Posted by Kostas Pantremenos in Constraint induced movement therapy CIMT on December 17, 2017
Constraint-Induced Movement Therapies (CIMTs) including the original Constraint- Induced Movement Therapy (CIMT) and the Modified Constraint-Induced Movement Therapy (mCIMT) gained considerable popularity as a treatment approach for upper extremity rehabilitation among patients with mild-to-moderate stroke.
However, a major barrier in rehabilitation generally and in CIMTs specifically; is the limited objectivity of some commonly used outcome measures and lack sensitivity to define “True” recovery vs. compensation. Thereby, they may not sufficiently detect of long term consequences and the associated neurological recovery. An essential approach to overcome such barrier is to better understand functional motor recovery, associated neural changes and how they may relate to recovery of the pre-morbid movement pattern.
Such Understanding for these relationships would add more in-depth insights on the
functional relevance of plastic brain changes in stroke following CIMTs to optimize the field of neuro-rehabilitation. This review synthesizes findings from studies to on the use of the CIMTs including CIMT and mCIMT as efficient practice in the management of upper limb dysfunction following a stroke. The analysis will include (1) the functional recovery and (2) the cortical reorganization following the use of mCIMT and CIMT on patients in the chronic stage following stroke.
Stroke is considered the fifth leading cause of death in the United
States [1]. To date, stroke affects at least 6.4 million persons in the United
States [2]. Projections show that by 2030, an additional 3.4 million
people above 18 years will have had a stroke which is approximately a
20.5% increase in prevalence from 2012 statistics [1]. Stroke is a leading
cause of serious long-term disability in the United States [1].
Arm paresis is one of the most common impairments after stroke
[3,4]. After six months, about two-thirds of patients continue to suffer
from arm sensorimotor impairment that impacts the individual’s
activities of daily living [5]. Motor deficits consist of weakness of
specific muscles [6], abnormal muscle tone [7-9], abnormal postural
adjustments [10], abnormal movement synergies [11], lack of mobility
between structures at the shoulder girdle [10] and incorrect timing
of components within a movement pattern [12]. As a result of such
impairment, patients may progressively avoid using the affected arm in
favor of the unaffected arm for successful ADL, resulting in a learned
non-use phenomenon [13].[…]
Posted by Kostas Pantremenos in Constraint induced movement therapy CIMT, Paretic Hand on August 25, 2017
Background
Constraint induced movement therapy (CIMT), an intervention to increase upper limb (UL) function post-stroke, is not used routinely by therapists in the United Kingdom; reasons for this are unknown. Using the Promoting Action on Research Implementation in Health Services (PARIHS) framework to analyse CIMT research and context, a series of related studies explored implementation of CIMT into practice.
Methods and Findings
Systematic review: nineteen CIMT randomised controlled trials found evidence of effectiveness in sub-acute stroke, but could not determine the most effective evidence-based protocols. Further review of qualitative data found paucity of evidence relating to acceptability and feasibility of CIMT.
Focus group: perceptions of the feasibility, including facilitators and barriers, of implementing CIMT into practice were explored in a group of eight therapists. Thematic analysis identified five themes: personal characteristics; setting and support; ethical considerations; education and training; and practicalities, which need to be addressed prior to implementation of CIMT.
Mixed-methods, pilot study (three single cases): pre- and post-CIMT (participant preferred protocol) interviews explored perceptions and experiences of CIMT, with pre- and post-CIMT measurement of participation and UL function. Findings indicated: (i) provision of evidence-based CIMT protocols was feasible, although barriers persisted; (ii) piloted data collection and analysis methods facilitated exploration of stroke survivors’ perceptions and experiences, and recorded participation and UL function.
Conclusions
Findings traversed PARIHS elements (evidence, context, facilitation), and should be considered prior to further CIMT implementation. Future studies of CIMT should explore: effects of CIMT protocol variations; characteristics of stroke survivors most likely to benefit from CIMT; interactions between CIMT and participation.
Posted by Kostas Pantremenos in Constraint induced movement therapy CIMT on August 16, 2017
Constraint-induced movement therapy (CI therapy) is a well-researched intervention for treatment of upper limb function. Overall, CI therapy yields clinically meaningful improvements in speed of task completion and greatly increases use of the more affected upper extremity for daily activities. However, individual improvements vary widely. It has been suggested that intrinsic feedback from somatosensation may influence motor recovery from CI therapy. To test this hypothesis, an enhanced probabilistic neural network (EPNN) prognostic computational model was developed to identify which baseline characteristics predict extent of motor recovery, as measured by the Wolf Motor Function Test (WMFT). Individual characteristics examined were: proprioceptive function via the brief kinesthesia test, tactile sensation via the Semmes-Weinstein touch monofilaments, motor performance captured via the 15 timed items of the Wolf Motor Function Test, stroke affected side. A highly accurate predictive classification was achieved (100% accuracy of EPNN based on available data), but facets of motor functioning alone were sufficient to predict outcome. Somatosensation, as quantified here, did not play a large role in determining the effectiveness of CI therapy.
Posted by Kostas Pantremenos in Constraint induced movement therapy CIMT on August 16, 2017
In order to ensure total focus on the affected arm and hand, you will wear a constraint mitt on your unaffected side for most of the CIMT programme. The constraint mitt is a lightweight glove that fits on your hand and wrist.
To gain the most benefit from constraint induced movement therapy you should wear the mitt for 90% of your waking hours. On the first day of your CIMT programme your therapist will go through your daily routine in detail with you to agree the specific activities when you are allowed to remove the mitt. These may include:
A detailed list of activities will be drawn up and you will sign a contract to agree to only remove the mitt for an activity on the list. This gives you strict guidance on wearing the mitt and helps you to obtain maximum benefit from the CIMT programme.
While wearing the mitt you will find day-to-day activities more difficult. We therefore strongly recommend you complete a CIMT programme with support from a partner, family member or carer. They will be able to assist in tasks and allow you to wear the mitt for longer, which will help with your progress. Your CIMT therapist will provide guidance to your supporter on how they can help you while also promoting use of your affected side.
It is common to feel frustration while wearing the mitt. Constraint induced movement therapy is an intensive and challenging process. However, if you persevere with a CIMT programme you will make some significant improvements over a short period of time.
On completion of the programme you may take the constraint mitt with you – either to continue practice or as a memento of your hard work!
Posted by Kostas Pantremenos in Constraint induced movement therapy CIMT on August 8, 2017
ABSTRACT
Objective: The aim of this was to compare the effects of constraint movement therapy and conventional therapy for improving motor function of upper limb in patients with sub-acute stroke.
Study Design: A randomized controlled trial.
Place and Duration of Study: The study was carried out from January 2016 to December 2016 in Rafsan Neuro Rehabilitation Centre, Peshawar.
Materials and Methods: A total of 60 patients with sub-acute stage of stroke were randomly allocated into constraint induced movement therapy and conventional therapy groups. Patients in conventional therapy group followed conventional physical therapy rehabilitation activities while patients in the constraint induced movement therapy group were guided to perform the same activities while constraining their less effected limb. Patients in both groups were assessed just before and six weeks after the start of these therapies. Mann Whitney U test was used to compare the results of both treatment.
Results: The patients in constraint induced movement therapy group showed better results on upper arm function, hand movement and advanced hand activities of motor assessment scale as compared to the patients in conventional therapy group. The mean rank for upper arm function of constraint induced movement therapy and conventional therapy group were 40 and 20, respectively (p=0.001), hand movement for CIMT and CT were 40 and 20 (p=0.001) and advanced hand activities for CIMT and CT group were 43 and 17 (p=0.001), respectively. The patients in induced movement therapy group showed 20% better result on upper arm function, 21% on hand movements and 26% on advanced hand activities of motor assessment scale. Conclusion: It is concluded that constraint induced movement therapy provides improved upper arm function, hand movement and advanced hand activities as compared to the conventional therapy for the patients with sub-acute stroke.
Posted by Kostas Pantremenos in Constraint induced movement therapy CIMT on July 21, 2017
In order to ensure total focus on the affected arm and hand, you will wear a constraint mitt on your unaffected side for most of the CIMT programme. The constraint mitt is a lightweight glove that fits on your hand and wrist.
To gain the most benefit from constraint induced movement therapy you should wear the mitt for 90% of your waking hours. On the first day of your CIMT programme your therapist will go through your daily routine in detail with you to agree the specific activities when you are allowed to remove the mitt. These may include:
A detailed list of activities will be drawn up and you will sign a contract to agree to only remove the mitt for an activity on the list. This gives you strict guidance on wearing the mitt and helps you to obtain maximum benefit from the CIMT programme.
While wearing the mitt you will find day-to-day activities more difficult. We therefore strongly recommend you complete a CIMT programme with support from a partner, family member or carer. They will be able to assist in tasks and allow you to wear the mitt for longer, which will help with your progress. Your CIMT therapist will provide guidance to your supporter on how they can help you while also promoting use of your affected side.
It is common to feel frustration while wearing the mitt. Constraint induced movement therapy is an intensive and challenging process. However, if you persevere with a CIMT programme you will make some significant improvements over a short period of time.
On completion of the programme you may take the constraint mitt with you – either to continue practice or as a memento of your hard work!
Posted by Kostas Pantremenos in Constraint induced movement therapy CIMT on July 17, 2017
A direct comparison between the effects of constraint-induced movement therapy (CIMT) applied early after stroke and that of CIMT applied in the chronic phase has not been conducted. This study aimed to compare the long-term effects of CIMT applied 6 months after stroke with the results of CIMT applied within 28 days post-stroke.
This study was a single-blinded, multicentre, randomized controlled trial with a crossover design. Forty-seven patients received CIMT either early (within 28 days) or 6 months after stroke. Both groups received standard rehabilitation and were tested at 5 time points. The primary outcome measure was Wolf Motor Function Test (WMFT); the secondary measures were Nine-Hole Peg Test (NHPT), the Fugl-Meyer Assessment (FMA) of the upper extremity, Stroke Impact Scale, and Modified Rankin Scale (MRS).
Compared with baseline data, both groups showed significant improvements in the primary and secondary outcome measures after 12 months. No significant differences between the 2 treatment groups were found before and after the delayed intervention group received CIMT at 6 months and during the 12-month follow-up. Both groups recovered considerably and showed only minor impairment (median FMA score of 64) after 6 months. The early intervention group showed an initially faster recovery curve of WMFT, NHPT, and MRS scores.
In contrast to most CIMT studies, our study could not find an effect of CIMT applied 6 months after stroke. Our results indicate that commencing CIMT early is as good as delayed intervention in the long term, specifically in this group of patients who might have reached a ceiling effect during the first 6 months after stroke. Nevertheless, the early CIMT intervention group showed a faster recovery curve than the delayed intervention group, which can be a clinically important finding for patients in the acute phase.
Posted by Kostas Pantremenos in Constraint induced movement therapy CIMT, Paretic Hand, Spasticity on June 24, 2017
Purpose: The purpose of this study was to explore the effect of modified constraint-induced movement therapy (CIMT) in a real-world clinical setting on spasticity and functional use of the affected arm and hand in patients with spastic chronic hemiplegia.
Method: A prospective consecutive quasi-experimental study design was used. Twenty patients with spastic hemiplegia (aged 22–67 years) were tested before and after 2-week modified CIMT in an outpatient rehabilitation clinic and at 6 months. The Modified Ashworth Scale (MAS), active range of motion (AROM), grip strength, Motor Activity Log (MAL), Sollerman hand function test, and Box and Block Test (BBT) were used as outcome measures.
Results: Reductions (p<0.05–0.001) in spasticity (MAS) were seen both after the 2-week training period and at 6-month follow-up. Improvements were also seen in AROM (median change of elbow extension 5°, dorsiflexion of hand 10°), grip strength (20 Newton), and functional use after the 2-week training period (MAL: 1 point; Sollerman test: 8 points; BBT: 4 blocks). The improvements persisted at 6-month follow-up, except for scores on the Sollerman hand function test, which improved further.
Conclusion: Our study suggests that modified CIMT in an outpatient clinic may reduce spasticity and increase functional use of the affected arm in spastic chronic hemiplegia, with improvements persisting at 6 months.
Posted by Kostas Pantremenos in Constraint induced movement therapy CIMT on June 24, 2017
Objective: This presentation will review the basic neuroscience research origins and the effects of Constraint-Induced Movement therapy (CIMT) on CNS structural neuroplasticity.
Background: Experimental hemiparesis in primates overcame chronic limb nonuse by applying specific behavioral neuroscience principles. This research led to formulating a model for the origination of sustained motor disability after neurological injury and its improvement by a novel therapeutic program. The therapy became adapted to treating children and adults and termed CIMT. Over the past 25 years multiple worldwide Randomized Controlled Trials of CIMT enrolled nearly 2000 patients with diverse neurological disorders (stroke, cerebral palsy [CP], multiple sclerosis [MS]), which indicated superiority of the approach against control therapies, with large treatment Effect Sizes and sustained retention of improved spontaneous real-world use of the hemiparetic limb. Ongoing research will describe basic and clinical neuroimaging methods to explore the basis for the clinical efficacy of CIMT.
Design/Methods: (1) Basic neuroscience models of experimental limb nonuse in rodents that had undergone adapted CIMT, which were followed by histological studies. (2) Voxel-based morphometry (VBM) of grey matter and Tract-based spatial statistics (TBSS) of white matter on structural brain MRI, which evaluated neuroplastic changes after upper extremity CIMT.
Results: (1) CIMT in rodents resulted in increased CNS axonal growth, synaptogenesis, and neurogenesis compared to control interventions, parallel with improved paretic limb use. (2) VBM demonstrated profuse cortical and subcortical grey matter increase following CIMT for stroke, CP, and MS. TBSS indicated significantly improved white matter integrity in MS. Neither structural brain changes nor comparable improved paretic limb use followed control interventions.
Conclusions: CIMT is increasing worldwide practice to improve reduced real-world limb use in chronic hemiparesis in diverse neurological diseases and ages of patients. Structural CNS changes following CIMT may support improved and extended functional use of the paretic limb.
TBI Rehabilitation 