1. SANA BATOOL LECTURER IPM&R, DUHS CONSTRAINT INDUCED MOVEMENT THERAPY

2. Objectives  Background and Evidence  Description of Components  CIMT Vs. mCIMT program  Further Applications

3. constraint induced movement therapy  A recent intervention that has gained much consideration in the treatment of post stroke paretic arm  It was described by Dr Edward Taub in the late 1970s and 1980s on the basis of his initial research with primates.  Monkey's one forelimb was surgically deafferented by dorsal rhizotomy, as a result monkeys were unable to use their affected forelimb despite of a great effort & developed a learned non-use phenomenon.  This phenomenon is also seen in patients who experience hemiparesis following stroke.

4.  The treatment technique three components:  First, stroke patients underwent CIMT program need intensive task training of paretic arm for six hours per day of successive two weeks.  Second it involves constraining movement of unaffected arm with a sling, mitt or splint for 90% of waking hours.  And, third, CIMT involves application of simple behavioral technique called shaping of hemiplegic arm which is useful in overcoming learned non use phenomenon.

6. SHAPING: A BEHAVIORAL APPROACH A. Shaping:  Shaping is a treatment technique that includes performing tasks such as spooning beans or blocks to a box.  The tasks increase in difficulty as performance improves and frequent feedback is given immediately  tasks chosen based on movement goals, potential for improvement, patient preference  goal is not ‘skill acquisition’ but cortical stimulation and overcoming learned non-use  Also called “Adapted Task Practice”

7. Constraint Induced Therapy  CIT protocol  Restraint aarm/hand with a mitt or sling 90% of the time  In the clinic 5 days a week 6 hours in clinic 2 weeks  mCIT protocol  Restraint aarm/hand with a mitt or sling 5 hours per day  In the clinic 3 days a week 30 minutes in clinic 10 weeks

8. Inclusion Criteria  To take part in CIMT program patient’s hemiplegic upper limb should have a functional level of;  ≥ 20 degrees of wrist extension & ≥10 degrees of extension of all digits  Passive movement: no major contractures limiting function  Able to focus exclusively on UE training for two week period (ie. not requiring other therapies for duration of CI training)  Motivated and able to comply with the demands of the program

9. Exclusion Criteria  medical condition requiring monitoring or intervention during treatment day (including administration of medication), unless responsible caregiver present.  requires assistance to transfer or toilet, unless caregiver present  unable to tolerate half a day of activity (due to fatigue, pain, concentration, motivation)  vision or hearing not sufficient to participate in self-rating scales

10. Exclusion Criteria  communication abilities not sufficient to participate in self-rating scales, unless caregiver who is knowledgeable in patient’s daily performance of activities at home present  unable to provide reliable yes/no answers  unable to follow one-step commands  motor and functional impairments not significant enough to warrant intensive therapy

11. Case Study  51 year old female, left lentiform nucleus infarct in August 2005  Rehab at Glenrose Subacute, Outpatient, CRIS Program, acupuncture, Spasticity Clinic  Participated in CIMT September 2007

12. Subjective Feedback  “It has totally changed the way I think about using my weak arm.”  “I feel like I ‘rehired’ the arm that I fired after the stroke.”  “Overall, my daily life is so much easier.”  “My body seems more aligned.”  “I saw a lot of improvement in my family member.”

13. Reaching forward Reaching sideways

14. Grasping & Pouring

15. Stacking Blocks

16. Stacking cones