Chapter 13: Constraint-Induced Movement Therapy

INTRODUCTION

Constraint-induced movement therapy, or CI therapy, involves a variety of intervention components to promote increased use of a more-impaired extremity in the clinic setting, the research laboratory, and, most importantly, in the home setting.^1–15 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.^18–25 Substantial evidence has accumulated to support the efficacy of CI therapy for hemiparesis after chronic stroke (i.e., greater than 1 year postinjury).^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.^2–9 There has also been a large multisite randomized clinical trial in patients with UE hemiparesis in the subacute phase of recovery (i.e., 3 to 9 months poststroke).^28–30 Positive findings regarding CI therapy after chronic stroke are also published in several studies from other laboratories employing between-group and within-subject control procedures and numerous case studies.^31–35 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

INTERVENTION: THE CI THERAPY PROTOCOL

Constraint-induced movement therapy for the UE consists of intervention elements that 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 ...