Constraint Induced Movement Therapy

CONSTRAINT-
INDUCED MOVEMENT
THERAPY
(CIMT)
ZAHID MEHMOOD BHATTI

Assistant Professor
CONSTRAINT-INDUCED MOVEMENT
THERAPY
DEVELOPED AT THE UNIVERSITY OF ALABAMA
BIRMINGHAM
BACKGROUND
• Began with basic research done with monkeys in which somatic
sensation was surgically abolished in one forelimb resulting in
somatosensory differentiation.
• After somatosensory differentiation, monkeys do not use the forelimb
in the free situation (problem is nonuse).
• Hypothesis that the nonuse was a learning mechanism termed
‘learned nonuse’.
• Two general types of techniques were effective in overcoming the
nonuse in the monkeys.
THE PROCEDURES OF CI THERAPY
• Arm, therapy involves ‘promoting use of the more affected UE

for a target of 90% of waking hours restraining or reducing use
of the less-affected UE for 2-3 weeks (depending on the severity
of the deficit)’
• Training of the more-affected UE is given 6 hrs daily for 10
consecutive weekdays during that period (ie, massing of practice
or concentrated, repetitive training).
• For the lower extremity (LE) the less-affected LE is not
restrained, but the more affected LE is given intensive training for
7 hrs per day over a period of 3 weeks.
CRITICAL CONCEPT: LEARNED NONUSE
CIMT is intended to help stroke patients overcome

‘learned nonuse’ of the paretic arm by discouraging
the use of the unaffected or less affected arm in
combination with intensive training of the paretic arm.
DEVELOPMENT OF LEARNED NONUSE:
“HYPOTHESIS”
OVERCOMING LEARNED NONUSE:
“HYPOTHESIS”
CIMT ADMISSION CRITERIA
• Motor Criteria UE :
• All movement criteria includes
• Ability to start from a resting position of forearm Pronation and Wrist flexion.
• 10 degrees of active MCP and IP joint extension.
• 20/10 degrees of active wrist extension.
• 10 degree of Thumb Abduction
• CIMT is focused on 4 major patient population
• CVA (Stroke)
• Cerebral Palsy (Pediatrics)
• TBI
• Multiple Sclerosis
INCLUSION CRITERIA
• Active movement:
• patients must be able to pick up a tennis ball and place on surface
approximately 20 centimeters higher, three times in one minute, from
sitting.
• 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
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
MEASUREMENT TOOLS
1. Chedoke McMaster Disability Inventory (Arm & Hand)

2. CAHAI (Chedoke Arm & Hand Activity Inventory)
3. Canadian Occupational Performance Measure
4. Motor Activity Log (Amount Scale)
MOTOR ACTIVITY LOG: “AMOUNT”
• 0 - did not use my weaker arm
• 1 - occasionally tried to use my weaker arm (very rarely)
• 2 - sometimes used my affected arm, but did most of the activity with my
stronger arm (rarely).
• 3 - used my weaker arm about half as much as before the stroke (half
prestroke).
• 4 - used my weaker arm almost as much as before the stroke (3/4
prestroke)
• 5 - used my weaker arm as much as before the stroke (same as prestroke).
30 different questions: “In the last week, how often did

you…..use your weaker arm to turn on a light with a light
switch”?
MOTOR ACTIVITY LOG: “HOW WELL”
• 0 - the weaker arm was not used at all for that activity (never)
• 1 - the weaker arm was moved during that activity, but was not helpful
(very poor).
• 2 - the weaker arm was of some use during that activity, but needed some
help from the stronger arm, moved very slowly, or with difficulty (poor).
• 3 - the weaker arm was used for the purpose indicated, but movements
were slow or were made only with some effort (fair).
• 4 - the movements made by the weaker arm were almost normal, but not
quite as fast or accurate as normal (almost normal)
• 5 - the ability to use the weaker arm for that activity was as well as before
the stroke (normal).
“When you used your weaker arm to….turn on a light with a light
switch, how well did it work”?
ACTUAL AMOUNT OF USE TEST (AAUT)
VIDEOTAPE SPONTANEOUS ACTIONS
• open file folder • turn pages of photo album

• go through material • place pictures in album
• remove pages • hand album to experimenter
• put paper in pocket or • fill out form or hold paper
while writing
purse • unfold newspaper
• open box • open newspaper to indicated
• remove cards from box article
• take photo album • gesture with affected arm
• posture when walking/when
standing or sitting
SHAPING
• Shaping is a training method in which a motor task is gradually made

more difficult.
• Shaping programs are individualized consisting of 10-15 tasks selected
primarily from a basic battery of tasks.
• Each task is usually performed in a set of 10-30 sec trials. At the end of
each set of 10 trials, the task is changes.
• Only one shaping parameter is changed at a time. Requires constant
therapist involvement.
TASK PRACTICE
• Task practice is repetitive practice of individual functional tasks

that takes roughly 15-20mins.
• Rest is provided as required.
• Encouragement is given on an infrequent basis (i.e. every 5 mins)
with feedback at end of task as well about how they performed.
• Requires less therapist involvement.
THANK YOU

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CONSTRAINT-

ZAHID MEHMOOD BHATTI

• Arm, therapy involves ‘promoting use of the more affected UE

CIMT is intended to help stroke patients overcome

• Medical condition requiring monitoring or intervention during

1. Chedoke McMaster Disability Inventory (Arm & Hand)

30 different questions: “In the last week, how often did

• open file folder • turn pages of photo album

• Shaping is a training method in which a motor task is gradually made

• Task practice is repetitive practice of individual functional tasks

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