7.cimt & MRP

Constraint Induced Movement
Therapy
Introduction
– CIMT involves constraining the unaffected limb, along
with intense therapy, in order to force the use of the
affected with the intent to improve motor function.
– Teaches the brain to “rewire” itself following a major
injury such as stroke or TBI (NEUROPLASTICITY)

History
– Early research was done by Edward
Taub on surgically deafferented
monkeys.
– “learned non-use”.
3 components of CIMT
– Restraint of unaffected arm.
– Repetition, structured, intense practice of affected arm.
– Monitored arm used in life situation and problem solving
to overcome barriers.
Technique
– Types of restraint included
– Sling
– Glove
– Splint
– Plaster
– Total time of restraining – 90% of waking hours.
– 6 hours/day of intense therapy on consecutive weekdays.
– 2 to 3 week period.
CIMT patients
– Stroke
– Cerebral palsy (pediatrics)
– Traumatic brain injury or spinal cord injury
Minimum inclusion criteria
– 10 X10 X 10
– Upto 10 degree wrist extension
– Upto 10 degree thumb abduction
– Upto 10 degree finger extension of
any other two digits .

Advantages Disadvantages
Overall great improvements in Requires enormous labour.

function as compared to conventional
treatment.
Highly researched treatment Patient endures many hours of

approach. frustration.
Increased social participation. Patient can suffer from muscle

soreness resulting in stiffness and
discomfort in the involved UE as well
as skin lesions.
Cortical reorganisation observed. Not beneficial for all stroke or head
injury patients.
Modified CIMT
– To promote better compliance.

– Protocol :
– 30 mins of 1 to 1 therapy for 3 days a week;
– 5 hours/day in restraint (weekdays) for 10 weeks.
Thank you !
MOTOR
RELEARNING
PROGRAMME
Motor Relearning Programme
 Focus on practice of missing task components

and whole tasks, and transference of learning
 Examples: Use of “real-world” environments
“Forced use” of affected UL Inc.
activity of UL muscles Stretching of
key UL muscles Feedback
and guidance
4 STEPS
i. Analysis of task
ii. Practice of missing component
iii. Practice of task
iv. Transference of learning
1.ANALYSIS OF TASK-
* Observation
* Comparison
* Analysis
2. PRACTICE OF MISSING COMPONENTS-
* Explanation – Identification of goal

* Instruction
* Practice + verbal + visual feedback +
manual guidance
3. PRACTICE OF TASK-
•Explanation – Identification of goal
•Instruction
•Practice +verbal + visual feedback + manual guidance
*Progression:-
Increase complexity
Add variety
Dec. feedback & guidance
•Reevaluation
•Encourage flexibility
4. Transference of learning
*Opportunity to practice
*Consistency of practice +ve reinforcement
*Organization of self-monitored Practice
*Structured & stimulating learning environment

*Involvement of relatives and staff
Common adaptive movements
1. Flexion at the hips instead of flexion at the GHJ during

reach
2. Shoulder girdle elevation, spinal lateral flexion, GHJ
abduction with elbow flexion, and GHJ IR with forearm
pronation during reach
3. Excessive hand opening for grasp
4. Excessive flexor force during grasp
5. Finger extension with the wrist flexed and thumb CMC
and MCP extension during release
.
This provides sensory input to the
involved
side through proprioception.
Patient awareness to affected side.
Therapist manual
guidance
Hemi paralytic hand

Scapular Protraction
protraction
* helps to dec. abnormal flexor tone..
Position-
*while in side lying on the involved side,
*during dressing activities
*while sitting (table top polishing) .
* standing (washing the car).
Protraction
at scapula
Scapular Protraction-
with Weight bearing
1..Full protraction,
pt roll over the shoulder
I
inc. wt bearing
on affected side.
2. dynamic trunk
control
Bobath
Approach
Concepts and Principles

History…
– Developed by Dr. Karel Bobath, a neuropsychiatrist, and

Mrs. Berta Bobath, a physical therapist
– 1943 – while working with children with cerebral palsy
Original theoretical
framework…
– Based on the works of Jackson, Sherrington, and Magnus
 who described nervous system as HIERARCHICAL in nature
– Model
 Higher brain centers exerted control over lower-level centers
 Eg. The cerebral cortex control supercedes that of the brainstem
Original theoretical
framework…
– Hypothesis
 A neurologic insult will lead to a

release of the lower-level centers from
higher-level center inhibitory control,
resulting in stereotypical postures,
primitive movement patterns and
predominant reflex activity
Adult hemiplegia..
– Treatment approach was later on expanded to include the

rehabilitation of adults with motor problems, particularly
CVA
– Main problem: the abnormal coordination of movement
patterns combined with abnormal postural tonus
(Bernstein, 1967)
– Secondary problem: muscle strength and muscle activity
Bobath concept…
– Is a living concept, it is not static

 It has undergone changes in its theoretical base to accommodate
developments in the fields of neurophysiology, biomechanics, and typical
development
– Holistic approach
 It involves the whole patient, his sensory, perceptual and adaptive
behaviour, and motor problems
Traditional View
– Principles of treatment
– Normalize muscle tone

– Inhibit primitive reflexes
– Facilitate normal postural reactions
– Treatment should be developmental
– Techniques
– Handling
– Weight bearing over the affected limb
– Utilize positions that allow use of the affected limbs
– Avoidance of sensory input that affect muscle tone
Previously…
– The control of movement was thought to be dependent on

the normal postural reflex mechanism
 E.g. utilizing righting reactions and equilibrium reactions
in association with normal postural tone
Reconstruction of
Systems Theory the
NDT approach
Hierarchical Theory
Premise
– Different parts of the CNS influence one another
– Nervous system is capable of initiating, anticipating, and controlling

movements
– feedforward and feedback mechanisms
– CNS has the ability to shape and/or renew itself in response to

practiced activities: neuroplasticity
Evidence on neuroplasticity
(Fisher, BE and Sullivan, KJ, 2001)
– Neuroplasticity can occur on the lesioned side of the cerebral
cortex following CVA when provided appropriate practice in
using involved side
– Rehabilitation strategies should promote recovery rather than
compensation
– Techniques should incorporate the following:
– Active participation in motor skill learning
– Specific skills training and strengthening directed to the involved
limbs
– Intense, task-specific practice that optimizes the sensorimotor
experience
Basic premises…
– Sensations of movements are learned

– Basic postural and movement patterns are learned that
are later elaborated on to become functional skills
Problems in the adult
patient with stroke
– Abnormal tone
– Loss of postural control
– Abnormal coordination
– Abnormal functional performance
Goals…
– Decrease the influence of spasticity and abnormal

coordination
– Improve control of the involved trunk, arm and leg
– Retain normal, functional patterns of movement in the
adult stroke patient
Principles of treatment:
Adult hemiplegia
– Treatment should avoid movements and activities that increase muscle tone
or produce abnormal reflex patterns in the involved side
– Treatment should be directed toward the development of normal patterns

of posture and movement (movement patterns are not based on the
developmental sequence but on patterns important for function)
Adult hemiplegia
– The hemiplegic side should be incorporated into all
treatment activities to reestablish symmetry and increased
functional use
Adult hemiplegia
– Individualize functional outcomes

– Emphasize motor control
– Increase active use of the involved side
– Provide practice to improve motor performance that lead to motor
learning
– Teach 24-hour management to increase retention and carryover
– Use an interdisciplinary approach to intervention
Stages of hemiplegia and
the Bobath Approach
– Initial Flaccid Stage
 focus on positioning and movement in bed to avoid the typical
postural patterns of hemiplegia
– Stage of Spasticity
 it is a continuation of the previous stage with the goal of breaking
down the total patterns by developing control of the intermediate joints
Stages of hemiplegia and
the Bobath Approach
– Stage of Relative Recovery
 aims at improving the quality of gait and the use of the affected hand
children with cerebral palsy
– Treat the child as a whole
– Basis for intervention is normal movement and their interrelationships
– Treatment incorporates facilitation and inhibition using key points of

control
 abnormal tone is always inhibited
 normal responses, once elicited, are always repeated
Facilitation-Inhibition
– Facilitation
 is a mean by which movement is made easy, made possible, and made
necessary
– Inhibition
 involves decreasing the use of pathological movements and the effects of tonal
dysfunctions on movement
– Facilitation and inhibition may be used simultaneouly and may be applied
throughout the session

7.cimt & MRP

Uploaded by

Copyright:

Available Formats

7.cimt & MRP

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

7.cimt & MRP

Uploaded by

Copyright:

Available Formats

Constraint Induced Movement

– CIMT involves constraining the unaffected limb, along

with intense therapy, in order to force the use of the

affected with the intent to improve motor function.

– Teaches the brain to “rewire” itself following a major

injury such as stroke or TBI (NEUROPLASTICITY)

– Early research was done by Edward

Taub on surgically deafferented

– Restraint of unaffected arm.

– Repetition, structured, intense practice of affected arm.

– Monitored arm used in life situation and problem solving

– Types of restraint included

– Total time of restraining – 90% of waking hours.

– 6 hours/day of intense therapy on consecutive weekdays.

– Upto 10 degree wrist extension

– Upto 10 degree thumb abduction

– Upto 10 degree finger extension of

any other two digits .

Overall great improvements in Requires enormous labour.

Highly researched treatment Patient endures many hours of

Increased social participation. Patient can suffer from muscle

– To promote better compliance.

 Focus on practice of missing task components

* Explanation – Identification of goal

•Explanation – Identification of goal

•Practice +verbal + visual feedback + manual guidance

*Consistency of practice +ve reinforcement

*Organization of self-monitored Practice

*Structured & stimulating learning environment

1. Flexion at the hips instead of flexion at the GHJ during

Hemi paralytic hand

with Weight bearing

Concepts and Principles

– Developed by Dr. Karel Bobath, a neuropsychiatrist, and

 A neurologic insult will lead to a

– Treatment approach was later on expanded to include the

– Is a living concept, it is not static

– Normalize muscle tone

– The control of movement was thought to be dependent on

– Nervous system is capable of initiating, anticipating, and controlling

– feedforward and feedback mechanisms

– CNS has the ability to shape and/or renew itself in response to

– Sensations of movements are learned

– Decrease the influence of spasticity and abnormal

– Treatment should be directed toward the development of normal patterns

– Individualize functional outcomes

– Basis for intervention is normal movement and their interrelationships

– Treatment incorporates facilitation and inhibition using key points of

You might also like