CONSTRAINT INDUCED MOVEMENT THERAPY Healing is a matter of time, but sometimes it is also a matter of opportunity. Hippocrates. Healing in Neurological conditions is a ongoing process and usually consumes long treatment durations. Many treatment approaches are introduced in Neurological Rehabilitation. One among them and the most popular treatment approach commonly practiced in Neurological Rehabilitation is Constraint Induced Movement Therapy (CIMT).CIMT is a technique that supports the use of traditional Neuro Rehabilitation and motor recovery therapies, in which constraint of the non-affected upper extremity, combined with repetitive use of the affected upper extremity, works to improve motor recovery and subsequently function and performance. CIMT helps a client overcome forced nonuse and at the same time helps the patient train the affected upper extremity. CIMT is a type of treatment of clients with motor system limitations that combined constraint or immobilization of the unaffected arm with forced use of the affected limb. A hand mitt or sling is used to constrain the use of unaffected upper limb while the affected limb is engaged in forced use, mass practice meaningful motor task. The treatment focus on shaping the behavior to improve functional use of impaired limb. CMT is based on the theory that impairment in hand and arm function in clients after a stroke is compounded by learned nonuse of affected upper extremity,which leads to physical change in the cortical representation of upper limb. Origin of CIMT: The principles of this method originated from theories in behavioural psychology, motor learning, and skills acquisition. Early research was done by Dr. Edward Taub on surgically deafferented monkeys.early primate studies demonstrated that if the upper limb was surgically impaired by dorsal rhizotomy to disrupt afferent input to the sensory cortex, the animal stopped using the limb for function. Later, the active mobility was restored by immobilizing the intact upper limb for several days while training the animal to use the affected limb. It was then used to treat humans with stroke or traumatic brain injury, and more recently to treat children with cerebral palsy.
Types of restraints used: The restraints commonly used for CIMT includes, sling triangular bandage splint sling combined with a resting hand splint, half glove mitt Figure: 1.splints used as restraints Figure: 2. Mitt.
Figure: 3. half glove Selection of restraints: Determination of the type of restraint used for therapy depends on the required level of safety versus 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. 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 in complete tasks. 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.
Treatment Models of CIMT: The treatment models are commonly explained in two methods the Unmodified and Modified CIMT. Unmodified CIMT: Unmodified is a treatment model that uses a variety of motor control approaches to promote the affected limb for 90% of the individuals waking hours. Only activities involving toileting, hygiene (at least weight bear) and bathing or an activity which would be dangerous if the other limb was not used are permitted. This is done by constraining or reducing the use of the unaffected extremity for 2-3 weeks. The most used Constraints of the UE are that of a sling, mitts with Velcro or resting hand splints. Modified CIMT: Modified CIMT, a more pragmatic model. The program consists of 3 hour per day sessions for 5 days/week, for a minimumof 4 successive weeks. In total there will be 20 treatment sessions totaling to 60 hours. The client is expected to use his/her affected extremity for a minimum of the five top arm use hours at home during each week day. Figure: 4. CIMT treatment session
Neurophysiologic basis for CMT: The neurophysiologic mechanisms that are believed to underline treatment benefits of CIMT include overcoming learned nonuse and plastic brain reorganization. It influences the brain to develop connectivity that improves motor function. The brain changes itself when the affected extremity is involved intensively and repetitively for various activities. Furthermore, Page et al. found that repeated task-specific practice (shaping/repetition) is more critical than intensity in improving function. The effect of CIMT is explained as Cortical Reorganization Dendrite branching Redundancy Synaptic strength. Neurons that fire together, wire together. When the extremity associated with those neurons is not used, the neurons are used by the brain for other functions. In essence, the goal is to rewire or develop new paths referred as dendritic branching. The hardwiring (synaptic intensity) of the motor and sensory centers of the brain.neuroimaging studies such as transcranial magnetic stimulation (TMS),Fmri and electroencephalography have been used to provide cortical evidence of Neuroplasticity and cortical changes after CIMT. Studies have validated that massed practice of CIMT produce a massive use-dependent cortical reorganization. This change increases the area in which the cortex is involved during voluntary movements of an affected limb. Treatment components: The three important components of CIMT is Repetition, structure, intense practice of the affected arm. Restraint of the less-affected arm, Monitored arm use in life situations and problem solving to overcome barriers
Therapeutic effects and procedures: CIM, or forced-use, treatment may be an appropriate method to improve sensorimotor recovery after stroke. Most rehabilitation treatments for hemiplegic patients focus on compensatory strategies to promote independence in ADL by any means rather than restoration of UE function. Typically, patients are taught to use the unaffected UE and various assistive devices for ADL. In contrast, CIM treatment discourages the use of the unaffected UE and encourages the use of the hemiplegic arm. The goal of this treatment is to maximize or restore motor function. Requirements for participation: The individual needs to have a basic grasp/release to be eligible for the program. They also need to be safe for mobility while having one hand in a cast a three-week period of at least two hours of direct, one-to-one treatment three times per week and following a Home exercise programme. Simply, follow 10 x 10 x 10 eligibility criteria in selecting a patient for CIMT. 10 degrees active wrist extension 10 degrees active thumb abduction 10 degrees active extension of any other two digits on affected hand. General Treatment Protocol: The following points are important to be remembered in training sessions, Repetitive training of more affected UE Behavioral agreement Treatment diary. Unmodified CIMT protocol: Direct intervention for 6-8 hours per day continuing for 5 days in a week, the programme is scheduled for 2-3 weeks. During week end the duration allotted should be 3-4 hours. The specific task in Home programme along with Activities of daily living is practiced.
Modified CIMT treatment protocol: Exercise activities would be done with the restraint on. On weekends, patient should wear the belt and prevented from any kind of specific exercises. Patients were encouraged to be active and to use the affected arm in daily activities at home. Shaping was used by giving strong reinforcement when patients succeeded in performing a functional activity; the activity was then increased in difficulty. Training programme will be performed 6 hours per day, Monday through Friday, for 2 weeks. Varied shaping, task practice, and exercises are designed on the basis of individual resources and problems; patient-specific tasks were chosen and practised. Each task was subdivided into sub-task practice; all aspects of the task were practised (strength, coordination, and speed). For example, a patient's training programme might include weightbearing practice, moving articles as fast as possible, playing ball games, and writing or working in the kitchen. The intensity of the exercises will be increased depending on patient functional level. Such alterations included increasing the number of repetitions per unit, increasing the resistance or load, changing the spatial domain or the level of complexity in which the task was undertaken, and introducing new and more difficult tasks. Training was organized on the basis of the theories of motor control, motor learning, and recovery of function. In the cognitive phase of motor learning, patients were stimulated to find the motor function; in the associative phase of learning, exercises were practised repetitively, varied, and done under different conditions and in different environments. The environment varied during the day between the physiotherapy gymnasium, the occupational therapy room, the kitchen, the dining room, the occupational workshop, and the rehabilitation garden. Short rest periods are included regularly during the training hours, and after lunch patients can take a half-hour rest. If the patient did not complete the 6 hours of training during the rehabilitation day, he or she can practice the same at home.
Advantages of CIMT: Overall greater improvements in function vs. conventional treatment Highly researched and credible treatment approach Increases daily/social participation Decrease in medical cost over lifetime. Disadvantages to CIMT: Requires enormous labor from both patient & medical staff Patient endures many hours of frustration Patients can suffer from muscle soreness resulting in Stiffness and discomfort in the involved upper extremity as well as skin lesions and skin burns. Typically for patients with higher level of function Application of CIMT for patients with stroke: The centers for disease control and prevention states that,stroke is a leading cause of death in the United States, killing nearly 130,000 Americans each year that s 1 of every 19 deaths. Although most stroke survivors recover to some degree, many survivors are left with significant sensorimotor and cognitive deficits. These deficits produce long-term need for assistance from caregivers and society. Most stroke treatment research has focused on minimizing brain injury in the acute phase, promoting early reperfusion of ischemic brain, developing neuro protection strategies, and treating cerebral edema. Another treatment strategy is to promote clinical improvement despite neurological deficit. One potential method to improve sensorimotor recovery after stroke is constraint induced movement (CIM), or forced use. Most rehabilitation treatments of the hemiplegic patient focus on compensation rather than restoration of upper-extremity (UE) function. Patients are taught to use the unaffected UE for activities of daily living (ADL). In contrast, CIM treatment discourages the use of the unaffected extremity and encourages active use of the hemiplegic arm. The goal is to maximize or restore motor function.
Recent findings regarding neuroplasticity and cortical reorganization also explain the reported effectiveness of CIM. Dr.Nudo and others describe cortical representation shrinking after lesioning or sensory/motor deprivation. Changes in representational areas were prevented or reversed by focused motor training in primates with concurrent improvements in motor function In addition, functional imaging studies in humans with stroke have found recovery to be associated with shifts of activation during motor tasks involving the affected hand to ipsilateral secondary and tertiary motor areas and to contra lateral homologous motor Areas.CIM might be more effective than traditional therapies in promoting these representational changes for stroke population. Constraint Induced Movement Therapy for children: Children with impaired functioning of one of their arms can have disabling symptoms affecting play, school, and self-care. Hand and arm functioning may be affected by abnormal muscle tone and flexion synergies, decreased strength, decreased active and passive range of motion, altered sensation, and neglect.also, children with hemiplegia due to central nervous system damage are often affected by mirror movements--unconscious and uncontrolled movement of one hand following the same pattern as the contra lateral hand impacting the ability to use two hands when the hands are required to do different movements for example, one hand stabilizes an object while the other acts on the object. Current theory suggests that children with unilateral upper extremity impairment must overcome developmental non-use, a term indicating that the children never have effectively used the impaired upper extremity. Another term frequently used in literature is learned non-use, a term referring to hemiplegia in an individual who previously had functional use of the arm (e.g. a person who had an acquired stroke or traumatic brain injury).traditionally, children with hemiplegia or brachial plexus injury receive occupational therapy and physical therapy services to maximize their functional skills. Conventional treatment approaches focus on a mix of biomechanical, developmental, Neurodevelopmental, and Rehabilitative models. Children with hemiplegia or brain injury receiving CIMT for 21 consecutive days, 6 hours a day, demonstrated significant improvement in the amount of use, quality of movement and spontaneous use of affected Upper extremity.
Treatment Protocol: It is recommended that the therapists engage in shared decision making and educate parents. Proper guidelines should be informed to the parents prior the treatment sessions. PROTOCOL 1: Based on Eliasson et al Criteria Duration of Intervention Daily Constraint Wear Daily Structured Practice with Caregiver Method of Constraint Treatment specifications 8 weeks 2 hours per day 2 hours per day while wearing constraint Ace Wrap Pedi-wrap Splint/Glove Removable Cast Frequency of Therapy 1 time per week PROTOCOL 2: Based on Willis et al Criteria Duration of Intervention Daily Constraint Wear Daily Structured Practice with Caregiver Method of Constraint Frequency of Therapy Treatment specifications 4 weeks 24 hours per day No additional practice required but 2 hours daily practice with caregiver encouraged Removable Cast 1 time per week Method and Fabrication of Constraint: Many types of constraints have been studied in the literature but there is insufficient evidence to support the use of a specific type. The common method of constraint was a "constraining glove" using a volar splint with thumb fixed against index finger inside of a cloth glove, with the goal of preventing "the ability
to grasp" while allowing the child to "use the hand for support or for breaking a fall". The practical experience of the author, some young children do well with ace wrapping their unaffected arm or wearing a Pedi-wrap. However, some toddlers and children require a more robust constraint from which they cannot slip out. These children will likely benefit from a hand splint with a cover (a puppet or sock) or a removable cast. Older children who are able to understand the reason for constraint use may be able to use less restrictive constraints such as ace wrap to the unaffected arm. It is recommended that the fabrication of removable casts for constraint be completed by occupational therapists with specific training in their fabrication.cast fabrication is a skill that, done incorrectly, has potential to cause harm to the child's arm. Parent Education and Home Program: The success of the therapy depends on the efficient continuity of the training programme. It is recommended that a home program be developed and updated weekly to guide caregivers' daily structured practice with the children. Features of the home program include: Concentrate on specific functional activities of interest to the family and child. It is ideal to focuses on one specific skill each week Provide them the form of an activity log to encourage daily follow up throughout the program. Figure: 5. CIMT for child, Left upper limb is constrained A decline in function and performance may not be due to the change in context/contextual interference (generalization) but instead or also due to this phenomenon of diminished limb
recognition in the brain. In trying to foster behavioral change, plasticity changes occur with this intensive rehabilitation model resulting in improved motor control and performance and motor learning. The ultimate goal of treatment is to maximize social participation and quality of life. However, in the early phase of treatment development, it seemed most reasonable to use measures that directly assessed the mechanism by which gains in social participation and quality of life would be achieved. Several lines of reasoning support early implementation of CIM. From a motor learning perspective, early implementation might minimize learned nonuse. It might be easier to prevent behaviors than attempt to extinguish them once they are established. Research evidences also suggest that early implementation of motor training could prevent shrinkage of cortical representational areas. There might also be a window of opportunity after brain injury.
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