Archive for category Constraint induced movement therapy CIMT

[ARTICLE] Effects of lower extremity constraint-induced movement therapy on gait and balance of chronic hemiparetic patients after stroke: description of a study protocol for a randomized controlled clinical trial – Full Text

Abstract

Background

Protocols involving intensive practice have shown positive outcomes. Constraint induced movement therapy (CIT) appears to be one of the best options for better outcomes in upper limb rehabilitation, but we still have little data about lower extremity constraint-induced movement therapy (LE-CIT) and its effects on gait and balance.

Objective

To evaluate the effects of an LE-CIT protocol on gait functionality and balance in chronic hemiparetic patients following a stroke.

Methods

The study adopts a randomized, controlled, single-blinded study design. Forty-two patients, who suffered a stroke, who were in the chronic phase of recovery (>6 months), with gait disability (no community gait), and who were able to walk at least 10 m with or without the advice or support of 1 person, will be randomly allocated to 2 groups: the LE-CIT group or the control group (intensive conventional therapy). People will be excluded if they have speech deficits that render them unable to understand and/or answer properly to evaluation scales and exercises selected for the protocol and/or if they have suffered any clinical event between the screening and the beginning of the protocol. Outcome will be assessed at baseline (T0), immediately after the intervention (T1), and after 6 months (T2). The outcome measures chosen for this trial are as follows: 6-min walk test (6minWT), 10-m walk test (10mWT), timed up and go (TUG), 3-D gait analysis (3DGA), Mini Balance Evaluation Systems Test (Mini-BESTest), and as a secondary measure, Lower Extremity Motor Activity Log will be evaluated (LE-MAL). The participants in both groups will receive 15 consecutive days of daily exercise. The participants in the LE-CIT group will be submitted to this protocol 2.5 h/day for 15 consecutive days. It will include (1) intensive supervised training, (2) use of shaping as strategy for motor training, and (3) application of a transfer package (plus 30 min). The control group will receive conventional physiotherapy for 2.5 h/day over 15 consecutive days (the same period as the CIT intervention). Repeated measures analyses will be made to compare differences and define clinically relevant changes between groups.

Results

Data collection is currently on-going and results are expected in 2021.

Discussion

LE-CIT seems to be a good protocol for inclusion into stroke survivors’ rehabilitation as it has all the components needed for positive results, as well as intensity and transference of gains to daily life activities.

Trial registration

www.ensaiosclinicos.gov.brRBR-467cv6. Registered on 10 October 2017. “Effects of Lower Extremities – Constraint Induced Therapy on gait and balance function in chronic hemipretic post-stroke patients”.

Peer Review reports

Background

Cardiovascular disease is the leading cause of death in the world, representing 31% of the total number of deaths in 2017 [1]. Stroke accounts for almost half of these deaths [1] which means that it is the second greatest cause of death around the world [2] and the third most common cause of disability [3]. Hemiplegia is often the most common sequel caused by stroke, compromising independence in mobility at home or in the community, which sometimes results in losing premorbid society roles and requiring care for a long period of time [4].

Studies have reported that 6 months after the injury, 30% of patients are still unable to walk without assistance [5,6,7], and 1 year after the event (with relatively good recuperation), half of these patients are still not able to complete the 6-min walk test, walking just 40% of the predicted distance [7]. Despite all rehabilitative efforts, 35% of patients with initial paralysis in lower limbs are still unable to recover a functional gait and 25% are not able to walk without external aid [8]. Thus, within physiotherapy services, the majority of interventions involve approaches to gait training [9].

Protocols involving intensive practice have shown positive outcomes. Constraint induced movement therapy (CIT) appears to be one of the best options for better outcomes in upper limb rehabilitation. Experimental studies in the 1960s using CIT demonstrated that monkeys that suffered sensory deafferentation of their forelimb and then acquired learned non-use were able to use that paw again after having their unimpaired limb constrained for a number of days [10].

A growing number of studies have since supported the efficacy of CIT in upper limb rehabilitation for patients with chronic hemiparesis caused by stroke, which has been recognized and recommended within the treatment sets for this population [11,12,13]. Moreover, it has been considered the most effective physiotherapy approach for getting better rehabilitation outcomes for paretic upper limbs [1415].

CIT has been defined as a “therapeutic package” consisting of different numbers of compounds of combined treatment, used in a systematic and integrated way to engage the patient in using their affected limb for many hours per day over 2–3 consecutive weeks [16]. One of the main advantages of CIT in relation to the various different approaches used in neurological rehabilitation is that it is focused on the behavioral aspects of the method (monitoring, self-efficacy, solving problems, and contractual intervention); this guarantees the active participation of patient during the entire protocol [16].

The current CIT protocol consists of 3 main elements with multiple components and sub-components: (1) repetitive and task-oriented training (diary training with supervision), (2) behavioral strategies (transference package), and (3) constraint of affected limb (for upper extremity protocol) and/or any method to constantly remind the participant to use their more affected limb [16,17,18].

Post-stroke patients submitted to the CIT protocol for upper extremities present notable changes in the central nervous system (CNS) with improvement in cortical activation and increase of brain areas, using transcranial magnetic stimulation [19,20,21] or functional magnetic resonance [22,23,24].

There are still few data about lower extremity constraint-induced movement therapy (LE-CIT). In 2013, a case series was published which had been conducted on multiple sclerosis patients with a 4-year follow-up. At the end of the protocol they observed that these patients showed a notable improvement in Lower Extremity Motor Activity Log (LE-MAL) [25].

Although the studies used modified CIT, its methodology was not fully applied. For instance, the intensity applied was lower than that defined by the protocol; the presence of physical constraint on the non-affected side is described (this was discarded as it can create a bigger asymmetry and more abnormal movement); structure of training built without citing shaping (approaching in small steps); adoption of only one exercise, or a simple combination of different therapeutic approaches such as Bobath, muscle strengthening, or climbing stairs [26]; absence of a transference package, or differences in its structure (making only one homework list with exercises instead of a new list every day with different functional tasks); absence of a behavioral contract; and control group not receiving the same intensity of training [2728].

Despite not adhering exactly to the recommended model of CIT, these studies observed positive results such as an improvement in motor function, mobility, dynamic balance, discharge weight symmetry, gait ability, gait speed, length and width of step, and force of foot ground contact [2628]. However, in view of the above information, the investigation of the effects of the original LE-CIT protocol on gait functionality and balance of chronic hemiparetic patients following a stroke was not completely clarified.

The following research question was established to examine the effects of LE-CIT vs intensive conventional therapy on gait functionality and balance, as well as the transference of these gains in therapy to the environment outside the clinical setting in chronic hemiparetic patients following a stroke: is LE-CIT more effective compared with intensive conventional therapy with regard to gait functionality and balance in people suffering from stroke?[…]

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[BLOG] Using Neofect smart glove to maximize Constraint Induced Movement Therapy

Constraint-Induced Movement Therapy

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Constraint-Induced Movement Therapy (CIMT) is used to treat people with hemiplegia by constraining or restricting movement of the non-affected hand to force a person to use their affected hand. The idea capitalizes on neuroplasticity to encourage intensive repetitions of movements, which create stronger neural pathways to move the affected hand.

CIMT has been extensively studied for people with hemiplegia as a result of stroke or cerebral palsy. It has been shown to be an effective therapeutic approach to increase spontaneous use, quality of movement, and improve the ability to engage in daily activities.

The key components of CIMT are constraining the non-affected arm and intensive shaping. There are a variety of constraints used and none of them have been shown to be more effective than another. People have used casts, splints, and mitts. Intensive shaping refers to intensive repetitions of movements and tasks that are designed to become progressively harder.

Neuroplasticity

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The brain changes throughout our lifetime. We do create habits and strong neural connections as we get older, but even if the brain is damaged and the signal from the brain to a muscle is impaired, the brain is able to rewire itself to create new pathways. We develop these pathways with intensive repetitions. This is called neuroplasticity.

The brain is neurologically wired to complete an activity in the easiest way possible. After a stroke, it’s easier for the brain to compensate with other body parts then to send a signal to your affected hand (i.e. you’re more likely to use your mouth to open a snack package then attempt to grasp with your affected hand). It’s not that people are “cheaters”, their brain is using adaptations to be the most efficient. But we also know that if you don’t use it, you lose it. So how can we get those intensive repetitions in if the brain is telling us there’s an easier way? That’s where CIMT comes in.

The mechanism by which constraint-induced therapy is not fully understood, but hypothetically if you can make your brain believe that your non-affected hand is less useful than your affected hand AND your brain is making every effort to complete a task, the brain will start working on sending better signals to the arm that is not constrained.

In CIMT we focus on sending signals to the muscles to move our arm and hand in specific ways because there are certain movements that improve function.

Movements and Function

Every person is unique when it comes to what movements and joints are used to complete a task, but there are several movements that assist us in being the most effective and efficient: supination, wrist extension, wrist radial/ulnar deviation, and finger flexion/extension. We need to practice these motions over and over until our brain is able to send a signal to the muscle easier. When doing CIMT, occupational therapists recommend a wide variety of activities to elicit these movements.

Supination
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Turning the palm up towards the ceiling, even a little, helps us hold large objects, feed ourselves, stabilize a bottle to open, hold our phone to access it with our other hand, hold paper to cut with scissors, and manage buttons.

Activities to practice supination:

  • Throwing a beanbag or ball underhand
  • Scooping sand or water with a small cup
  • Turning a rain stick or glitter wand over
  • Playing musical instruments, such as cymbals
  • Card games/flipping cards over

Wrist Extension
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Bending the wrist up and down helps our fingers open and close to provide a more effective grasp then simply moving our finger joints. Try it out: bend your wrist downward completely and hold it there, now try to pick up a coin from the tabletop without sliding it to the edge. Then try to simulate placing the penny in a vertical slot the way a vending machine slot would be positioned. You might be able to pick up the coin, but I guarantee you no matter how hard you compensate with the rest of your body, if your wrist is completely flexed, you won’t be able to get the coin where it needs to be.

Wrist extension helps us be more successful with activities such as putting socks and shoes on, pulling up our pants, holding a glass, zipping a zipper, and tying shoes.

Activities to practice wrist extension:

  • Rolling dough to make large pretzels
  • Washing windows or mirrors
  • Working on a vertical surface (fridge, mirror, wall, whiteboard, bulletin board, easel, etc.); place or remove stickers, magnets, velcro, push pins, etc

Wrist Radial/Ulnar Deviation
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Bending the wrist side to side is radial and ulnar deviation (think about your wrist moving like a windshield wiper). Radial deviation is moving the wrist to the thumb side. I remember it by “thumbs up when something is rad!” (radial deviation), and ulnar deviation is moving the wrist towards the pinky side. I don’t have a trick for this one, I just know it’s the other one. 🙂

Having the ability to move the wrist into radial and ulnar deviation is helpful for eating with a fork or spoon, buttoning pants, brushing hair, pouring from a pitcher, and zipping a zipper.

Activities to practice radial and ulnar deviation:

  • Playing drums with a drumstick
  • Putting money in a vending machine
  • Turning a nut on a bolt
  • Turning a door knob

Finger Flexion and Extension
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Opening and closing the fingers is needed to pick up or stabilize objects. Flexing the fingers creates a gross grasp that is good for holding a cup, pushing a grocery cart, holding a fork for cutting with a fork and knife, and opening a jar.

Activity ideas to work on finger flexion and extension:

  • Carrying a bucket
  • Pushing a grocery cart
  • Squeezing a stress ball
  • Pulling a rope

NEOFECT Smart Glove

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When it comes to neuroplasticity it’s all about repetitions. In a typical therapy session, one can expect to complete 20-30 repetitions of movement by completing activities that incorporate the movements above. With the NEOFECT Smart Glove, you can get up to 200-300 repetitions in a 30 minute session.

The other key feature of the Smart Glove is the algorithm and the ability to set the parameters of the game to your movements. The Smart Glove and the software allow you to complete a game within your capabilities and then pushes you a little further by progressively making the demands of the game more difficult, which is the concept of intensive shaping.

The NEOFECT Smart Glove is only one piece of the rehab journey in CIMT. Isolating movements create stronger neural pathways to specific muscles so that when you go to complete a functional task, you’re more likely to utilize those muscles, but there are many ways to accomplish a task. You use a combination of muscles to coordinate your movement. When it comes to intensive repetition for neuroplasticity, you also need to do intensive repetitions of a functional task to work on coordinating multiple muscles to work together. You can do this by incorporating the self-care activities you already do everyday as your “exercises”. Be on the lookout for the NEOFECT connect app that will show you how to work your training into everyday life.

To learn about how the Neofect Smart Glove can help you perform repetitive exercises in a fun and motivating way during CIMT and beyond please call us at 888-623-8947 or email us at contactus@neofect.com. Our occupational therapists are available to help you on your rehab journey!

References:

  1. Yu-Ping Chen, Stephanie Pope, Dana Tyler, Gordon L. Warren
    Clin Rehabil. 2014 Oct Effectiveness of constraint-induced movement therapy on upper-extremity function in children with cerebral palsy: a systematic review and meta-analysis of randomized controlled trials.; 28(10): 939–953. Published online 2014 Aug 14. doi: 10.1177/0269215514544982
  2. Kwakkel, G., Veerbeek, J. M., van Wegen, E. E., & Wolf, S. L. (2015). Constraint-induced movement therapy after stroke. The Lancet. Neurology, 14(2), 224–234. doi:10.1016/S1474-4422(14)70160-7
  3. Shin, J. H., Kim, M. Y., Lee, J. Y., Jeon, Y. J., Kim, S., Lee, S., … Choi, Y. (2016). Effects of virtual reality-based rehabilitation on distal upper extremity function and health-related quality of life: a single-blinded, randomized controlled trial. Journal of neuroengineering and rehabilitation, 13, 17. doi:10.1186/s12984-016-0125-x

Additional References:
Constraint Induced Movement Therapy:
Cleveland Clinic – Constraint-Induced Movement Therapy
Physiopedia – Constraint-Induced Movement Therapy
Canadian Partnership for Stroke Recovery – Constraint-Induced Movement Therapy – Upper Extremity
Neuroplasticity:
Brainworks – What is Neuroplasticity
ScienceDirect – Neuroplasticity

All content provided on this blog is for informational purposes only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. If you think you may have a medical emergency, call your doctor or 911 immediately. Reliance on any information provided by the NEOFECT website is solely at your own risk.

WRITTEN BY


Clarice Torrey, OTR/L

Clarice is an occupational therapist, product designer, and health writer based out of San Francisco, CA. Clarice currently works as a Senior Clinical Manager for Neofect USA.

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[ARTICLE] Effects of Lower Extremities Constraint Induced Movement Therapy on Gait and Balance of Chronic Hemiparetic Patients After Stroke: Description of a Study Protocol for a Randomized Controlled Clinical Trial. – Full Text

Abstract

Background

Protocols involving intensive practice have shown positive outcomes. Constraint Induced Movement Therapy (CIT) appears to be one of the best options for better outcomes in upper limb rehabilitation, but we still have little data about Lower Extremities – Constraint Induced Movement Therapy (LE-CIT) and its effects on gait and balance.

Objective

To evaluate the effects of an LE-CIT protocol on gait functionality and balance in chronic hemiparetic patients following a stroke.

Methods

The study adopts a randomized, controlled, single-blinded study design. 42 patients who suffered a stroke event, in the chronic phase of recovery (>6 months), with gait disability (no community gait), able to walk at least 10 meters with or without the advice or support of 1 person, will be randomly allocated to 2 groups: the LE-CIT Group or the Control Group (Intensive Conventional Therapy). People will be excluded if they have speech deficits that render them unable to understand and/or answer properly to evaluation scales and exercises selected for the protocol and/or if they have suffered any clinical event between the screening and the beginning of the protocol. Outcome will be assessed at baseline (T0), immediately after the intervention (T1), and after 6 months (T2). The outcome measures chosen for this trial are: 6 minute walk test (6minWT), 10 meter walk test (10mWT), Timed Up and Go (TUG), 3-D gait analysis (3DGA), Mini Balance Evaluation Systems Test (Mini-BESTest) and, as a secondary measure, Lower Extremity Motor Activity Log will be evaluated (LE-MAL). The participants in both groups will receive 15 followed days of daily exercise. The participants in the LE-CIT Group will be submitted to this protocol 2.5 hour/day for 15 followed days. It will include: 1) intensive supervised training, 2) use of shaping as strategy for motor training, and 3) application of a transfer package (plus 30 minutes). The Control Group will receive conventional physiotherapy for 2.5 hours/day over 15 followed days (the same period as the CIT intervention). Repeated measures analyses will be made to compare differences and define clinically relevant changes between groups.

Results

Data collection is currently on-going and results are expected in 2021.

Discussion: LE-CIT seems to be a good protocol for inclusion into stroke survivors’ rehabilitation as it has all the components needed for positive results, as well as intensity and transference of gains to daily life activities.

Trial Registration: www.ensaiosclinicos.gov.br (Register Number: RBR-467cv6). Date of registration: October 10, 2017. “Effects of Lower Extremities – Constraint Induced Therapy on gait and balance function in chronic hemipretic post-stroke patients”.

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[Abstract] Constraint Induced Movement Therapy Increases Functionality and Quality of Life after Stroke

Highlights

CIMT reduced spasticity

• Motor function of the upper limb and functional range improved with CIMT

• CIMT changed the quality of life

• One hour daily for 3x a week and without additional restriction time was sufficient

• CIMT promoted better adherence compared to the original protocol.

Abstract

This blind randomized clinical trial evaluated the effect of CIMT on the functionality and quality of life (QOL) of chronic hemiparetics. Thirty volunteers were divided into two groups: Control (CG) and CIMT (CIMTG); evaluated before and after 12 and 24 intervention sessions. The scales used were: adapted Fugl-Meyer Motor Assessment (FMA), Modified Ashworth, Stroke Specific Quality Of Life (SS-QOL) and the Functional Reach Test (FRT). The scores for all FMA variables in the CIMTG increased until the 24th session, differing from the pre-treatment. In the CG, the scores increased for pain, coordination/ speed and sensitivity. In the FRT there was an increase in the scores in both groups; after the 12th and 24th sessions, the result of the CIMTG was superior to the CG. For the SS-QOL in the CIMTG, the general score and most of the variables increased, as well as in the CG. Muscle tone in CIMTG was lower compared to CG after 24 sessions. Both protocols used in the study were effective, the CIMT protocol showed benefits in recovering the functionality of the paretic upper limb, in the functional range and in reducing muscle tone, with a consequent improvement in quality of life.

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[BLOG POST] TeleCIMT TIDE Project | Stroke arm rehabilitation

TeleCIMT

Supporting the delivery of Constraint-Induced Movement Therapy (CIMT) for arm recovery via telehealth (TeleCIMT)

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The TeleCIMT Approach
Constraint-Induced Movement Therapy (CIMT) is a proven arm rehabilitation approach that involves intensive use of your weaker arm whilst wearing a mitt on your stronger arm. CIMT has been developed to improve arm function after a neurological injury, such as after a stroke. Constraint-Induced Movement Therapy (CIMT) is a proven arm rehabilitation approach that involves intensive use of your weaker arm whilst wearing a mitt on your stronger arm. CIMT has been developed to improve arm function after a neurological injury, such as after a stroke.

CIMT works on simple ‘use it to improve it’ principles and results in rewiring of the brain as new pathways develop, along with increased arm movement.

​TeleCIMT is a three-week home-based CIMT program developed by an international group of therapists experienced in CIMT. 

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About the TeleCIMT team

The TeleCIMT team is known as the TIDE (TeleCIMT International DEvelopment) group.  We are passionate about high quality rehabilitation treatment and have voluntarily developed these free resources to help break down current barriers to face-to-face treatment.

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[Abstract] The clinical effect of Kinesio taping and modified constraint-induced movement therapy on upper extremity function and spasticity in patients with stroke: a randomized controlled pilot study

BACKGROUND: Spasticity and impaired hand function are common complication in patients with stroke, and it pose negative impact on quality of life.


AIM: We aimed to assess the effect of the combined administration of kinesio taping (KT) and modified constraint-induced movement therapy (mCIMT) on upper extremity function and spasticity in hemiplegic patients with stroke.


DESIGN: A randomized controlled pilot study.


SETTING: A hospital center.

POPULATION: Patient of stroke with hemiplegia for 3-12 months


METHODS: 35 patients were enrolled and allocated into three groups, including the sham KT and mCIMT group, KT group, or KT and mCIMT group. The KT, sham KT, and mCIMT serve as additional therapies (5 days/week for 3 weeks) besides regular rehabilitation (5 days/week for 6 weeks). KT was applied over the dorsal side of the affected hand, while mCIMT was applied to restrain the unaffected upper extremity. The outcomes included the modified Tardieu scale (mTS), Brunnstrom stage, Box and Block Test (BBT), Fugl-Meyer assessment for the upper extremity (FMA-UE), and Stroke Impact Scale version 3.0. Measurements were taken at baseline, immediately after intervention (third week), and 3 weeks later (sixth week).


RESULTS: Between baseline and the third week, within-group comparisons yielded significant improvement in the wrist and hand parts of the FMA and BBT of the Sham KT and mCIMT group (p=0.007-0.035); in the hand part of the FMA, BBT, and mTS degree (p=0.005-0.024) of the KT group; and in the Brunnstrom stage of the wrist, FMAUE, BBT, and mTS degrees (p=0.005-0.032) of the KT and mCIMT group. Between baseline and the sixth week, there was significant difference in the proximal part of the FMA and mTS degree in groups with KT, but an additional improvement on the Brunnstrom stage of the wrist was noted in the KT and mCIMT group.


CONCLUSIONS: KT benefits patients with stroke in spasticity reduction and upper extremity function. The combination of KT and mCIMT provides extra benefit in motor performance with a more long-lasting effect.


CLINICAL REHABILITATION IMPACT: Kinesio taping could act as potential adjuvant therapy in patient of stroke with hemiplegia.

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[ARTICLE] Combined effects of Telehealth and Modified Constraint-Induced Movement Therapy for Individuals with Chronic Hemiparesis – Full Text

Abstract

Telehealth use allows improved access to services and results in potential cost savings. The purpose of this study was to examine the effectiveness of a combined modified Constrained Induced Movement Therapy (mCIMT) program using telehealth and in-person sessions, for participants with higher (Group 1) and lower (Group 2) functional ability of the hemiparetic upper extremity. Using a pre-experimental design with a 6-week intervention, 28 participants were assessed twice on use of upper extremity via subjective and objective measures. For the Motor Activity Log, the amount of use and quality of use were significant for Groups 1 and 2. Significant improvements were shown on the Wolf Motor Function Test (WMFT), the Fugl-Meyer UE, and the Functional Independence Measure (FIM) for both groups except for the strength subtest on the WMFT and the timed portion for Group 1. Percentages of attendance for telehealth and in-person sessions were also compared. Telehealth sessions had a higher attendance rate (84.5%) than in-person sessions (75.3%) (p=.004). The combined mCIMT program of telerehabilitation and in-person group sessions was effective in improving functional ability after a stroke.

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Stroke is a prevalent cause of disability and death throughout the world. Damage to the nervous system after a person experiences a stroke often results in hemiparesis, affecting use of the arm and hand on the hemiparetic side. Approximately 80% of individuals with stroke experience difficulties in performing activities of daily living (ADLs); consequently, social participation is limited because of the impairments (Kwakkel et al., 2015). Research exploring the effects of deafferentation in primates led to the discovery of the phenomenon of “learned non-use,” in which an individual avoids the use of the affected limb due to pain, aversion, or repeated failure from previous attempts (Taub et al., 1994). This leads to the predominant use of the unaffected limb as a compensatory technique to overcome the lack of mobility in the affected upper limb (Nijland et al., 2013). The approach of Taub et al. (1994), constraining the non-affected limb and forcing use of the affected limb is termed Constraint Induced Movement Therapy (CIMT). Preliminary research on primates was found to improve functional use of the affected upper extremity (UE) and was foundational in addressing “learned non-use.” CIMT has been shown to reverse the phenomenon of “learned non-use” in individuals who experienced a stroke (Kwakkel et al., 2015Taub et al., 2005Wolf et al., 2008Wen et al., 2014).

Traditional CIMT focuses on restraining the unaffected UE for up to 18 hours per day in order to force the affected UE to be used during both functional and strengthening tasks (Nilsen et al., 2015Treger et al., 2012). While the unaffected UE is restrained, participants of traditional CIMT partake in intensive therapy that requires use of only the affected UE. By focusing on using the affected UE, traditional CIMT can combat the learned non-use phenomenon and helps the participant begin to use their affected UE in a functional way (Wu et al., 2007).

Although CIMT has been shown to be an effective intervention, the intensity of the approach requires high participant adherence. According to Schaumberg et al. (1999), (conference paper cited by Page et al., 2004), there is only a 32% compliance rate with the traditional CIMT protocol. Several reasons for this low compliance rate may be the impracticality of the time the affected UE is restricted, the intensive amount of therapy, or participants’ lack of adherence to the protocol (Page et al., 2004). Other limitations with CIMT include concerns about cost effectiveness, worthiness of the cost, and concerns about cost reimbursement (Shi et al., 2011).

Modified CIMT (mCIMT) protocol involves a family of treatments (Taub et al., 1999). The restraint procedures are altered, and the amount of therapy is distributed over a longer period (Page et al., 2004). For example, the study conducted by Yu et al. (2017) regarding the effect of mCIMT on subcortical cerebral infarction only required the participants to wear a mitt on their unaffected arm for 30% of their waking hours, whereas the studies by Nijand et al. (2012), El-Helow et al. (2015), and Smania et al. (2012) mandated that their participants wear the constraining mitt for a minimum of 3 hours, 6 hours, and 12 hours a day, respectively. Variation in intensity level, length of time of constraint, and length of mCIMT program resulted in improved tolerance and increased compliance with many participants (El-Helow et al., 2015Yu et al., 2017).

A newer approach is Internet-based constraint-induced movement therapy (iCIMT); iCIMT is a mCIMT approach that incorporates telehealth. Telehealth allows delivery of therapy services to individuals who may not have the ability to frequently access the clinic, as both mCIMT and CIMT approaches require consistent adherence for therapy sessions (AOTA 2018; Jacobs et al., 2015). The rise of telehealth allows for therapy services to be provided through technology, including telephones, videoconferencing, personal digital assistants, smartphones, and virtual reality (McCue et al., 2010). Technology-based rehabilitation services may benefit individuals who have difficulty traveling to a clinic setting, those in rural areas, or even patients with chronic conditions that require frequent visitation (AOTA 2018; Jacobs et al., 2015). This is a client-centered approach, providing increased access to CIMT and mCIMT programs.

Telehealth is a fast-growing service delivery model that shows potential to create, implement, and maintain health promoting habits and routines. At the time of this writing, a COVID-19 pandemic waiver allows occupational therapists to be reimbursed for occupational therapy services provided through telehealth to Medicare beneficiaries. However, prior to the COVID-19 pandemic, Medicare did not recognize occupational therapy practitioners as eligible providers of therapy services through telehealth (AOTA 2019). Therefore, it is imperative that clinical research demonstrate the effectiveness of programs for individuals with hemiplegia, incorporating newer technologies and potentially cost-effective interventions.

In most studies using mCIMT, individuals with severe spasticity and/or limited wrist and hand movements were excluded, in accordance with the general guidelines for mCIMT (Taub et al., 1999). However, Wolf (2007) reports improved function in participants with severe hemiparesis, citing case reports; Bonifer & Anderson (2003) and Bowman et al. (2006). Although the case reports have mixed results; Taub et al. (1999) report that a larger percentage of participants with lower function in the hemiparetic UE, qualify for CIMT, and improve in functional abilities, than was previously expected. There are many unanswered questions about improvement in functional ability following CIMT in lower functioning individuals with hemiparesis. In this study we have included participants who are lower functioning in their affected UE. In addition, we encouraged informal caregivers to attend sessions.

The purpose of this study was to examine the effectiveness of a combined approach for a mCIMT program, which is traditional group rehabilitation and iCIMT telehealth technology, on increasing the use of the affected UE in individuals who are both higher and lower functioning. Expanding on previous studies, a combination of iCIMT with the addition of in-person group sessions, may enhance adherence with the CIMT treatment regimen. To our knowledge, this is the first study using two types of CIMT to identify its effectiveness with hemiplegia.[…]

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Figure 1. Tool kit for iCIMT participants.

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[ARTICLE] Neurobiology of Recovery of Motor Function after Stroke: The Central Nervous System Biomarker Effects of Constraint-Induced Movement Therapy – Full Text

Abstract

Recovery of motor function after stroke involves many biomarkers. This review attempts to identify the biomarker effects responsible for recovery of motor function following the use of Constraint-Induced Movement Therapy (CIMT) and discuss their implications for research and practice. From the studies reviewed, the biomarker effects identified include improved perfusion of motor areas and brain glucose metabolism; increased expression of proteins, namely, Brain-Derived Neurotrophic Factor (BDNF), Vascular Endothelial Growth Factor (VEGF), and Growth-Associated Protein 43 (GAP-43); and decreased level of Gamma-Aminobutyric Acid (GABA). Others include increased cortical activation, increased motor map size, and decreased interhemispheric inhibition of the ipsilesional hemisphere by the contralesional hemisphere. Interestingly, the biomarker effects correlated well with improved motor function. However, some of the biomarker effects have not yet been investigated in humans, and they require that CIMT starts early on poststroke. In addition, one study seems to suggest the combined use of CIMT with other rehabilitation techniques such as Transcortical Direct Stimulation (tDCs) in patients with chronic stroke to achieve the biomarker effects. Unfortunately, there are few studies in humans that implemented CIMT during early poststroke. Thus, it is important that more studies in humans are carried out to determine the biomarker effects of CIMT especially early on poststroke, when there is a greater opportunity for recovery. Furthermore, it should be noted that these effects are mainly in ischaemic stroke.

1. Introduction

Stroke is a leading cause of long-term disability. It is a neurological deficit due to impaired blood supply to the brain areas caused by ischaemia or haemorrhage or occasionally both [12]. Impaired blood supply to the brain results in a cascade of pathological processes that disrupt neurophysiological mechanisms and expression of Central Nervous System (CNS) biomarkers that eventually cause neuronal cell injury or death. When neuronal cells are injured, they discharge cytotoxic molecules that further injure or damage other apparently healthy neuronal cells [24]. This in turn creates a vicious cycle of cell injury and/or death that cause impairments in brain functions such as motor, sensory, and cognitive functions. Therefore, preventing or reducing the disruption of neurophysiological mechanisms and expression of CNS biomarkers by these pathological processes should be the target of treatment and rehabilitation following stroke. This may help prevent neuronal cell damage, improve neuronal cell homeostasis, and restore functions of the CNS.

One of the most promising rehabilitation techniques used for recovery of motor function after stroke is Constraint-Induced Movement Therapy (CIMT). The CIMT is a technique that comprises of massed task practice with the affected limb, constraint of the unaffected limb, and transfer package [57]. It has been reported to improve the use of limbs in daily activities and improve the quality, quantity, and precision of movement [89]. However, these findings relate to the system or functional level of the nervous system. According to Cohen, to effectively understand the functions of the nervous system, it needs to be studied at the molecular and functional levels, and possibly also at other sublevels between them [10]. Consequently, current evidence has shown that repetitive functional activity or modulation of afferent inputs can induce growth, modification, degradation, and death of neuronal cells which can help the CNS to recover from injury [1112].

In practice, however, understanding the precise biomarkers of the process of recovery after stroke may be difficult due to differences in patients’ presentations and the recovery processes [13]. The aim of this article is to review some of the CNS biomarkers CIMT targets after stroke and their correlations with motor function outcomes in both humans and animals (since animal studies serve as basic foundations for studies in humans). This will help us further understand the biomarkers of motor recovery following stroke, and possibly help researchers and clinicians identify the type of patients CIMT is more suitable for. A biomarker can be a gene, a naturally occurring molecule, or a particular characteristic by which a physiological or pathological process or disease can be identified [14]. It includes imaging biomarkers that are identified using computed tomography, positron emission tomography, transmagnetic stimulation, and magnetic resonance imaging; and molecular biomarkers such as a particular protein or gene expression [1517]. The search engine PubMed was used using the search term Constraint-Induced Movement Therapy. The biomarkers extracted from the CIMT studies obtained from PubMed were further searched on Google Scholar in order to obtain more information. The characteristics of some of the reviewed studies in humans are presented in Table 1.[…]

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[Abstract + Similar articles] Recovering Functional Independence After a Stroke Through Modified Constraint-Induced Therapy

Abstract

Background: Population ageing and changes in the epidemiological profile of neurological pathologies has resulted in an increase in patients with disabilities. Rehabilitation strategies such as Modified Constraint-Induced Movement Therapy (CIMTm) play a key role in treating patients with neurologic deficiencies and motor impairments. This intervention is intended to mitigate disability, promote maximum functional independence, and optimize social and economic participation of patients with upper extremity weakness. Our goal was to assess the recovery of functional independence in patients after a stroke using to CIMTm.

Patients and method: Thirty-six subjects who had suffered stroke took part in a randomised clinical trial. The treatment was applied through either collective or individual modalities for three hours per day for a period of ten days. Participant’s functional independence was assessed using the Functional Independence Measure (FIM) scale at the before and after of the intervention.

Results: An analysis of covariance carried out on the pre-test assessments indicates that the dependent variable presents significant differences (F1.31 = 42.78, p < 0.001, η2p = 0.72) in favour of the collective intervention modality.

Conclusion: Both modalities of CIMTm intervention promote functional independence. However, the greatest improvements were observed in participants in the collective modality. Improvements in functional independence pursue a reduction in learned non-use behaviours through greater use of the paretic upper extremity in everyday activities.

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[Case Study] Constraint-Induced Movement Therapy for Improving Motor Function of the Paretic Lower Extremity After Stroke – Abstract

Abstract

A 56-yr-old woman with chronic stroke and gait dysfunction was recruited for this study. A lower-extremity constraint-induced movement therapy protocol was given consisting of 3.5 hrs/d of supervised intervention activities on 10 consecutive weekdays. Motor training was intensive and involved shaping. In addition, a group of behavior management strategies was used to induce further unsupervised practice and transference of motor skills from the laboratory to real-world situations. Changes in functional mobility, walking speed, balance, level of assistance, perceived quality of movement, and level of confidence while performing daily activities were assessed five times in both the baseline and intervention phases. The outcomes observed after the intervention were determined by calculating the difference between the average scores obtained in both phases. Changes in perceived quality of movement, level of confidence, level of assistance, and balance were observed.

https://journals.lww.com/ajpmr/Abstract/2020/06000/Constraint_Induced_Movement_Therapy_for_Improving.24.aspx

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