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Introduction

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Constraint-induced movement therapy, or CI therapy, involves a variety of intervention components used to promote increased use of a more-impaired extremity in the clinic setting, the research laboratory, and, most importantly, in the home setting.1,2,3,4,5,6,7,8,9,10,11,12,13,14,15 The CI therapy protocol has its origins in basic animal research that led Taub to propose a behavioral mechanism that can interfere with recovery from a neurological insult—learned nonuse.11,16,17 A linked but separate mechanism, use-dependent brain plasticity, has also been proposed as partially responsible for producing positive outcomes from CI therapy.18,19,20,21,22,23,24,25 Substantial evidence has accumulated to support the efficacy of CI therapy for hemiparesis after chronic stroke (i.e., greater than 1-year post injury).4,26 Evidence for efficacy comes from several studies: an initial small, randomized controlled trial (RCT) of CI therapy in patients with upper extremity (UE) hemiparesis secondary to chronic stroke,1 a larger placebo controlled trial in patients of the same chronicity and level of impairment,27 and a number of other studies.2,3,4,5,6,7,8,9 There has also been a large multisite randomized clinical trial in patients with UE hemiparesis in the subacute phase of recovery (i.e., 3–9 months poststroke).28,29,30 Positive findings regarding CI therapy after chronic stroke are also published in several studies from other laboratories employing between-group and within-subjects control procedures and numerous case studies.31,32,33,34,35 Altogether, several hundred studies on the clinical effects of CI therapy have been published, almost all with positive results. Moreover, the most recent poststroke clinical care guidelines, developed by a working group organized by the Veteran's Administration and Department of Defense, describe CI therapy as an intervention that has evidence of benefit for survivors of stroke with mild-to-moderate UE hemiparesis.35

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Intervention: The CI Therapy Protocol

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Constraint-induced movement therapy for the UE consists of four different components. Some of these intervention elements have been employed in neurorehabilitation previously, but usually as individual procedures and at a reduced intensity compared with CI therapy. The main novel features of CI therapy are (1) the introduction of a number of techniques designed to promote transfer of the therapeutic gains achieved in the clinic/laboratory to the home environment, termed the transfer package, and (2) the combination of these treatment components and their application in a prescribed, integrated, and systematic manner. This involves many hours a day for a period of 2 or 3 consecutive weeks (depending on the severity of the initial deficit) to induce a patient to use a more-impaired extremity. In the University ...

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