Does the Application of Constraint-Induced Movement Therapy During Acute Rehabilitation Reduce Arm Impairment After Ischemic Stroke? Constraint-induced movement therapy: time for a little restraint? Modified constraint induced therapy: a randomized feasibility and efficacy study. AutoCITE: Automated Delivery of CI Therapy With Reduced Effort by Therapists Forced use of the upper extremity in chronic stroke patients: results from a single-blind randomized clinical trial. Evidence-based rehabilitation: the case for and against constraint-induced movement therapy. Longer versus shorter daily constraint-induced movement therapy of chronic hemiparesis: an exploratory study. Effectiveness of modified constraint-induced movement therapy on upper limb function in stroke subjects. Modified Constraint-Induced Therapy in Acute Stroke: A Randomized Controlled Pilot Study The EXCITE Trial: Attributes of the Wolf Motor Function Test in Patients with Subacute Stroke Methods for a Multisite Randomized Trial to Investigate the Effect of Constraint-Induced Movement Therapy in Improving Upper Extremity Function among Adults Recovering from a Cerebrovascular Stroke The Effects of Constraint-Induced Therapy on Precision Grip: A Preliminary Study Can forced-use therapy be clinically applied after stroke? An exploratory randomized controlled trial. Modified Constraint-Induced Therapy after Subacute Stroke: A Preliminary Study Constraint-Induced Therapy in Stroke: Magnetic-Stimulation Motor Maps and Cerebral Activation Efficacy of modified constraint-induced movement therapy in chronic stroke: a single-blinded randomized controlled trial.
Background and Purpose Motor dysfunction after unilateral deafferentation in primates can be overcome by restraining the unaffected limb . We asked whether a constraint-induced movement ( CIM ) program could be implemented within 2 weeks after stroke and whether CIM is more effective than traditional upper-extremity ( UE ) therapies during this period . Methods Twenty-three persons were enrolled in a pilot r and omized , controlled trial that compared CIM with traditional therapies . A blinded observer rated the primary end point , the Action Research Arm Test ( ARA ) .  Inclusion criteria were the following : ischemic stroke within 14 days , persistent hemiparesis , evidence of preserved cognitive function , and presence of a protective motor response . Differences between the groups were compared by using Student ’s t tests , ANCOVA , and Mann-Whitney U tests . Results Twenty subjects completed the 14-day treatment . Two adverse outcomes , a recurrent stroke and a death , occurred in the traditional group ; 1 CIM subject met rehabilitation goals and was discharged before completing 14 inpatient days . The CIM treatment group had significantly higher scores on total ARA and pinch subscale scores ( P < 0.05 ) . Differences in the mean ARA grip , grasp , and gross movement subscale scores did not reach statistical significance . UE activities of daily living performance was not significantly different between groups , and no subject withdrew because of pain or frustration . Conclusions A clinical trial of CIM therapy during acute rehabilitation is feasible . CIM was associated with less arm impairment at the end of treatment . Long-term studies are needed to determine whether CIM early after stroke is superior to traditional therapies Our aim was to consider some issues surrounding constraint-induced movement therapy ( CIMT ) , and in particular , its theoretical basis , effectiveness , utility and composition . We examined selected articles and related publications concerning CIMT . Considerable evidence from case studies and case series has accumulated but only a limited number of r and omized controlled trials ( RCTs ) exist . The two most positive RCTs represent a combined total of 15 people undergoing CIMT .  Other issues include : how analogous deafferentation of an upper limb in monkeys is to cerebral infa rcts in humans ; teasing out the active components of CIMT ; a need for replication by groups not already strongly associated with CIMT ; and patient/therapist acceptability .  CIMT may hold considerable promise , but independent , large-scale , multicentre RCTs comparing its effectiveness with conventional therapy of equal intensity are required , as is the consideration of some associated issues This case series examined the feasibility and efficacy of a modified constraint induced therapy ( CIT ) protocol administered on an outpatient basis . The Fugl-Meyer Assessment of Motor Recovery After Stroke ( Fugl ) , Action Research Arm Test ( ARA ) , Wolf Motor Function Test ( WMFT ) , and  Motor Activity Log  ( MAL ) were administered to six patients between 2 and 6 months poststroke ( CVA ) exhibiting stable motor deficits and learned nonuse of the affected limb . Two patients then participated in half-hour physical and occupational therapy sessions three times/week for 10 weeks . During the same period , their unaffected arms and h and s were restrained 5 days/week during 5 hours identified as times of frequent use . Two other patients received regular therapy and two control patients received no therapy . The ARA , Fugl , WMFT , and MAL were again administered after 10 weeks . Patients receiving modified CIT exhibited substantial improvements on the Fugl , ARA , and WMFT , as well as increases in amount and quality of use of the limb using the MAL . Patients receiving traditional or no therapy exhibited no improvements . Results suggest that modified CIT may be an efficacious method of improving function and use of the affected arms of patients exhibiting learned nonuse Background and Purpose — To evaluate the effectiveness of a device that automates Constraint-Induced Movement therapy ( CI therapy ) , termed AutoCITE , when only partially supervised by therapists . Methods — Twenty-seven participants with chronic stroke trained with AutoCITE for 3 hours per day for 10 consecutive weekdays . Participants were assigned to 1 of 3 groups in a fixed irregular order ( ie , in alternating blocks ) : supervision from a therapist for 100 % , 50 % , or 25 % of training time . Results — The effect sizes of the treatment gains for the 3 groups on the Motor Activity Log ( MAL ) were very large and for the Wolf Motor Function Test they were large ( all P<0.001 ) but were not significantly different from one another . Gains were comparable to those previously reported for participants who received an equal amount of st and ard one-on-one CI therapy without the device . At 1-month and long-term follow-up , gains from pretreatment on the MAL were also significant ( P<0.001 ) . Conclusion — These results demonstrate that AutoCITE training with greatly reduced supervision from a therapist is as effective as st and ard one-on-one CI therapy BACKGROUND AND PURPOSE Of all stroke survivors , 30 % to 66 % are unable to use their affected arm in performing activities of daily living . Although forced use therapy appears to improve arm function in chronic stroke patients , there is no conclusive evidence . This study evaluates the effectiveness of forced use therapy . METHODS In an observer-blinded r and omized clinical trial , 66 chronic stroke patients were allocated to either forced use therapy ( immobilization of the unaffected arm combined with intensive training ) or a reference therapy of equally intensive bimanual training , based on Neuro-Developmental Treatment , for a period of 2 weeks . Outcomes were evaluated on the basis of the Rehabilitation Activities Profile ( activities ) , the Action Research Arm ( ARA ) test ( dexterity ) , the upper extremity section of the Fugl-Meyer Assessment scale , the Motor Activity Log ( MAL ) , and a Problem Score . The minimal clinical ly important difference ( MCID ) was determined at the onset of the study . RESULTS One week after the last treatment session , a significant difference in effectiveness in favor of the forced use group compared with the bimanual group ( corrected for baseline differences ) was found for the ARA score ( 3.0 points ; 95 % CI , 1.3 to 4.8 ; MCID , 5.7 points ) and the MAL amount of use score ( 0.52 points ; 95 % CI , 0.11 to 0.93 ; MCID , 0.50 ) . The other parameters revealed no significant differential effects . One-year follow-up effects were observed only for the ARA . The differences in treatment effect for the ARA and the MAL amount of use scores were clinical ly relevant for patients with sensory disorders and hemineglect , respectively . CONCLUSIONS The present study showed a small but lasting effect of forced use therapy on the dexterity of the affected arm ( ARA ) and a temporary clinical ly relevant effect on the amount of use of the affected arm during activities of daily living ( MAL amount of use ) . The effect of forced use therapy was clinical ly relevant in the subgroups of patients with sensory disorders and hemineglect , respectively Along with much of psychiatry and complementary therapies , the field of rehabilitation lacks the solid foundation of empirically derived data demonstrating the efficacy of key interventions . Rehabilitation research lags behind drug development , in which at least one multicenter trial with adequate statistical power is required before regulatory approval is granted . Rehabilitation even lags behind many surgical fields , where many expensive or commonly performed procedures are eventually put to the test of a r and omized controlled trial . Many widely performed procedures , hailed by their advocates as so obviously effective that r and omized controlled trials were not needed or were even unethical , litter the medical literature . Once performed by the thous and , procedures such as extracranial-intracranial bypass for stroke prevention and irrigation of knees for degenerative joint disease are now ab and oned because objective clinical trials showed no benefit to the participants . Rehabilitation has several features that make it peculiarly susceptible to the acceptance of treatments with little or no direct evidence of efficacy . First is the lack of obvious and catastrophic clinical failure to force rehabilitationists to test and refine ideas and treatments . While rehabilitation probably does reduce long-term morbidity and mortality , patients do not obviously and immediately die from bad rehabilitation , as they might from poor surgical techniques or ineffective drugs . Thus , rehabilitationists do not face the same discipline of clinical failure that many other clinicians face . Second , treatment often has no hard end points , such as survival time in oncology trials or the counting of seizure events in epilepsy trials . Since rehabilitationists strive to promote independence , quality of life , and other difficult-to-measure goals , development of clinical trials has been hampered by difficulties in methodology — how do we measure what we cl aim to be improving ? A third problem is that the nature of most rehabilitation interventions makes st and ardizing the treatment intervention difficult ; a behavioral treatment such as a motor therapy or a memory-retraining strategy is much more operator-dependent than simply giving the patient a drug or device . Finally , rehabilitation lacks the type of industry interest that drives the development of new drugs and devices . Though there is no shortage of for-profit rehabilitation enterprises , they spend miniscule bits of their revenue on research and development . This is a striking contrast to the pharmaceutical and medical-device companies that view new treatments as their lifeblood and spend accordingly .  Constraint-induced movement therapy ( CIMT ) is a rehabilitation treatment with some promise and is Alex and er W. Dromerick , MD Associate Professor of Neurology and Occupational Therapy Washington University School of Medicine St. Louis , OBJECTIVE To evaluate and compare the effects of 3-hour versus 6-hour daily training sessions in constraint-induced movement therapy ( CIMT ) . DESIGN Intervention study , 2-group r and omized trial ; baseline , pretreatment , and posttreatment measures ; 1-month follow-up ( weekly measures ) . SETTING University department of psychology in Germany . PARTICIPANTS A convenience sample of 15 adults with chronic hemiparesis ( 13 stroke , 2 traumatic brain injury ) . INTERVENTION CIMT ( 14 consecutive days ; constraint of unaffected h and for a target of 90 % of waking hours ) with either 6 hours ( 6h/d group , n=7 ) or 3 hours ( 3h/d group , n=8 ) of shaping training with the affected h and per day . MAIN OUTCOME MEASURES The Motor Activity Log and Wolf Motor Function Test . RESULTS Significant improvements in motor function in the laboratory and increased use of the affected h and in the real-world environment were found in both groups . The beneficial effects were significantly greater in the 6h/d group than in the 3h/d group . CONCLUSION The 3-hour CIMT training schedule significantly improved motor function in chronic hemiparesis , but it was less effective than the 6-hour training schedule BACKGROUND AND PURPOSE Of all stroke survivors , more than 50 % are left with motor disabilities . Impairment of upper limb movement is a common motor disability . Constraint-Induced Movement Therapy ( CIMT ) is an intervention which has been used for the treatment of upper extremity motor disabilities in stroke patients . Although CIMT is an effective intervention , a recent survey revealed that this procedure is viewed with apprehension by many clinicians because of concerns about practicality and re source issues . We developed a modified CIMT that reserves the massed training of the affected arm without any physical restriction of the intact one and then used it on our stroke patients . This study was design ed to evaluate the effectiveness of this Modified-Constraint-Induced Movement Therapy ( m-CIMT ) . METHODS Thirty stroke patients were r and omly assigned to either an m-CIMT ( n=13 ) or a control group ( n=17 ) . Subjects in the m-CIMT group received a 2-week course of m-CIMT . Outcomes were evaluated using the Wolf Motor Function Test ( WMFT ) . RESULTS After only 2 weeks of training , significant differences ( p<0.05 ) in favor of m-CIMT were found in the following 6 elements of the WMFT : Extend elbow with weight , Lift pencil , Stack checkers , Flip cards , Turn key in lock , and Lift basket . CONCLUSION The present study shows that our m-CIMT is useful in improving the function of the affected upper extremity in stroke patients To determine modified constraint-induced therapy ( mCIT ) feasibility and compare its efficacy to traditional rehabilitation ( TR ) in acute stroke patients exhibiting upper limb hemiparesis . Method . Before-after , multiple baseline , r and omized controlled pilot study . Setting . Rehabilitation hospital . Patients . Ten stroke patients < 14 d poststroke and exhibiting upper limb hemiparesis and affected limb nonuse . Interventions . Five patients were administered mCIT , consisting of structured therapy emphasizing more affected arm use in valued activities 3 d/week for 10 weeks and less affected arm restraint 5 d/week for 5 h. Five other patients received 1/2 sessions of traditional motor rehabilitation for the affected arm , which included affected limb manual dexterity exercises and stretching , as well as compensatory strategies with the unaffected limb . The TR regimens occurred 3 d/week for 10 weeks . Main Outcome Measures . The Fugl-Meyer Assessment of Motor Recovery ( Fugl-Meyer ) , Action Research Arm Test ( ARA ) , and Motor Activity Log ( MAL ) . Results . Before intervention , all patients exhibited stable motor deficits and more affected arm nonuse . After intervention , mCIT patients displayed increased affected arm use ( + 2.43 on the MAL amount of use scale ) , uniformly exhibited increases on the Fugl-Meyer and ARA ( mean change scores = + 18.7 and + 21.7 , respectively ) , and were able to again perform valued activities .  TR patients exhibited nominal change in affected limb use ( + 0.07 on the MAL amount of use scale ) and modest changes on the Fugl-Meyer and ARA ( + 4.4 and + 4.8 , respectively ) . Fugl-Meyer and ARA changes were significant for the mCIT group only ( P < 0.01 ) . Conclusions . mCIT is a promising regimen for improving more affected limb use and function in acute cerebrovascular accident . However , larger confirmatory studies need to be performed The Wolf Motor Function Test ( WMFT ) has been used in rehabilitation studies of chronic stroke patients , but until now its psychometric properties have not been evaluated in patients with subacute stroke . Two hundred twenty-nine participants with subacute stroke ( 3 - 9 months postinjury ) at 7 research sites met inclusion criteria for the EXCITE Trial and were r and omized into immediate or delayed ( by 1 year ) constraint-induced movement therapy treatment . All evaluations were undertaken by assessors st and ardized in the administration of the WMFT and masked to treatment design ation . Participants were also assessed using the  Fugl Meyer Motor Assessment ( FMA ) . Delayed group members had measurements repeated 2 weeks following baseline assessment to determine learning or exposure effects . The results demonstrate that the WMFT differentiated higher from lower functioning participants across sites ; scores were uninfluenced by h and dominance or affected side . Women exhibited slower performance times than men . The Functional Ability scale ( FAS ) portion of the WMFT also revealed lower scores among lower functioning participants and women . Minimal changes were observed after repeating the WMFT among delayed group participants 2 weeks later . The FMA revealed similar results when the total group was divided into higher and lower functional levels at its midpoint score of 33 . The WMFT discriminates higher from lower functioning participants tested across research sites . Comparable findings using the FMA support the criterion validity of the WMFT This article describes the study design , method ological considerations , and demographic characteristics of a phase III RCT to determine if 1 ) constraint-induced therapy ( CI therapy ) can be applied with therapeutic success 3 to 9 months after stroke across different sites , 2 ) gains that might occur persist over 2 years , 3 ) initial level of motor ability determines responsiveness to CI therapy , and 4 ) the treatment effect differs between those treated before 9 months and after 1 year . Six sites will screen and recruit poststroke survivors stratified on initial level of motor ability and after r and omization allocate participants to immediate or delayed intervention . Primary outcomes include a laboratory-based measure of function ( Wolf Motor Function Test [ WMFT ] ) and a real-world participant-centered functional use measure ( Motor Activity Log [ MAL ] ) . Secondary outcomes concern function , behavior , and compliance . This is the first multisite , single-blind RCT of a formal training intervention for upper extremity rehabilitation in subacute stroke in the United States Objective . This preliminary study examines the effects of a 2-week constraint-induced therapy ( CIT ) intervention on the force-producing capabilities of the hemiparetic h and during the performance of a functional dexterous manipulation task . Methods . A 6-degree-of-freedom force/torque transducer that was embedded into the h and le of a key allowed for the quantification of grasping forces and torques produced during the performance of a functional key-turning task . Clinical and kinetic data were collected from 10 subacute patients ( 3 - 9 months poststroke ) who were participating in an ongoing national clinical study ( EXCITE trial ) examining the effects of CIT on upper extremity motor performance . Investigators were blinded to treatment design ation . Five patients receiving treatment immediately completed 2 weeks of intensive CIT , whereas a group r and omized to treatment 1 year later did not receive any therapy during a similar 2-week span . Results . Results indicated that 4 of the 5 patients in the CIT group , compared to the delayed group , showed significant clinical improvements in h and function , increased maximum precision grip force , improved force and torque regulation , and reduced variability in rate of force production during task performance . Conclusions . Improved force control may be a mechanism contributing to the observed improvements in dexterous function in those patients undergoing CIT OBJECTIVE To determine the efficacy , safety , and compliance with forced-use therapy ( FUT ) applied without additional " shaping " therapy during the rehabilitation phase of stroke . DESIGN Prospect i ve , r and omized controlled trial . SETTING Tertiary mixed rehabilitation center . PARTICIPANTS Consecutive sample of 30 in patients or out patients with first stroke showing minimal movement of the arm and h and . Subjects who scored below 26 on the Mini-Mental State Examination were excluded . Seven subjects either did not provide consent or withdrew from the study . The remaining subjects were r and omized into the  control group ( n=13 ) and the FUT group ( n=10 ) . INTERVENTION FUT involved wearing a thick constraint mitten on the sound arm for as many as 6 hours a day . MAIN OUTCOME MEASURES The Chedoke McMaster Impairment Inventory for arm , h and , postural control , and shoulder pain ; Action Research Arm Test ; grip strength ; and FIM instrument . RESULTS FUT subjects experienced 20 % more recovery of the arm than did control subjects and more recovery of postural control ( P=.04 ) . Men benefited most from the program , and there was a tendency for FUT subjects to have more shoulder pain . Compliance was related to cognitive status . CONCLUSIONS FUT , without shaping therapy , appears to augment arm recovery , but a larger sample is required to confirm these findings . The FUT mitten was safe and well tolerated ; however , more research is needed to determine the relation between FUT and hemiplegic shoulder pain Objective : To determine the efficacy of a modified constraint-induced therapy ( mCIT ) administered to patients with subacute stroke . Design : Prospect i ve , multiple-baseline , before-after , r and omized clinical trial . Setting : Subacute outpatient clinic . Subjects : Fourteen patients with subacute stroke who exhibited learned nonuse and stable motor deficits in their affected upper limbs . Intervention : Four patients participated in half-hour , structured physical and occupational therapy sessions that emphasized affected arm use in valued functional activities , 3 times per week for 10 weeks . Their less affected upper limbs were restrained 5 days per week during 5 hours identified as times of frequent use ( mCIT ) . Five patients received regular therapy ( TR ) with similar therapeutic contact time to mCIT , and 5 patients received no therapy ( CON ) . Main Outcome Measures : The Fugl-Meyer Assessment of Motor Recovery ( Fugl ) , Action Research Arm ( ARA ) test , and Motor Activity Log ( MAL ) . Results : After intervention , Fugl , ARA , and MAL scores remained virtually the same for TR and CON groups ; scores improved by 11.4 and 11.5 points , respectively , on the Fugl and ARA for the mCIT group . Amount and quality of arm use , as measured by the MAL , also improved for mCIT patients ( 2.49 and 0.47 , respectively ) . Conclusions : mCIT may be an efficacious method of improving affected arm function and use in stroke patients exhibiting learned nonuse Constraint-induced movement therapy ( CI ) , a st and ardized intensive rehabilitation intervention , was given to patients a year or more following stroke . The goal was to determine if CI was more effective than a less-intensive control intervention in changing motor function and /or brain physiology and to gain insight into the mechanisms underlying this recovery process . Subjects were recruited and r and omized more than 1 year after a single subcortical infa rct ion . Clinical assessment s performed before and after the intervention and at 6 months postintervention included the Wolf Motor Function Test ( WMFT ) , the Motor Activity Log ( MAL ) , and the Assessment of Motor and Process Skills ( AMPS ) .  Transcranial magnetic stimulation was used to map the motor cortex . Positron emission tomography was used to measure changes in motor task-related activation due to the intervention . MAL increased by 1.08 after CI therapy and decreased by 0.01 after control therapy . The difference between groups was significant ( P < 0.001 ) . Changes in WMFT and AMPS were not significantly different between groups . Cerebral activation during a motor task decreased significantly , and motor map size increased in the affected hemisphere motor cortex in CI patients but not in control patients . Both changes may reflect improved ability of upper motor neurons to produce movement OBJECTIVE To determine efficacy of a modified constraint-induced movement therapy ( mCIMT ) protocol for patients with chronic stroke . DESIGN Multiple-baseline , pre-post , single-blinded r and omized controlled trial . SETTING Outpatient clinic . PARTICIPANTS Seventeen patients who experienced stroke more than 1 year before study entry and who had upper-limb hemiparesis and learned nonuse . INTERVENTION Seven patients participated in structured therapy sessions emphasizing more affected arm use in valued activities , 3 times a week for 10 weeks . Their less affected arms were also restrained 5d/wk for 5 hours ( mCIMT ) . Four patients received regular therapy with similar contact time to mCIMT . Six patients received no therapy ( control ) . MAIN OUTCOME MEASURES The Fugl-Meyer Assessment of Motor Recovery ( FMA ) , Action Research Arm ( ARA ) Test , and Motor Activity Log ( MAL ) . RESULTS The mCIMT patients exhibited greater motor changes on the FMA and ARA ( 18.4 , 11.4 ) than regular therapy ( 6.0 , 7.1 ) or control ( -2.9 , -4.5 ) . Statistical analyses showed significant differences in motor improvement on the FMA ( F(2,12)=11.2 , P=.002 ) and the ARA ( F(2,12)=14.0 , P=.001 ) . Post hoc analyses showed that , when pretreatment motor differences are controlled , mCIMT result ed in substantially higher posttreatment FMA and ARA scores . Amount and quality of arm use , measured by the MAL , improved only in mCIMT patients . CONCLUSIONS mCIMT may be an efficacious method of improving function and use of the more affected arms of chronic stroke patients . Findings further affirm that repeated , task-specific practice is critical to reacquisition of function , whereas practice schedule intensity is less critical
AIM The aim of this study was to analyse the evidence of effectiveness on adult stroke patients of the Constraint Induced Movement Therapy ( CIMT )  , an original rehabilitation method that consists in strongly encouraging patients to use the affected arm , mainly immobilising the unaffected arm .