Constraint Induced Movement Therapy

Constraint Induced Movement Therapy Putting evidence into practice

Karen Leslie (Senior CIMT Therapist)Nikki Owen (Senior CIMT Therapist)

Objectives

• Understand the background theory to CIMT and how evidence base was developed• Learn about the protocols for adults and how they were adapted for children• Overview of evidence base for treatment and its limitations• Understand our treatment criteria and protocols• Case studies

Development of a theoretical approach

Edward Taub’s work with monkeys between the 1960’s and 1980’s • Deafferentation of sensory nerves in forelimb results in decreased

functional use and increased reliance on unaffected limb • Initial motor depression following insult results in negative experiences of

using the limb but positive experience of unaffected limb. • Leads to learned non-use of affected limb, even after motor control restored• Theory of “learned non-use” developed• (Taub, 1963, 1976, 1980,)

Reversing learned non-use

• Restricting use of unaffected limb for 24 hours resulted in improved use of affected limb.

• However reverted back to original pattern of use once restriction removed• Restriction of use for longer period – eg 1 week of 24 hour continuous

restriction – resulted in carry-over once restriction removed. Limb use was clumsy but functional.

• With addition of specific task training, quality of limb activity improved (not to “normal” but to “very good”)

• (Taub, 1976, 1980)

Transfer to humans• Initial studies looked only at the constraint element (“Forced Use”)• Results were promising but treatment effect small (Ostendorf et al,

1981)• Taub’s team implemented the full protocol: constraint of unaffected

side and intensive training of affected side• They took patients > 4 years post stroke and split into groups• Experimental group wore mitt 90% waking hours, 6 hours training per

day for 14 days. Control group given passive movement programme• Experimental group showed significant increases in all objective

measures and in real-world arm use at two weeks, and at a two year follow up. No change in control group (Taub et al, 1993)

Transfer to humans• Other sites carried out similar research, all achieving positive results.• A large effect size for transfer of treatment outcome to daily activities is

considered to be 0.8. • Most studies of CI Therapy were producing effect sizes of between 2.1

to 4.0 (Taub, 2002)EXCITE RCT (Wolf et al, 2006)Single-blind, randomised multisite trial.7 sites, 222 patients, 12 month follow-up.2 week CIMT Programme –v- customary careCIMT produced statistically significant and clinically relevant improvements in arm motor function that persisted for at least 1 year.

CI Protocol for adultsThe key elements for CIMT in adults :

• Restraining the less affected arm• Shaping behaviour in the training tasks • Assuring the patient could understand and conduct the

training• Treatment provided by well trained therapists who could

motivate patients to participate• A transfer package to ensure achievements are carried out of

the clinic and into real life

Why CIMT works - Cortical Reorganisation

The representation of your body is continually reorganised on the cortexRepresentation is “use dependent”

• Braille readers (Sterr et al, 1998)• Violin players (Elbert et al, 1995)• Stroke patients (Liepert et al, 1998)

Representation can be altered quickly, but may not last.• Web four fingers together – “smudging” noted after 30 minutes. • Can last for 2 hours if webbed for 5 hours (Stavrinou et al, 2007)

Use-Dependent Cortical Reorganisation

CIMT has repeatedly been associated with use-dependent increase in cortical organisation.• Liepert et al (1998, 2000) showed increases in cortical regions of the

affected hand after CIMT.• The cortical changes remained on 6 month follow up.

CIMT - expanding applications• TBI• Hemispherectomy (up to

10 years post surgery)• Congenital hemiparesis

in adults• Focal hand dystonia• Nerve surgery

• Parkinson’s Disease• MS• Spinal cord injury• Lower limb• Speech

CIMT for ChildrenTaub’s team realised that the principles of CI Therapy for adults could easily be applied to children

“Learned non-use” / “Development Disregard”• For children who suffer CNS injury in prenatal, perinatal or early

postnatal the theoretical situation differs to that of an adult with a sudden CNS lesion.

• The underlying neural framework for movement with complex cortical pathways has not developed.

• The lack of movement and appropriate sensory input during early development can be devastating.

• The differences between the two sides of the body become greater and more noticeable with increasing age and functional use.

CIMT for ChildrenTaub et al (2004) applied CI Protocols to children for first time• RCT of 18 children with CP (7 – 96 months old)• CIMT vs conventional therapy• Casting unaffected arm and intensive training of affected side for 6 hours per

day over 21 consecutive days• CIMT group acquired significant improvements in:

• motor skills • amount and quality of more-affected arm use at home

• Benefits were maintained over 6 months, with supplemental evidence of quality-of-life changes for many children.

CIMT for Children• Deluca et al (2005) conducted a cross-over trial with

the same group of children.• Graph shows QUEST results at pre, post and 3 week

follow up.Evidence base for paediatrics continues to build.• Sakzewski et al (2009) – Systematic review

summarised that “CIMT resulted in a large treatment effect for the development of new UL motor skills and an increased amount of use of the impaired limb.”

• Sterling et al (2013) – replicated findings in changes to grey matter in children

Critique of Evidence

Sakzewski et al, 2009 • Inconsistencies in outcome measure & the intensity of intervention for control groups• Not all studies follow the same protocols.

CIMT – Developing our protocols• Multisite RCT with 6 month follow up (Case-Smith et al, 2012)• Compared 6 hours therapy per day with 3 hours per day (cast worn 24

hours)• Found no significant difference in improvements between groups

Our criteria and protocols - Adult

Criteria • > 6 months post-stroke• At least 10 degrees active wrist and finger extension (from any start position)• Cognitive ability to engage in treatment programme

Protocol• Constraint mitt worn 90% waking hours• 3 hours therapy a day, 5 days a week• 2 or 3 week programme

Our criteria and protocols - ChildrenCriteria • > 18 months old• Ability to tolerate treatment programme• Enough activity to positively participate in play• Parents / carers who are able to actively participate in programme and post-

treatment

Protocol• Non-removable cast worn for duration (changed weekly)• 3 hours therapy a day, 5 days a week – play based• 3 or 4 week programme

Boundaries of CIMTCIMT has a robust evidence base that shows it can make significant improvements to real-world use of an affected upper limb. However:• CIMT does not make movement “normal”• CIMT cannot restore motor function to match unaffected side• Effect of CIMT is determined by severity of the initial impairment• Taub (2007) – Retention rates tend to be 70% at 6 months follow up. • “One of the important factors contributing to good retention was the compliance of recommended post-

treatment regimen.”• He suggested “top-up” CIMT may be of benefit in future years for those children.• Highlights importance of follow up therapy input after CIMT programmes

Case Studies

Pre-Treatment Post-Treatment Difference

Dissociated Movements (%) 65 75 10Grasps (%) 44 55 11Weight Bearing (%) 72 84 12Overall Score (%) 60 71 11

Archie

QUEST – Quality of Upper Extremity Skills TestNote – an increase of 4.89% or more is considered statistically significant.

Case Studies

Pre-Treatment Post-Treatment Difference

Dissociated Movements (%) 65 75 10Grasps (%) 44 55 11Weight Bearing (%) 72 84 12Overall Score (%) 60 71 11

Archie

QUEST – Quality of Upper Extremity Skills TestNote – an increase of 4.89% or more is considered statistically significant.

Case StudiesHarry

ReferencesCase-Smith, J., DeLuca, S., Stevenson, R., Ramey, S. L (2012) Multicenter Randomized Controlled Trial of Pediatric Constraint-Induced Movement Therapy: 6-Month Follow-Up. American Journal of Occupational Therapy, 66, 15–23Deluca, S. C., Echols, K., Law, C. R., Ramey, S. L. (2006) Intensive Pediatric Constraint-Induced Therapy for Children With Cerebral Palsy: Randomized, Controlled, Crossover Trial. Journal of Child Neurology 21:931–938 Elbert T, Pantev C, Wienbruch C, Rockstroh B, Taub E. (1995) Increased use of the left hand in string players associated with increased cortical representation of the fingers. Science 1995; 220:21-23.Liepert J, Bauder H, Sommer M, Miltner WHR, Dettmers C, Taub E, Weiller C (1998). Motor cortex plasticity during Constraint-Induced Movement therapy in chronic stroke patients. Neuroscience Letters 1998; 250:5-8Liepert J, Bauder H, Miltner WHR, Taub E, Weiller C. (2000) Treatment-induced cortical reorganization after stroke in humans. Stroke; 31:1210-1216Ostendorf CG, Wolf SL. (1981) Effect of forced use of the upper extremity of a hemiplegic patient on changes in function. Phys Therapy 61:1022-1028.

ReferencesSakzewski, L., Ziviani, J., Boyd, R., (2009) Systematic Review and Meta-analysis of Therapeutic Management of Upper-Limb Dysfunction in Children with Congenital Hemiplegia. Pediatrics ;123;e1111-e1122; Stavrinou, M.L, Penna, S. D., Pizzella, V., Torquati, K., Cianflone, F., Franciotti, R., Bezerianos, A., Romani, G. L., Rossini, P. M. (2007) Temporal Dynamics of Plastic Changes in Human Primary Somatosensory Cortex after Finger Webbing. Cerebral Cortex 17(9) 2134-2142Sterling, C., Taub, E., Davis, D., Rickards, T., Gauthier, L.V., Griffin, A., Uswatte, G. (2013) Structural Neuroplastic Change After Constraint-Induced Movement Therapy in Children With Cerebral Palsy. PEDIATRICS Vol. 131 No. 5Sterr A, Müller MM, Elbert T, Rockstroh B, Pantev C, Taub E. (1998) Changed perceptions in Braille readers. Nature 391:134-135Taub E, Berman AJ. (1963) Avoidance conditioning in the absence of relevant proprioceptive and exteroceptive feedback. J Comp Physiol Psychol; 56:1012-1016Taub E. (1976) Motor behavior following deafferentation in the developing and motorically mature monkey. In: Herman R, Grillner S, Ralston HJ, Stein PSG, Stuart, D, eds., Neural Control of Locomotion. New York: Plenum, 675-705

ReferencesTaub E. (1980) Somatosensory deafferentation research with monkeys: implications for rehabilitation medicine. In: Ince LP, ed., Behavioral Psychology in Rehabilitation Medicine: Clinical Applications. New York: Williams & Wilkins, 371-401Taub E, Miller NE, Novack TA, Cook EW III, Fleming WC, Nepomuceno CS, Connell JS, Crago JE. (1993) Technique to improve chronic motor deficit after stroke. Arch Phys Med Rehabil; 74:347-354Taub E, Uswatte G, Elbert T. (2002) New treatments in neurorehabilitation founded on basic research. Nature Reviews Neuroscience 3:228-236Taub, E., Griffin, A., Nicka, J., Gammonsa, K., Uswattea, G., Law, C. R. (2007) Pediatric CI therapy for stroke-induced hemiparesis in young children. Developmental Neurorehabilitation, 10 (1)Taub E, Ramey S L, DeLuca S, Echols K. (2004) Efficacy of Constraint-Induced (CI) Movement therapy for children with cerebral palsy with asymmetric motor impairment. Pediatrics ;113: 305-312Wolf, S., Winstein, C., Miller, P. J., Taub, E., Uswatte, G., Morris, D., Giuliani, C., Light, K. E., Nichols-Larsen, D. (2006) Effect of Constraint-Induced MovementTherapy on Upper Extremity Function 3 to 9 Months After Stroke. The EXCITE Randomized Clinical Trial. Journal of the American Medical Association, November 1, Vol 296, No. 17