Constraint-induced movement therapy after stroke

Abstract

Constraint-induced movement therapy (CIMT) was developed to overcome upper limb impairments after stroke and is the most investigated intervention for the rehabilitation of patients. Original CIMT includes constraining of the non-paretic arm and task-oriented training. Modified versions also apply constraining of the non-paretic arm, but not as intensive as original CIMT. Behavioural strategies are mostly absent for both modified and original CIMT. With forced use therapy, only constraining of the non-paretic arm is applied. The original and modified types of CIMT have beneficial effects on motor function, arm-hand activities, and self-reported arm-hand functioning in daily life, immediately after treatment and at long-term follow-up, whereas there is no evidence for the efficacy of constraint alone (as used in forced use therapy). The type of CIMT, timing, or intensity of practice do not seem to affect patient outcomes. Although the underlying mechanisms that drive modified and original CIMT are still poorly understood, findings from kinematic studies suggest that improvements are mainly based on adaptations through learning to optimise the use of intact end-effectors in patients with some voluntary motor control of wrist and finger extensors after stroke.

Conflict of interest statement

Conflicts of interest: GK has received grants from the European Research Council, Dutch National Institutes of Health (ZonMw), The Dutch Brain Foundation (Hersenstichting Nederland), The Dutch Hearth Foundation, and the Royal Dutch Society for Physical Therapy.

JV has received grants from the Royal Dutch Society for Physical Therapy. EvW has received grants from the Stichting Parkinson Fonds, the Beatrix Fonds, the Dutch Brain Foundation, Fonds Nuts-Ohra, the Dutch Parkinson Association, and ZonMw.

SW has received grants from the National Institutes of Health (National Institute of Neurological Diseases and Stroke and the Center for Medical Rehabilitation Research within the National Institute of Child Health and Development).

Copyright © 2015 Elsevier Ltd. All rights reserved.

Figures

Figure 1. Constraint-induced movement therapy

Illustration of task-oriented practice with the paretic limb in a Constrained Induced Movement Therapy session. Use of the non-affected limb is restricted by a padded mitt.

Figure 2. Forest plot of constraint-induced movement therapy post intervention

This figure displays the summarized effects of original CIMT, modified CIMT and forced use post intervention, classified according to the International Classification of Functioning, disability and health (ICF; World Health Organization). Please consult supplementary web appendix 5 for Hedges' g (95%CI) in numbers. Background colors represent the different ICF-categories, body functions (pink), activities (blue), and participation (orange). The italic numbers in the statistical power column indicate sufficient power (1-β ≥0.80). 95%CI, 95% Confidence interval; ADL, Activities of daily living; C, Control group; CIMT, Constraint-induced movement therapy; E, Experimental group; N/A, Not applicable. References: (a) -, , , , , , , , , , , , , , , ; (b) , ; (c) , ; (d) , ; (e) , ; (f) ; (g) , - , - , -, , -, -; (h) ; (i) , , , , , , , , , -, -, , , , -; (j) , ; (k) ; (l) , , , , , , -, , , , , , , -, , , , -; (m) , , ; (n) , , , , -, , ; (o) , , ; (p) , .

Figure 3. Forest plot of constraint-induced movement therapy in the long term

This figure displays the summarized effects of original CIMT, modified CIMT and forced use in the long term (4-5 months), classified according to the International Classification of Functioning, disability and health (ICF; World Health Organization). Please consult supplementary web appendix 6 for Hedges' g (95%CI) in numbers. Background colors represent the different ICF-categories, body functions (pink), activities (blue), and participation (orange). The italic numbers in the statistical power column indicate sufficient power (1-β ≥0.80). 95%CI, 95% Confidence interval; ADL, Activities of daily living; C, Control group; CIMT, Constraint-induced movement therapy; E, Experimental group; N/A, Not applicable. References: (a) , , , , ; (b) , ; (c) ; (d) , , , , , , , , , , , , , ; (e) ; (f) , , , , , , , , , , ; (g) ; (h) , , , , , , , , , , ; (i) , ; (j) ; (k) .