Constraint Induced Movement Therapy (CIMT) is an evidence-based rehabilitation technique for improving upper limb function after stroke or cerebral palsy. It involves restraining the unaffected limb while intensively training the affected limb for several hours per day. Studies show CIMT leads to cortical reorganization and improved real-world arm use. The key elements are restraint of the less affected side and intensive task-specific training of the affected side. CIMT protocols have been developed for both adults and children with varying durations and intensities depending on the individual. Long-term follow up studies show benefits can persist for years after treatment.

1. Constraint Induced Movement Therapy

2. Constraint Induced Movement Therapy
Putting evidence into practice
Karen Leslie (Senior CIMT Therapist)
Nikki Owen (Senior CIMT Therapist)

3. 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

4. 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,)

6. 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)

7. 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)

8. 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 care
CIMT produced statistically significant and clinically relevant
improvements in arm motor function that persisted for at least 1 year.

9. CI Protocol for adults
The 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

10. Why CIMT works - Cortical Reorganisation
The representation of your body is continually reorganised on the cortex
Representation 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)

11. 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.

12. 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

13. CIMT for Children
Taub’s team realised that the principles of CI Therapy for adults could
easily be applied to children

14. “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.

16. CIMT for Children
Taub 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.

17. 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

18. 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.

19. 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

20. 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

21. Our criteria and protocols - Children
Criteria
• > 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

22. Boundaries of CIMT
CIMT 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

23. Case Studies
Pre-Treatment Post-Treatment Difference
Dissociated Movements (%) 65 75 10
Grasps (%) 44 55 11
Weight Bearing (%) 72 84 12
Overall Score (%) 60 71 11
Archie
QUEST – Quality of Upper Extremity Skills Test
Note – an increase of 4.89% or more is considered statistically significant.

24. Case Studies
Pre-Treatment Post-Treatment Difference
Dissociated Movements (%) 65 75 10
Grasps (%) 44 55 11
Weight Bearing (%) 72 84 12
Overall Score (%) 60 71 11
Archie
QUEST – Quality of Upper Extremity Skills Test
Note – an increase of 4.89% or more is considered statistically significant.

25. Case Studies
Harry

26. References
Case-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, 15–23
Deluca, 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; 250:5-8
Liepert J, Bauder H, Miltner WHR, Taub E, Weiller C. (2000) Treatment-induced cortical reorganization after stroke in
humans. Stroke; 31:1210-1216
Ostendorf 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.

27. References
Sakzewski, 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) 2134-2142
Sterling, 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. 5
Sterr A, Müller MM, Elbert T, Rockstroh B, Pantev C, Taub E. (1998) Changed perceptions in Braille readers. Nature
391:134-135
Taub E, Berman AJ. (1963) Avoidance conditioning in the absence of relevant proprioceptive and exteroceptive
feedback. J Comp Physiol Psychol; 56:1012-1016
Taub 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

28. References
Taub 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,
371-401
Taub 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; 74:347-354
Taub E, Uswatte G, Elbert T. (2002) New treatments in neurorehabilitation founded on basic research. Nature
Reviews Neuroscience 3:228-236
Taub, 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: 305-312
Wolf, 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