groups and started either with Eco-CIMT or as controls with a four-month washout period before crossing over. A significant effect of Eco-CIMT was found when compared to the control period, and the estimated treatment effect was 5.47 (95% C.I. 2.93-8.02) (including both Group 1 and Group 2) (p < 0.001). The non-significant estimated carryover effect allowed us to collapse the two groups based on estimates from the ANOVA model. No clear relationship to hours of training, age or general attitudes of mastery was found. Eco-CIMT influenced development more than ordinary treatment at this age when Eco-CIMT was performed by parents and preschool teachers supervised by the child's ordinary therapist.

Transcranial magnetic stimulation mapping and upper limb dexterity in subacute hemiplegic patients after treatment with Constraint Induced Movement Therapy

Transcranial magnetic stimulation mapping and upper limb dexterity in subacute hemiplegic patients after treatment with Constraint Induced Movement Therapy

Home based therapy can be of, at least, short term value

Home based therapy can be of, at least, short term value

New design of dynamic orthoses for neurological conditions

Repetitive task-specific training appears to improve upper extremity function among individuals with neurological injuries. However, treatment options are limited for neurological patients who cannot effectively incorporate their hand consistently for functional grasp and release/prehension activities. Traditional therapy approaches are not considered to be effective in controlled clinical trials. However, constraint induced movement therapy (CIMT) has shown to be a successful treatment approach for patients who exhibit some wrist and finger extension. The vast majority of stroke survivors, head injury and incomplete spinal cord Injury patients do not exhibit sufficient wrist and/or finger extension to qualify for CIMT. Patients with moderate to severe upper extremity hemiparesis are therefore unable to benefit from the latest advances in neuro-rehabilitation. The SaeboFlex and SaeboReach Functional Dynamic Orthoses have the biomechanical advantage in allowing prehension/grasp and release activities for individuals with moderate to severe hemiparesis. These orthoses are designed to position the neurological wrist and fingers into extension for proper functional training. This article describes Saebo's functional dynamic orthoses--the SaeboFlex, SaeboReach, and the SaeboStretch dynamic resting hand splint for contracture prevention--and summarizes developing evidence for the orthoses in the clinic/rehabilitation environment. This is a review article.

COMPARISON OF ARM-HAND BIMANUAL INTENSIVE THERAPY AND CURRENT THERAPY FOR UNIMANUAL AND BIMANUAL FUNCTIONS IN CHILDREN WITH CEREBRAL PALSY

Introduction: Studies have showed that although Constraint Induced Movement Therapy can lead into improvement of hand function in children with Cerebral Palsy, it has several important limitations. Charles and Gordon introduced Hand-Arm Bimanual Intensive Therapy (HABIT) in an attempt to compensate for such deficits. This study aimed at evaluating the efficacy of HABIT on unimanual and bimanual functions in children with Cerebral Palsy. Materials and Methods: The participants of this single-blinded randomized control study were twenty-eight children with CP who were divided into two groups of HABIT and controls according to a set of inclusionary and exclusionary criteria. Subjects in HABIT group received the intervention 6 hours per day over 10 successive days and the members of the other group were provided with occupational therapy services. Assessment tools administered in this study were Bruininks-Oseretsky Test of Motor Proficiency, Caregiver Functional Use Survey (CFUS), and Jebsen-Taylor Test in Hand Function. Independent and paired t tests were respectively used for comparing the two groups and to compare each group with regard to pre-test and post-test conditions. Results: Study results showed significant differences between two groups concerning dexterity, bilateral coordination, bimanual coordination, bimanual function, unimanual function and Caregiver Functional Use Survey (how well & how frequently) (P < 0.05). Also comparison of pre-test and post-test results for each of the two studied groups indicated improvement in most of domains evaluated. Conclusion: The protocol of Arm-Hand Bimanual Intensive Therapy may result in improvement of either bimanual or unimanual hand functions in children with cerebral palsy. Keywords: Arm-Hand bimanual intensive therapy, Hand function, Hemiplegia, Occupational therapy

Review of the randomized clinical stroke rehabilitation trials in 2009

SummaryBackgroundRecent review of the available evidence on interventions for motor recovery after stroke, showed that improvements in recovery of arm function were seen for constraint-induced movement therapy, electromyographic biofeedback, mental practice with motor imagery, and robotics. Similar improvement in transfer ability or balance were seen with repetitive task training, biofeedback, and training with a moving platform. Walking speed was improved by physical fitness training, high-intensity physiotherapy and repetitive task training. However, most of these trials were small and had design limitations.Material/MethodsIn this article, randomized control trials (RCT’s) published in 2009 of rehabilitation therapies for acute (≤2 weeks), sub-acute (2 to 12 weeks) and chronic (≥12 weeks) stroke was reviewed. A Medline search was performed to identify all RCT’s in stroke rehabilitation in the year 2009. The search strategy that was used for PubMed is presented in the Appendix 1. The objective was to examine the effectiveness of these treatment modalities in stroke rehabilitation.ResultsThis generated 35 RCT’s under 5 categories which were found and analyzed. The methodological quality was assessed by using the PEDro scale for external and internal validity.ConclusionsThese trials were primarily efficacy studies. Most of these studies enrolled small numbers of patient which precluded their clinical applicability (limited external validity). However, the constraint induced movement therapy (CIT), regularly used in chronic stroke patients did not improve affected arm-hand function when used in acute stroke patients at ≤4 weeks. Intensive CIT did not lead to motor improvement in arm-hand function. Robotic arm treatment helped decrease motor impairment and improved function in chronic stroke patients only. Therapist provided exercise programs (when self-administered by patients during their off-therapy time in a rehabilitation setting) did improve arm-hand function. Tai Chi exercises helped improve balance and weight bearing. Exercise programs for community dwelling stroke patient helped maintain and even improve their functional state.

Constraint induced movement therapy for stroke survivors in Jordon: a home-based model

Aims: This article describes a home-based study evaluating the effectiveness of modified constraint induced movement therapy (CIMT) in improving upper limb function in stroke survivors, and compares it with the clinical-based Neurodevelopmental Treatment (NDT) approach. Methods: In this pretest-post-test randomized study, 10 stroke survivors received home-based modified CIMT and eight stroke survivors received conventional NDT rehabilitation. The focus of the CIMT was on the hemiplegic hand, by which the less affected hand was restrained, with structured training for the more affected arm and hand. The intervention was executed two hours a day, seven days a week for two months, in the patients' normal day-care environment. Arm motor function outcomes were evaluated using the Wolf Motor Function Test as a primary outcome measure. The motor activity log, and the Fugl-Meyer Assessment were used as secondary outcome measures. Findings: Stroke survivors in the CIMT group showed a statistically significant improvement in all arm motor function outcomes. However, while numerically the improvement was better in the CIMT group, it failed to be significantly better than that seen in the NDT group. Conclusions: Home based CIMT conducted by caregivers with therapists' support is a promising approach for improving affected upper limb in stroke survivors. However, additional studies are needed to confirm these findings.

Session B: Measurements and Neural Networks of Motor Impairment

Background/Objectives: To understand the neural mechanisms underlying response to Constraint Induced Movement Therapy (CIMT) compared with Bimanual Training (BIM). Conclusions/Significance: Our results provide direct evidence of neural plasticity for the group who received constraint induced movement therapy (increased cortical excitability of the impaired motor cortex supported by neurovascular changes on fMRI). Both groups made significant improvements with movement efficiency (JTHFT) and bimanual coordination (AHA) however the CIMT group demonstrated a significant improvement in unimanual capacity (MUUL). Our data suggest that upper limb rehabilitation should commence with CIMT followed by bimanual training to maximize neural plasticity. © 2010 The Authors. Journal compilation © 2010 Mac Keith Press Developmental Medicine & Child Neurology

Constraint therapy versus intensive training: Implications for motor control and brain plasticity after stroke

Many studies have demonstrated that constraint induced movement therapy (CIMT) improves upper limb motor impairment following stroke. This rehabilitation method combines constraint of the less-affected upperlimb with intensive training of the paretic limb. The aim of the present study was to evaluate, in a single case study, the respective effects of each of these two therapeutic interventions. The patient selected was a 32-year-old right-handed woman. Three and a half years prior to inclusion, she suffered a left capsular infarct responsible for a right hemiparesis. Several assessments were carried out before and after constraint therapy and then after intensive training. Each assessment included measures of hand function as well as a three-dimensional (3D) analysis of prehension. Results showed a significant improvement of motor performance after the constraint period and an additional amelioration after the intensive training period. Kinematic analysis showed that the transport phase of movement (movement time and velocity peaks) was improved after the constraint period, whereas the grasping phase (maximum grip aperture) was modified after intensive training. These data could reflect a specific effect of treatment on each phase of the prehension task, or a more general proximal-to-distal gradient of recovery. Although firm conclusions are not warranted on the basis of this single case study, we confirm the utility of 3D motion analysis to evaluate objectively the effectiveness of a therapeutic intervention. We also discuss the implications of our findings for understanding processes of motor control reorganisation.

Action planning in typically and atypically developing children (unilateral cerebral palsy)

In the present study, we investigated the development of action planning in children with unilateral Cerebral Palsy (CP, aged 3–6 years, n = 24) and an age matched control group. To investigate action planning, participants performed a sequential movement task. They had to grasp an object (a wooden play sword) and place the sword in a hole in a wooden block. Our main dependent variable was the grip type that participants used, i.e., did they adapt their initial grip choice such that they would reach a comfortable posture at the end of the action? This end-state comfort effect has been abundantly shown in research on action planning, and is taken as evidence for anticipatory planning. The first aim of the study was to investigate the development of action planning in the unilateral CP group and the control group. Our hypothesis was that action planning improves with age in the control group, but not in the unilateral CP group. The results showed that planning was impaired in the unilateral CP group compared with the control group. Consistent with our hypothesis, we found an age effect in the control group, but not in the unilateral CP group. In the control group 5 and 6 years olds showed more anticipatory planning compared with the 3 and 4 years olds. The second aim of this study was to examine whether an intervention for children with unilateral CP (i.e., constrained induced movement therapy combined with bimanual training) affected action planning. The children with unilateral CP were therefore measured on the experimental task before and after an 8-week intervention period. The results showed that planning improved after the intervention. This finding suggests that action planning ability in young children with unilateral CP may be sensitive to improvement. These findings are discussed within the context of typical and atypical development of action planning and further guidelines for intervention in children with unilateral CP are given.

A randomized trial of novel upper limb rehabilitation in children with congenital hemiplegia

A randomized trial of novel upper limb rehabilitation in children with congenital hemiplegia

Phy04 Effects of the Group-based Modified Constraint Induced Movement Therapy (mCIMT): A Longitudinal Study of Nine Stroke Patients

Phy04 Effects of the Group-based Modified Constraint Induced Movement Therapy (mCIMT): A Longitudinal Study of Nine Stroke Patients

Intensity of practice after stroke: More is better

The present debate paper addresses four relevant issues related to the impact of intensity of practice after stroke. First, the best way to define intensity of practice is discussed. Second, the paper describes the evidence that exists for a dose-response relationship in stroke rehabilitation. Third, the relevance of an appropriate patient selection for a meaningful intensive practice is explored. Finally, the feasibility of intensive practice by: (1) early started mobilization of stroke patients (2) ability to practice in groups, (3) using forced use paradigms such as constrained induced movement therapy for the upper limb, (4) using robotics and (electronic) devices that help patients to practice on their own and (5) preventing poor compliance in terms of practice in therapeutic sessions by identifying factors that predict poor adherence are discussed.

Effect of small group treatment of the modified constraint induced movement therapy for clients with chronic stroke in a community setting

This study investigated the effects of the group treatment component of the modified constraint induced movement therapy (mCIMT) protocol for clients with chronic stroke in a community setting. A within-subjects longitudinal study was conducted to which eight participants with chronic stroke being treated in a community setting in Hong Kong were recruited. Ten 3-h group sessions were conducted on two occasions within a four-week period, with four participants per group. Participants’ less-affected hands were restrained in a mitt, with a target of wearing it for 4 h per weekday. Laboratory based tests and the Motor Activity Log (MAL) were used repeatedly to measure participants’ hemiparetic upper extremity functions and the use of the limb in real-life on four measurement occasions: at baseline (four weeks before training), pre-test (one day before training), post-test (one day after training), and follow-up (four weeks after training). The Wilcoxon signed-rank test showed participants’ baselines were stable four weeks before the intervention. The Friedman test found significant differences between pre-test, post-test and follow-up in the Box and Block Test (BBT), the total score, grasp and pinch subscores of the Action Research Arm Test (ARAT), and the Hong Kong Version of the Functional Test for the Hemiplegic Upper Extremity (FTHUE-HK), the Wolf Motor Function Test (WMFT), and the MAL. All these gains were maintained during the 1-month follow-up. The small group treatment component of the mCIMT was found to be effective, feasible, and capable of improving both motor performance and functional use of the affected upper extremity for patients with chronic stroke in a community setting.