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Veterans International-CambodiaA Project of the International Center

Effectiveness of Constraint Induced Movement Therapy (CIMT) in

Hemiplegic Stroke and Cerebral Palsy (CP) on Upper Extremity

Presented by Song SitSenior PT October 26th 2009

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A stroke patient is wearing a sling on his unaffected hand

whilst holding a rail with his affected hand

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A stroke patient is wearing a mitt on her unaffected hand whilst writing with her affected hand

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Child is wearing an uninvolved cast Child is wearing a sling

Child is in a plaster cast

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Outline Presentation

1. Objective outcome2. History of CIMT3. Learned non-used4. Application of CIMT5. The Shaping Method6. The Repetitive Task Practice method7. Effectiveness of CIMT on Stroke 8. Effectiveness of CIMT on Hemiplegic CP9. Outcome measures

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Objective Outcome1. PT will understand the benefits of CIMT in

patients with stroke and hemiplegic CP.2. PT will understand how to apply CIMT in their

practice with patients with stroke and hemiplegic CP.

3. PT will understand the benefits of using outcome measures (MAL and PMAL) when working with people with stroke and hemiplegicCP.

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History of Constraint Induced Movement Therapy ( CIMT)

Developed at the University of Alabama Birmingham in the late 1970s to 1980s (Edward Taub, Director, CIMT Research Group).[18]

Began with basic research done on monkeys where somatic sensation was surgically abolished in one arm (dorsal rhizotomy) resulting in somatosensory deafferentation (desensitized). [18,19]

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History of Constraint Induced Movement Therapy ( CIMT)

After somatosensory desensitization, monkeys did not use their affected arm. [19]

Hypothesis - the non-use of the affected arm was a learning mechanism, termed “learned non-use”. [4]

After restraining the good arm in a sling, the monkey subsequently used its desensitized arm to feed and move itself around. [3]

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Learned Non-UseLearned non-use develops during the early stages following a stroke.

Stroke patients begin to compensate for difficult activities by using the unaffected arm, delaying recovery of function in affected arm. [8]

CIMT is based on the theory “ learned non-use”.

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Application of CIMT

Restrain unaffected arm by wearing a sling, mitt or plaster cast.[8,20,23]

Shaping (adaptive task practice) and /or Repetitive task practice on affected arm under supervision of PT or caregiver with time limit.[23]

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ShapingAlso called “ Adapted Task Practice”.[23]

Form of operant or instrumental conditioning characterized by repetition a defined movement. It is graded to slowly increase in difficulty.[14,16,23]

Patient is coached and encouraged by therapist. Increase successful number of repetitions or reduce the time to complete the task demand with effort.[9]

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ShapingThe patient is rewarded and encouraged for improvement but is never blamed (punished) for failure.[12]

A basic principle is to keep extending motor capacity a small added amount beyond the performance level already achieved.[12]

Eg. Pick up block and move them toward a pail, in a series of 10 trails in a minute. Then increase a series of 15 trails after ptachieved 10 trails.Build up block as a tower in 10 cubes in a minute then increase to 10 cubes in 30 seconds.

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Repetitive Task Practice Efforts to perform movement are usually repeated.[23]

Tasks become more challenging and function.[23]

Eg. Eating, combing hair, brushing teeth, setting a table or folding towels etc.

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 limb segments for task completion.[23]

Feedback about overall performance is provided at the end of the period.[23]

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Effectiveness of CIMT on Stroke1. After one week of CIMT, van Der Lee, et al (1999) showed good

improvement of function in the affected arm. On follow-up after one year, the effectiveness of CIMT was still evident. This study showed that CIMT showed clinically significant results for activities in daily living. This would be relevant to people with stroke and sensory disorder and hemineglect after 2 weeks of CIMT.[21]

CIMT Group (24h except driving, sleeping, dressing and toileting)Worn resting splint at home Sling on unaffected arm during Rx 6hs/dIntensive training

Same intensive bimanual training based on Neuro-developmental Treatment (NDT).

2. Miltmer WH, et al (1999) showed this intervention has shown general applicability for chronic motor deficits stroke in Germany.[13]

Worn sling 90% of waking time a day for 12 days. Shaping 7hs/d for 8 days

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Effectiveness of CIMT on Stroke 3. Dromerick AW et al (2000) showed CIMT was possible for applying on

acute stroke (14 days after stroke).[5]

OT groupADL, Strength, ROM and positioningDuration: 2hs/d, 2weeks

CIMTWore mitt 6hs/d on unaffected armOT as aboveDuration same as above

4. Wolf SL et al, (2006) produced statistically significant and clinically relevant improvement in arm motor function after 2weeks and thisimprovement persisted for up to 1 year for patients who were recruited for the study 3-9 months after stroke.[22]

CIMTMitt worn 90% of waking time for 2 weeks. Shaping and repetitive task practice 6hs/d for 2 weeks and 30mins at home.

Usual and Customary CareCollect report by phone ( no Rx, Mechanical Rx (Orthotics), OT and PT Rx and outpatient Visit at home)

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Effectiveness of CIMT on Stroke 5. Lin KC et al. (2007) showed CIMT improved functional use of the affected

arm and daily functioning, motor control strategy during goal-directed reaching. Possible mechanism for the improved performance of stroke patient undergoing CIMT to compare with traditional rehabilitation for 3 weeks.[9]

CIMT GroupMitt worn 6hs of waking time for 3 weeks. Intensive training 2hs a day for 3 weeks.

Traditional Rehabilitation GroupMuscle strength, balance, fine motor skill, weight bearing on hand and functional tasks 2hs a day for 3 weeks.

6. Dahl AE et al. (2008) showed CIMT seems to be an effective and possible method to improve motor function in the short term, and able to maintain the improvement for 6 months in stroke but no long-term effect was found. [2]

CIMTSix hours arm therapy for 10 consecutive weekdays, while Using mitten on the unaffected hand.

Traditional rehabilitation

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Effectiveness of CIMT on Stroke 7. Lin KC et al. (2009) compared a modified CIT intervention with a

dose-matched control intervention. This study showed the effects in specific outcomes including increased motor function, basic and extended functional ability, and quality of life sub-acute stroke when applying a modified CIT intervention.[11]

CIMTrestraint of the less affected limb combined with intensive training of the affected limb for 2 hours daily 5 days per week for 3 weeksand restraint of the less affected hand for 5 hours outside of the rehabilitation training.

A dose-matched control intervention ( Control group)The same duration: restraint of the less affected hand for 5 hours outside of the rehabilitation training

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Effectiveness of CIMT on Stroke 8. Brogårdh C et al (2009) showed the long-term benefit of

constraint-induced group therapy. Hand function was maintained over time and daily hand use had increased compared to pre-treatment in chronic stroke with mild to moderate impairments of hand function in 4 years follow up.[1]

14 patients were applied CIMT ( Wore mitt for 80 -90% of waking hour and Shaping for 6hs a day) for 2 weeks.After 2 weeks, Patients were divided into 2 groups for 3 more months.1. One group wore the mitt with the same duration as

above2. Other group received no further Rx

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Effectiveness of CIMT on Stroke 9. Lin KC et al (2009) showed Bilateral Arm Training may

individually improve proximal UL motor impairment. On the contrary, applying CIT may produce better functional gains for the affected UL in subjects with mild to moderate chronic hemiparesis.[10]

In the study of Effects of Constraint-Induced Therapy Versus BAT on Motor Performance, Daily Functions, and Quality of Life in Stroke Survivors.Groups:

CIMT, BAT And a control intervention of less specific but active therapy.

Each group received intensive training for 2 hours a day, 5 days a week, for 3 weeks.

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Effectiveness of CIMT on hemiplegic CP

1. Taub E at el (2004) showed great improvement in functional ability and quality of life and sustained improvement 6 months after Rx in motor function in the young children with hemiparesis CP (7ms-8ys) in the study.[17]

CIMT GroupPlaster cast of the child’s less-affected 24hShaping for 6 hours a day for 21 days

Conventional GroupPT and OT mean time 2.2h a day for 21 days

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Effectiveness of CIMT in hemiplegic CP2. Gordom AM et al (2006) showed CIMT improved movement

efficiency and environmental functional limitations in children with hemiplegic CP (4-13 years) of varying ages and that this efficacy is not age-dependent.[7]

Divided into 2 groups One group (4-8 year-old)Other group (9-14 year-old)

Each group received Sling worn 6 hours a day for 2 weeks

Without restraining unaffected arm and doing exercise at home 1 hour a day and extend to 2 hours a day after 1 month to 6 month interventionShaping and Repetitive task practice with time calculation

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Effectiveness of CIMT on hemiplegic CP3. Deluca SC et al (2006) showed pediatric constraint-

induced therapy produced significantly greater gains than usual rehabilitation services (PT and OT).[6]

CIMT Bivalved cast for 24 hoursShaping method, bearing weight on the arm, reaching, grasping etc.. for 6hours a day for 3 weeks.

Conventional PT and OT an average duration 2.2h a week then crossed over to CIMT group.

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Effectiveness of CIMT on hemiplegic CP

4. Nascimento LR et al (2009) showed that although the studies have small sample sizes and methodological differences, this is evidence supports the effectiveness of CIMT on hemiparesis CP children.[15]

5. Gordon AM et al are conducting a new research of a randomized control trial to test the efficacy of constraint-induced movement therapy and a new treatment involving bimanual (Hand-Arm Bimanual Intensive Therapy (HABIT) which is starting in July 2007 and will be completed in February 2011 .[24]

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Outcome measureMotor Activity Log (MAL)

Structured subjective interview with self-reported grade of the amount (how often) and quality (how well) of affected arm use for 30-item questionnaire (e.g., open a drawer, use a fork for eating) of 30 daily activities in a 0-5 point scale.[20]

The MAL is reliable and valid in subacute stroke (3 to 12 months post-stroke and had mild to moderate paresis of an UL).[20]

It may be used to assess the real-world effects of upper extremity neurorehabilitation and detect deficits in spontaneous use of the hemiparetic arm in daily life.[20]

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Motor Activity log Form

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Motor Activity log Form con’t…

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Outcome measurePediatric Motor Activity Log (PMAL)

Adapted from the Motor Activity Log (MAL) developed for adult patients with stroke.[17]

The PMAL is a semi-structured interview administered every other day to a child’s principal caregiver.[17]

It obtains orderly figures about 22 different arm-hand functional activities typical of young children and assess on how often and how well a child performs these activities.[17]

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Pediatric Motor Activity Log Form

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Pediatric Motor Activity Log Form

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Relevant Video Showing

Hemiplegic CP child with CIMT VideoStroke with CIMT Video

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References1. Brogårdh C, Flansbjer UB & Lexell J. What is the long-term benefit of constraint-induced

movement therapy? A four-year follow-up. Clinical Rehabilitation. 2009;23 (5): 418-423.2. Dahl AE, et al. Short- and long-term outcome of constraint-induced movement therapy after

stroke: a randomized controlled feasibility trial. Clinical Rehabilitation. 2008;22(5): 436-447.3. Doidge 2007, p. 139.4. Doidge 2007, p. 141.5. Dromerick AW, Edwards DF & Hahn M. Does Application of Constraint Induced Movement

Therapy During Acute Rehabilitation Reduce Arm Impairment After Ischemic Stroke? Stroke. 2000;31;2984-2988.

6. Deluca SC, Echols K, Law CR & Ramey SL. Intensive Pediatric Constraint-Induced Therapy for Children With Cerebral Palsy: Randomized, Controlled, Crossover Trial. J Child Neurol.2006;21:931—938.

7. Gordon AM, Charles J and Wolf SL. Efficacy of Constraint-Induced Movement Therapy on Involved Upper-Extremity Use in Children With Hemiplegic Cerebral Palsy Is Not Age-Dependent. Pediatrics. 2006;117;e363-e373.

8. Grotta JC, et al. Constraint Induced Movement Therapy. Stroke.2004;35[suppl I]:2699-2701.

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References9. Lin KC, et al. Effects of modified constraint-induced movement therapy on reach-to-grasp

movements and functional performance after chronic stroke: a randomized controlled study. Clin Rehabil. 2007;21:1075.

10. Lin KC, Chang YF, Wu CY & Chen YA. Effects of Constraint-Induced Therapy Versus Bilateral Arm Training on Motor Performance, Daily Functions, and Quality of Life in Stroke Survivors. Neurorehabilitation and Neural Repair. 2009;23(5): 441-448.

11. Lin KC, et al. Constraint-Induced Therapy Versus Dose-Matched Control Intervention to Improve Motor Ability, Basic/Extended Daily Functions, and Quality of Life in Stroke. Neurorehabilitation and Neural Repair. 2009;23(2):160-165.

12. Miltner W H.R, Bauder H, Sommer M, Dettmers C and Taub E. Effects of Constraint-Induced Movement Therapy onPatients With Chronic Motor Deficits After Stroke: A Replication. America Stroke Association. 1999;30;586-592.

13. Miltner W H.R, et al. Effective of Constraint-Induced Movement Therapy on Patient With Chronic Motor Deficits After Stroke A Replication. Stroke. 1999;30:586-592.

14. Morgan WG. The shaping game:a teaching technique. Behav Ther. 1974;5:271–272. 15. Nascimento LR, Glória AE & Habib ES. Effects of constraint-induced movement therapy as a

rehabilitation strategy for the affected upper limb of children with hemiparesis: systematic review of the literature. Rev Bras Fisioter, São Carlos. 2009;13(2):97-102.

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References16. Skinner BF.The Technology of Teaching. New York, NY: Appleton-Century-Crofts; 1968. 17. Taub E et al. Efficacy of constraint-induced movement therapy for children with cerebral palsy

with asymmetric motor impairment. Pediatrics. 2004; 113:305-312.18. Taub E, Harger M, Grier HC, Hodos W. Some anatomical observations following chronic

dorsal rhizotomy in monkey. Neuroscience. 1980;5:389-401.19. Taub E, Heitmann RD, Barro G. Alertness, level of activity, and purposive movement following

somatosensory deafferentation in monkeys. Ann N Y Acad Sci. 1977;29”0:348-365.20. Uswatte G et al. The Motor Activity Log-28. Assessing daily use of the hemiparetic arm after

stroke. NEUROLOGY. 2006;67:1189-1194.21. van der Lee JH, et al. Forced Use of the Upper Extremity in Chronic Stroke Patients:Results

From a Single-Blind Randomized Clinical Trial. Stroke.1999;30;2369- 2375.22. Wolf SL, et al. Effective of Constraint- Induced Movement Therapy on Upper Extremity

Function 3 to 9 Months After Stroke: The EXCITE Randomized Clinical Trail.JAMA.2006;296(17):2095-2104.

23. Wolf SL. Revisiting Constraint-Induced Movement Therapy: Are We Too Smitten With the Mitten? Is All Nonuse “Learned”? And Other Quandaries. Phys Ther. 2007;87:1212-1223.

24. http://clinicaltrials.gov/ct2/show/NCT00305006

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