Constraint Induced Movement Therapy for Post Stroke Paralysis

Constrained Induced Movement Therapy is a breakthrough approach that can train the brain to re-wire its neuronal connections and thus recover lost function due to the damage caused to the neurons in conditions such as Stroke. In a stroke, the brain neurons are damaged due to loss of blood flow and oxygen, as a consequence of the arterial occlusion (see image of the CT Scan of the Brain showing Stroke. Courtesy – Wikipedia.com)

Stroke patients are often left paralyzed (hemiplegia or hemiparesis) in their arms or legs (usually the side of the body opposite to the area of the brain damaged by the stroke, ). Until now most Post Stroke Functional Rehabilitation has been limited to physiological exercises in the effected limbs, with the hope that the brain can regain some of the lost functional capacity. Post stroke rehabilitation treatment is currently limited to providing some physiological exercises, usually in the form of supported hand or leg movements. This has shown to only have modest improvements and that too in some patients only.

Accumulating evidence on the use of Constraint Induced Movement Therapy is changing the way how such patients can regain movement of their paralyzed extremities and in some cases even their cognitive functions like the ability to speak.

For instance, according to the results of the Extremity Constraint Induced Therapy Evaluation (EXCITE) Clinical trial, published in JAMA (2006;296[17]:2095-2104), CIMT is the first rehabilitation modality to show significant progress in helping patients regain motor functions (details below)

The central idea behind the CIMT is based on the pioneering work done by Edward Taube in 1977 when he was still a graduate student at Columbia University.  Taube found that when the spinal connections from the arms or legs of monkeys was severed on one side, while simultaneously immobilizing the “good” arm or leg using straps, the monkeys were able to regain some movement in their limbs that had their neuronal connections severed! When the good side arm was not immobilized, the monkeys didn’t regain movement in the severed arm. Taube termed this phenomenon as “learned non use“, that once the brain realized that it could no longer command the arms and legs to move on the severed side, it “learnt” that this side could no longer be used and thus stopped “trying” to command the effected limb.

On the other hand, the brain seems to follow a “use or lose it” principle (see Norman Doidge’s excellent account in the ‘Brain that Changes Itself‘) – the good side’s neuronal connections expand into the non used parts of the brain that was earlier processing the signals from the effected limb, further reducing the chance for the brain to rewire and regain some movement.

CIMT is administered to patients by providing them a very focused and rigorous physical training regimen for two weeks. In this time period, their good limb is strapped and immobilized using a mitt for ninety percent of the time the person is awake. And the effected limb is made to do a series of movements, starting with assisted movements to more complex self initiated movements (see picture of patient undergoing CIMT)

The strapping of the good limb (note the white mitt in the picture above) is the key as it reduces the overwhelming inputs from this arm that inhibit any weak signals that may arise in the effected part of the brain from the effected limb. Given the impetus to move, perhaps as a survival mechanism, the brain then begins to fire up the neurons that control the movement of the effected limb. Given that only few neurons in the damaged part of the brain remain, the signals are at first weak. But with constant effort to move the effected limb, the brain gets a chance to rewires its network so that the weak signals can be picked up by the neurons which are controlling the good limbs. As the EXCITE trial showed, after just two weeks of therapy, the CIMT group (compared with controls) achieved a 34% reduction in time to complete a task and a 65% increase in the proportion of tasks performed spontaneously with the partially paralyzed arm. These improvements persisted even twelve months later.

Till date some 300 patients have benefited from CIMT. If you have stroke induced paralysis, i would highly recommend that you consider making a call to Dr. Taube’s  clinic and research center

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25 thoughts on “Constraint Induced Movement Therapy for Post Stroke Paralysis

  1. you maybe wondering why a discovery made in 1977 has taken so long to come to effect? This is because Dr. Edward Taube had to face a number of significant hurdles. First, the findings received strong criticisms by the scientists of that time, including Taube’s PhD Advisor. Next came the unfounded charges of cruelty to animals (the monkeys used in the experiments), an accusation brought against Dr. Taube by PETA which resulted in withdrawal of funding for Taube’s research (a great account of this is provided in Norman Doidge’s recent book on the plastic nature of the brain, called “The brain that changes itself”). However, Taube proved that these accusations were false and managed to re-start his research and to re-gain funding from the NIH. This resulted in more studies and the first ever randomized control trial of the use of CIMT for treatment of stroke patients.

  2. There still is no acknowledgement that there is a difference between penumbra recovery where CIMT is valid. Dead brain neuroplasticity probably needs a different protocol. What is the starting point of any patient who was in the research? This is needed if there is any hope of repeating the research results.

  3. Dean, thanks for the question.
    Here is some more detail about the EXCITE TRIAL that evaluated CIMT. In this trial they randomized a total of 222 patients who had a first ischemic or hemorrhagic stroke. The stroke event had to be in the last 3 to 9 months before the patient was randomized. This period was chosen because by this much time period spontaneous recovery has generally reached a plateau but before many chronic post-stroke changes such as atrophy or spasticity have progressed.

    The participants selected had moderate, but not severe, deficits. For example, each study volunteer needed to demonstrate that they could actively move the wrist through at least 10° range of motion, demonstrate good balance, and have no advanced cognitive impairment. Those already showing substantial use of the affected arm were excluded.

    After the 2 weeks of therapy, they evaluated the motor functions using Wolf Motor Function test 50 weeks from the last day of the therapy.

    More information can be found in the JAMA Article

  4. Sorry, but that does not describe a diagnosis, What part of the brain was affected that causes the diabilities? Was the motor cortex dead or stunned and within the penumbra, or was the reson the movement was affected was that the pre-motor cortex was dead vs. stunned, or was the cognitive executive control center where the problem lies. Until there are specifics no amount of research is really useful because it is not repeatable because the starting point is not determined. Sorry about the rant but until someone points out that stroke rehabilitation research has no clothes will it change.

  5. The current gold standard for treatment of mild post-stroke upper limb impairment is constraint-induced therapy but, because of the inclusion criteria, alternative treatments are needed which target more impaired subjects.
    Upper extremity hemiparesis is the most common post-stroke disability. Longitudinal studies have indicated that 30-66% of stroke survivors do not have full arm function 6 months post-stroke.
    The key element of Physical rehabilitation is intensive active exercise practice. Therefore the patient has to stay motivated in order to do the intensive exercise practice. This is the reason why competitive and recreational sports are good tools for rehabilitation. The key to Physical rehabilitation is to return the patients performance of everyday functional and vocational tasks to their pre injury level. Sport provides an ideal opportunity to do repetive task practice.
    If however the patient does not have the ability to do repetive task practice then active exercises can take the form of intensive isolated exercise practice. In other words doing exercises within or slightly harder than the patients movement ability. Isolated intensive exercise practice is particular important for fine motor hand rehabilitation.
    The HandTutor is an innovative hand active exercise glove and software with biofeedback training which helps patients recovering from stroke improve hand movement.
    The software is dedicated to rehabiliation and is easy to understand by both the patient and the therapist. This enables the exercises to be customized to the patients movement impairment so that they remain encouraged and motivated to continue intensive exercise practice. The HandTutor is used in hospitals and community hand therapy clinics as well as through tele rehabilitation. Examples of patients that are treated include Stroke, TBI, spinal cord injury CP, Orthopedic hand and arm surgery

  6. Alan,

    Thanks for the detailed comment and useful information. CIMT is still emerging and lots of research will be needed to see how it applies to different types of stroke patients

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  8. While designed for the point-of-care, Rehabilitation Reference Center is able to serve many needs. Physical Therapy, Occupational Therapy and Orthopedics are some of the largest services offered in US hospitals and there are many Physical Therapy Clinics, both private and those associated with hospitals. In addition many academic institutions offer Physical Therapy Programs and Occupational Therapy Schools.

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