Document Type

Critically Appraised Topic

Publication Date

2013

Clinical Scenario

According to the Centers for Disease Control and Prevention (n.d.) more than 795,000 Americans have a stroke every year; these strokes cost the United States $38.6 billion dollars annually, resulting in lasting hemiplegia for many individuals, negatively affecting motor function in the upper extremity (UE). If neglected, the impaired UE loses the potential for improved functionality due to learned non-use. CIMT can be employed in stroke rehabilitation to address this issue.

Constraint induced movement therapy was developed by Edward Taub and his colleagues in response a concept known as learned non-use. Learned non-use is the idea that if a person tries to use their affected limb and does not get the results they want they will stop using it; this non-use will result in further limitation in functional use of the limb. In 1993 Taub and his colleagues published a standard protocol for CIMT for use with patients who have sustained a stroke. This standard protocol is what is now referred to as high intensity CIMT. (Thorne, 2009)

The standard CIMT protocol uses a padded mitt or sling on the less-impaired UE for 90% of waking hours over 2 weeks, while additionally performing monitored behavioral shaping and repetitive task practice 5 days/week for 6 hours/day. Modified protocols are common with decreased time required to wear the mitt and/or decreased hours of clinical therapy. Eligibility requirements typically include 10-20 degrees of active wrist extension, at least 10 degrees of thumb abduction/extension, and at least 10 degrees of extension in at least two other digits. Patients are expected to have adequate balance, ability to transfer independently, and the ability to stand for at least 2 minutes without upper extremity support. In addition, patients are screened with a cognitive exam, such as the Mini Mental State Examination (MMSE), and are only included if they score greater than 24. Some of these criteria can vary depending on the study.

In addition, CIMT can be used as an isolated therapy or in conjunction with traditional rehabilitation therapy. Results vary regarding the CIMT intervention timeline post-stroke. CIMT has been studied thoroughly and has proven to be effective in most intervention timelines for individuals that meet the eligibility requirements. This intervention approach is a valuable resource in stroke rehabilitation.

Clinical Question

Does combining constraint-induced movement therapy with traditional therapy in stroke patients improve UE motor function in the affected limb more so than traditional therapy alone?

Clinical Bottom Line

Constraint-induced movement therapy has produced significant UE functional improvements in patients as early as 3 months post-stroke. Improvements have also been clinically-demonstrated up to 2 years or longer after presentation of stroke. Several clinical outcome tests have been used to support these findings, including the Action Research Arm Test, Wolf Motor Function Test, and Functional Independence Measure.

The success of CIMT has proven to be dosage dependent, with high-intensity CIMT showing diminished functional improvements when used within one month post-stroke.

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