Neurorehabilitation and Neural
Repair
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Individual Factors in Constraint-Induced Movement Therapy after Stroke
Michel Rijntjes, Verena Hobbeling, Farsin Hamzei, Stefanie Dohse, Gesche Ketels, Joachim Liepert and Cornelius Weiller
Neurorehabil Neural Repair 2005 19: 238
DOI: 10.1177/1545968305279205
The online version of this article can be found at:
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M. Rijntjes Factors
10.1177/1545968305279205
Individual
and others
in CIMT
Individual Factors in Constraint-Induced
Movement Therapy after Stroke
Michel Rijntjes, Verena Hobbeling, Farsin Hamzei, Stefanie Dohse,
Gesche Ketels, Joachim Liepert, and Cornelius Weiller
Objectives. Constraint-induced movement therapy
(CIMT) has been shown to be effective in chronic stroke
patients. It is worthwhile to investigate the influence of
individual factors for two reasons: to find out whether
they influence outcome and to see whether they support
the theory underlying CIMT. Methods. A group of 26
patients were treated with CIMT and followed over 6
months. In total, 14 individual factors were identified.
Patients were assessed with 6 tests, including 2 commonly used after stroke (Frenchay Arm Test, 9 Hole Peg
Test). Results. There were individual differences, but as
a group, patients improved after therapy. There were no
individual factors that influenced improvement in more
than one test. Conclusions. CIMT is an effective therapy
in patients with moderate impairment after stroke, also
in tests commonly used in stroke rehabilitation. Factors
that could have expected to make a difference on the
basis of the theory behind CIMT (e.g., time since stroke,
previous therapy, sensory deficit) did not influence
results. Patients with hemorrhagic lesions and those with
a high level of performance (Motor Activity Log > 2.5)
profit as well. Pairwise therapy is as effective as
individual therapy.
Key Words: Stroke—Rehabilitation—CIMT.
C
onstraint-induced movement therapy
(CIMT) is a relatively recent intervention for
patients with neurological deficits, depending on massed practice, movement restriction, and
shaping. The idea behind this therapy is that
nonuse of a limb is also partly a learning phenomenon involving behaviorally reinforced suppression
From Department of Neurology, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany (MR, VH, FH, SD, GK, JL),
and Department of Neurology, University Clinic Freiburg,
Freiburg, Germany (MR, CW).
Address correspondence to Michel Rijntjes, Dept. of Neurology,
Universitätsklinikum Hamburg-Eppendorf, Martinistrasse 52,
20246 Hamburg, Germany. E-mail: rijntjes@uke.uni-hamburg.de.
Rijntjes M, Hobbeling V, Hamzei F, Dohse S, Ketels G, Liepert J,
Weiller C. Individual factors in constraint-induced movement
therapy after stroke. Neurorehabil Neural Repair 2005;19:238–
249.
DOI: 10.1177/1545968305279205
238
of movement.1 It is usually applied for paresis of
the upper extremity after stroke, if the motor deficit of the affected arm is not too severe. There are
several reasons that this therapy is enjoying
increasing popularity. It is one of the few
physiotherapies that has a well-founded theory.1–3
It is the only physiotherapy that has been shown
with different imaging methods to induce
reorganizational changes in the cortex4–9 and to
have such changes correlate with the functional
improvement of patients.10 And the assumption of
“learned nonuse” in chronic stroke has given new
hope to many patients who suffered a stroke even
many years ago.
Still, several investigators have expressed caution for too much enthusiasm. They point out that
there are only few randomized studies11–13 and that
therefore superiority over other, more traditional
therapies has not been proven conclusively. Also,
there could be an aspecific effect in CIMT, in that at
least in acute stroke, improvement of arm function
relates mainly to the intensity of different therapies.14–20 However, these arguments apply to more
traditional therapies as well and they do not
disqualify CIMT as such.
In recent years, several studies have shown the
efficacy of this therapy in groups of patients with
numbers ranging from 5 to about 30,4–7,10,21–23 but
there are several questions that warrant further
investigation. Studies usually report group results,
but in those studies that give individual data, not
all patients benefit equally, and sometimes patients
deteriorate slightly in one or more tests at followup. The main goal of the present study therefore
was to explore individual factors that could have
an influence on the result of CIMT, especially those
that are related to the theory of learned nonuse.
Another point is that in some studies, the Motor
Activity Log (MAL)24 and Wolf Motor Function Test
(WMFT)2 are the only tests used to monitor effectiveness of CIMT. Although these tests were especially developed to monitor the amount of use,
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Individual Factors in CIMT
movement quality, and the time required for predefined movements in the light of the theory
behind CIMT, we investigated also other tests that
are more widely used in stroke rehabilitation.
PATIENTS AND METHODS
Selection of Individual Factors
Interval since stroke, amount of rehabilitation, age.
Because overcoming learned nonuse is a cornerstone of the theory of CIMT, it could be expected
that the interval between stroke and therapy may
influence results, even as learned nonuse is thought
to occur already in the early stage after stroke. Also
the amount of previous rehabilitation (both inpatient and ambulatory) may play a role. Learning
processes are age-dependent, so younger patients
could show different results than older ones.
Sensory loss and spasticity. The amount of sensory
loss of the affected arm in patients could be decisive, as mentioned before.25 As far as we know, no
previous studies included spasticity as a factor.
Patients who have strong spasticity will not be eligible for CIMT, but in our experience, individual
differences are present and do interfere with the
smoothness and execution of the exercises. Also,
altered viscoelastic properties about joints may
play a role, but inclusion criteria should at least
partly correct for this.
Communication. Because CIMT puts a high
demand on communication of the patient with the
therapist, including continuous feedback from
both sides, patients with severe aphasia are
excluded. Still, those with difficulty to communicate because of dysarthria or slight aphasia could
be at a disadvantage.
Gender and social status. After 2 weeks of therapy,
patients return to their own surroundings.
Demands in everyday life could be lighter for
those who have help from a partner at home. Also,
it is possible that daily activities (e.g., in the household) are different in male and female patients.
Affected hemisphere. Although in one study it did
not make a difference in MAL and WMFT whether
the dominant hand was affected,23 we still wanted
to investigate whether this could have an impact
on the 2 additional standard stroke rehabilitation
tests (Frenchay Arm Test [FAT] and Nine-Hole Peg
Test [NHPT]) that we used.
Etiology. Studies so far included patients with
ischemic lesions. There is one report with 2
patients who suffered hemorrhagic infarction,9
and in some other studies, a few patients with
hemorrhage were included,23,25 but it has not been
proven whether these patients can profit from
CIMT as much as patients with ischemic lesions.
Therapy size. The setting for standard CIMT is individual therapy by the therapist. In one study in
which 4 patients were treated simultaneously, the
effect of therapy was small,25 but this might have
stretched the capacities of the therapist. Therefore,
we compared single and pairwise therapy.
Amount of impairment. Another question we had
was whether the motor impairment before therapy
can prognosticate improvement. One inclusion
criteria is the MAL, which should be smaller than
2.5, as recommended by the investigators who
developed this therapy.26 On the other hand, one
study23 found no correlation with outcome when
patients with the MAL-QOM (Quality of Movement) up to 3.0 were included. In several other
studies where patients are included with a MAL <
2.5, it is not always clear whether that value refers
to MAL-AOU (Amount of Use), MAL-QOM, or both.
In total, 14 factors were identified that could
have an impact on the result of therapy. Nine of
these were categorical, meaning that each patient
was in 1 of 2 categories. These included gender
(male versus female), affected hemisphere (right
versus left), etiology (ischemic versus hemorrhagic), disturbances in communication (present
versus not present), social status (married or partner at home versus single), sensibility (normal versus pathologic), sensory-evoked potentials (SEPs,
normal versus pathologic), pretherapeutic composite MAL (smaller versus greater 2.5), and therapy size (individual versus paired therapy). For 5
of the factors, each patient was assigned an individual value. These were age, interval between
stroke and beginning of therapy (in years),
spasticity (average points on the Ashworth for the
affected arm), duration of in-patient rehabilitation
therapy (in months), and amount of out-patient
physiotherapy and occupational therapy (counted
together, in hours per week).
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239
M. Rijntjes and others
Selection of Patients
Recruitment was done by announcements in the
press, contacting rehabilitation clinics, and
through the local network of physiotherapists. A
preliminary selection for suitability was done by
telephone interview. At the pretherapeutic session, patients were examined by a physiotherapist
and separately by a neurologist. Inclusion criteria
consisted of ischemic stroke, an active hand extension of more than 20 degrees, and an active finger
extension of at least 10 degrees, as recommended26
and used in other studies. Additionally, to assess
grasping function, patients should be able to grasp
a towel between the thumb and another finger and
to release it again. They should have regained
some motor function of the arm, but use it rarely in
daily life (MAL-AOU < 2.5).26,27 To exclude interference with spontaneous recovery, onset of stroke
should be at least 6 months before. Exclusion criteria were multiple infarcts, sitting in a wheelchair,
neglect, a degree of aphasia or dysarthria that
would severely interfere with communication during therapy (patients excluded because of this reason all presented with an accompanying person),
clinically manifest depression on the Hamilton
scale, uncontrolled hypertension or other medical
disorders, and spasticity in any of the joints of the
affected arm (shoulder, elbow, wrist, fingers) of 4
on the modified Ashworth scale.28 No patient
should have a disorder of balance so that he or she
could be endangered by immobilization of the
affected hand. The time interval between the 1st
presentation and start of therapy was at least 3
months in all patients, to ensure that there was no
spontaneous improvement that could interfere
with the result of therapy. For that purpose,
patients underwent the same testing that was used
for the pretherapeutic session and should have no
improvement in these tests. Additionally, they
should not have improved in the FAT in these
months. As we were interested in the effects of
CIMT in hemorrhagic stroke and in patients with a
higher level of performance., we also included 6
patients with hemorrhagic stroke and 2 patients
with a MAL-AOU > 2.5.
CIMT Procedure
A formal contract was signed by each patient, in
which he or she promised compliance with the
instructions given to them by the physiotherapist,
240
especially about the activities outside the therapy
situation. On the 1st day of therapy, a splint to the
unaffected arm (Daumen-Hand-Orthesen, Bort
GmbH, Weinstadt-Benzach, Germany) was individually adjusted, preventing wrist flexion and
grasping. Patients were taught how to remove and
adjust the splint. Patients were instructed to wear
the splint also outside the sessions, only taking it
off for grooming and during sleep. In total,
patients were wearing the splint at least 90% of
their waking time, including the weekend in which
no therapy took place. Patients followed a 2-week
therapy (10 working days), each day from 9:00 AM
until 3:30 PM. Except for the 1st and last day, in
which time was devoted to motor assessment and
scoring, each day consisted of 3 h therapy in the
morning and 3 h in the afternoon. For lunch, cutlery was handled with the affected hand with help
from the physiotherapist, if necessary.
Therapy consisted of behavioral training of the
affected arm. About 20 tasks were individually
chosen for training, depending on the deficits of
the patient and according to individual preferences about goals to be achieved, of which
approximately 7 were repeated 10 times each day.
Patients were given feedback on their progress
after each repetition to give positive reinforcement, and complexity of the task was gradually
increased accordingly (shaping). The amount of
repetition and shaping was varying constantly,
according to the individual requirements of
patients, but therapists took great care not to
induce negative reinforcement by increasing task
complexity too fast. To ensure that variability in
assessment was as low as possible, 2 physiotherapists and 2 neurologists in total were involved.
Ten patients were randomized for individual
treatment, and the remaining 16 patients were
treated pairwise. In the pairwise treatment,
patients and the therapist were in one room with
patients sitting next to each other, opposite the
therapist. Patients were trained alternately by the
therapist for each task, while the other was observing. Each task took approximately 30 seconds.
Although tasks for training were individually
selected for each patient, just like for the patients
treated individually, tasks were the same for both
patients in approximately 2 out of 7 that were
repeated continually. In that case, the patients
were comparing their results.
At 1 month after therapy, patients were contacted by telephone to ask about their progress in
general and to remind them to use the affected
hand in daily life activities. After 6 months, patients
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Individual Factors in CIMT
were assessed again by the same physiotherapist
who had performed the therapy (except for the
WMFT-FA, see below).
Assessment of Patients
Patients were scored on the 1st (Monday) and
last day (Friday of the 2nd week) of therapy, and
after 6 months. Scores used were the MAL-AOU
and MAL-QOM, Wolf Motor Function Test Functional Ability (WMFT-FA), and number of seconds
needed for these tests (WMFT-sec), measured with
a stop-watch. For the WMFT-sec, the average number of seconds for the subtests were calculated. For
the WMFT-FA, video sequences were recorded
and presented to a 2nd physiotherapist for evaluation who was blinded to the time point of recording (i.e., whether the recordings were made before
or after therapy or during follow-up).
Additional tests were the FAT and NHPT. The
FAT was chosen because it is widely accepted and
applied after stroke, with proven intertest reliability and validity.29 The NHPT was chosen because
of the same reasons30,31 and because improvement
can still be assessed in those patients who reach a
ceiling in the FAT.29 Still, here also a ceiling effect
can be reached, and to make comparisons
between patients possible, we extrapolated the
number of pegs that a patient would have managed in 50 seconds if he or she needed less time
than this. Before therapy, patients were also rated
with the Rankin scale, Scandinavian Stroke Scale,
and Barthel Index. All patients underwent a careful
neurological examination. Degree of paresis was
rated on the Medical Research Council (MRC)
scale. Sensibility was rated as pathologic if there
was an inability to discriminate sharp and blunt
pinpoints on the affected hand, when patients
indicated a difference in sensation when touching
the hands, or when the direction of small passive
movement of the fingers with eyes closed could
not be identified correctly. In addition, evoked
potentials of the median nerves were investigated.
These were considered pathological with an
amplitude difference of more than 50% compared
to the unaffected arm or a latency delay outside
normal range according to the normal values of
our laboratory (N20 at 19.3–22.3 ms). Spasticity
was rated according to the modified Ashworth
scale for the shoulder, elbow, wrist, and fingers of
the affected arm. These points were added and
divided by 4 to obtain an average value of
spasticity for the affected arm. Several patients had
aphasia or dysarthria that was not so severe as to
preclude the implementation of therapy, but did
interfere in normal communication with the
therapist, causing delays.
Because it is not always clear in previous studies
whether the pretherapeutic MAL refers to AOU,
QOM, or both, we averaged the values of MALAOU and MAL-QOM at each time point, giving a
composite MAL (comp-MAL) value.
As far as it was accurately possible, the amount
and duration of previous physiotherapy and occupational therapy was assessed. In only a few
patients, CT scans or MRI scans could be obtained.
The etiology and approximate localization of the
lesion was taken from clinical reports, but these
data were too inaccurate to enable a correlation
between the structural lesion and deficits or the
improvements by therapy.
Statistical Analysis
Statistical analysis was performed with SPSS
(version 11.0). Because a normal distribution of
patients could not be assumed, only
nonparametric tests were used. For the result of
therapy as such, we compared MAL-AOU, MALQOM, WMFT-FA, WMFT-sec, FAT, and NHPT after
2 weeks (“post”) with before therapy (“pre”),
between pretherapy and after 6 months (“6 mo”),
and between after therapy and after 6 months with
the Wilcoxon test.
The Mann-Whitney U test was used for the influence of categorical factors, the Spearman test for
the correlation with individual factors. Level of significance for all tests was set at P < 0.05.
RESULTS
In total, 26 patients were included. Characteristics of the patients are given in Table 1. None of the
patients improved in the 3 months before therapy
in our pretraining assessment, including patient 10
who had suffered stroke 6 months before the
beginning of therapy. All patients were righthanded, except for patient no. 21, who was told he
was left-handed but was taught to write with his
right hand in school. In 2 patients (nos. 9 and 10),
no data were available about etiology (hemorrhagic or ischemic). In 1 patient (no. 26), information was that she suffered an ischemia but the
localization of the infarct was not known. A 17year-old patient (no. 11) had suffered from hemor-
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242
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68
57
63
64
63
58
59
79
59
69
57
47
53
53
69
57
57
65
61
17
57
68
48
56
68
54
1
2
3
4
5
7
9
10
12
13
14
15
16
17
19
23
25
6
8
11
18
20
21
22
24
26
M
F
F
M
M
M
M
M
F
M
F
F
F
M
F
M
M
F
M
M
M
M
F
F
M
F
M/F
M
M
S
M
M
M
S
M
M
M
S
M
M
M
M
M
S
M
M
M
M
M
M
S
S
S
Social
R
L
L
R
R
L
R
R
R
L
R
R
R
R
R
R
R
R
R
R
L
L
L
R
L
L
Site
I
I
H
I
H
I
I
H
I
I
I
I
I
I
I
?
?
I
H
I
I
I
H
I
H
I
Etiol
1
1
1
1
2
1
1
2
?
1
1
1
1
1
1
?
?
1
2
2
1
1
1,2
3
2
1
Loc
8
2
3.5
1.5
4
2
9
2.5
6
1.5
2
7
4.5
6
6
4
0.5
3
3
5
0.8
1.0
20
2
1.3
3
Interval
0
0
8.5
1.5
1
2.5
11
1
2
2.5
7
6
8
1.5
8
2
3.5
4
3
0
1.5
7.5
1.5
2
1.5
3
Rehab
3
3
2
2
4
7
5
4
3
2
2
2
3
1
3
2
3
1
1
3
0.5
3
2
2
6
3.5
Amb
1
1
0
0
0
0
1
0
0
0
1
1
1
1
0
1
0
1
1
1
0
0
0
0
0
0
Comm
4
3.5
4
4
3.5
4
4
4
3.5
3.5
4
3.5
4
5
3.5
3.5
4
4
3.5
4.5
3.5
3.5
3.5
4
4
4.5
MRC
1.5
1.5
1.25
1.25
1
0.75
0.5
1
1.25
1
0.75
0.75
2.5
1
0.75
1.5
1
0.5
1.25
1
0.5
1
1
0.25
0.5
1
Spasticity
0
1
1
0
1
1
1
1
0
1
1
1
1
0
0
0
1
0
1
0
0
0
1
0
1
0
Sens
0
0
1
1
1
0
0
1
0
1
0
1
0
0
1
SEPs
1.5
1.9
1.7
2.6
2.3
1.9
2.1
2.6
2.7
1.8
1.6
1.6
1.3
3.0
1.6
1.5
1.8
1.7
1.6
2.8
1.9
1.7
2.3
2.4
2.0
3.1
CompMAL
3
3
2
2
3
2
2
2
3
3
2
3
3
2
3
3
3
3
3
3
2
3
2
3
2
2
Rankin
48
48
51
49
54
55
50
54
48
50
50
51
53
54
51
53
50
50
48
48
53
52
54
50
54
55
SSS
95
100
100
100
100
100
100
100
100
80
95
95
85
100
95
95
80
100
90
100
100
90
100
100
100
100
BI
1
2
1
1
2
2
2
2
2
1
1
2
2
1
2
1
2
1
1
2
2
2
1
2
2
2
Therapy
Pat = patient number according to time point of inclusion. Patients 6,8,11,18,20,21,22,24, and 26 are listed separately because of different results in follow-up (Table 2). M/F = male or female.
Social: M = married or living with partner; S = single. Site: L = left hemisphere; R = right hemisphere. Etiol = etiology; I = ischemic; H = hemorrhagic. Loc = location; 1 = territory of middle cerebral artery including cortex; 2 = subcortical lesion in territory of middle cerebral artery; 3 = in pons. Interval = between stroke and therapy, in years; Rehab = months of in-patient rehabilitation; Amb = weekly hours of ambulatory therapy; Comm = communication disorder (slight aphasia or dysarthria); MRC = degree of paresis on Medical Research Council scale; Spasticity =
average spasticity of arm joints on Ashworth scale. Sens = sensory disturbance; 1 = present; 0 = absent. SEPs = sensory-evoked potentials: 1 = pathologic; 0 = normal. Comp-MAL = average of
MAL-AOU and MAL-QOM; Rankin = Rankin scale; SSS = Scandinavian Stroke Scale; BI = Barthel Index. Therapy: 1 = individual, 2 = paired.
Age
Overview of Patients
Pat
Table 1.
Individual Factors in CIMT
rhage in a hemangioma that was not accessible to
surgical or neuroradiological intervention. SEPs
were available in 15 patients. As expected, the
degree of paresis (MRC) was highly similar in the
group. Also in standard impairment (Scandinavian
Stroke Scale) and disability (Rankin, Barthel index)
scales, patients showed little variation.
In all, 7 patients were lost for follow-up. Telephone contact revealed that 6 patients thought that
they lived too far away (more than 100 km) for presenting themselves and 1 patient had suffered an
additional disabling stroke.
icit, and SEPs), we used the χ2 test (level of
significance: P < 0.05) that showed there were no
differences in distribution (smallest P < 0.91, largest P > 0.3) between these groups.
In the correlational variables, we used the 2sample t test that showed there was no statistical
difference (P < 0.05) in the 2 groups in age, interval
since stroke, previous in-patient rehabilitation,
degree of spasticity, and comp-MAL. Only in the
hours of ambulant physiotherapy, those patients
who had more hours per week before therapy
(mean 3.67, SD 1.28) compared to those with less
hours (mean 2.35, SD 1.58) deteriorated more after
6 months (P = 0.03) compared to posttherapy.
Effect of Therapy
Individual test results are listed in Table 2. The
group of patients improved significantly after 2
weeks of therapy (pre-post) in all tests (Table 3) at
P < 0.001. Compared to the status before therapy,
this improvement was also significant in the 19
patients who participated in the follow-up after 6
months (4 tests at P < 0.001, 2 tests at P < 0.05). The
comparison between the status after therapy and
after 6 months showed that in none of the tests was
there a significant deterioration.
Influence of Individual Factors
In the comparison of categorical factors (Table
4), only gender showed a significant influence in 2
tests (MAL-QOM and MAL-AOU); 5 other comparisons (affected hemisphere, etiology, communication
disorder, MAL > 2.5, and sensibility) showed influences of the respective factors in not more than 1
test. In 3 comparisons (presence of pathological
SEPs, social status, and single versus paired therapy), there was no statistical relevance in any test.
In the analysis of correlational factors, only age
had a statistically significant influence in 1 test: the
older the patient, the more he or she indicated an
improvement in the quality of movement after
therapy.
There were 9 patients (nos. 6, 8, 11, 18, 20, 21,
22, 24, 26) who did less well in 3 or 4 tests during
follow-up compared to posttherapy (but still did
better than pretherapy). We performed a post hoc
analysis of this group of patients, to see whether
there was an unequal distribution in any of the categorical and correlational factors compared with
the others.
In the categorical variables (gender, affected
hemisphere, communication disorder, sensory def-
DISCUSSION
Effect of Therapy
As a group, patients showed a highly significant
improvement (P < 0.001) in all tests after 2 weeks
of therapy, and this improvement was still significant (4 tests at P < 0.001, 2 at P < 0.05) during followup in the 19 patients that could be assessed. These
results are in line with previous studies and underline the effectiveness of this therapy for arm function in chronic stroke. The results of follow-up
demonstrate the durability of therapy effects that
are brought about, even if some patients cannot
retain the level that they had achieved after
therapy.
In most other studies, a normal distribution of
patients is assumed and calculated “effect-sizes”
are given. The present study shows the effectiveness of CIMT also if a nonrandomized population
is assumed. It has been questioned whether the
increased use of the affected arm also indicates an
increased functionality. The present data show
that both the amount of use in daily life and the
quality of movement (assessed subjectively by the
patients in the MAL-AOU and objectively with the
WMFT-sec, NHPT, and FAT) improved significantly.
Tests that are used to monitor improvement
vary from study to study, although nearly all
included the MAL and WMFT scores. The MAL is
subjective, which sometimes is criticized,25 but the
WMFT-FA and WMFT-sec have been shown to be
reliable, internally consistent, and stable. 3 2
Although the WMFT-sec showed a large standard
deviation, which was also the case in another
study,23 it was still significant at the 0.01 level in the
comparison between follow-up and pretherapy.
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2.4
2.9
2.9
3.1
2.5
2.8
2.8
2.8
3.6
6
8
11
18
20
21
22
24
26
2.8
2.9
3.3
3.6
3.0
3.1
3.0
3.8
4.0
3.5
2.5
2.8
2.4
3.9
2.7
3.1
2.8
2.2
3.0
3.7
2.9
2.6
3.4
3.4
3.5
3.5
2.6
2.9
2.7
3.4
3.1
2.9
3.3
3.7
3.8
3.6
2.7
3.4
4.3
3.7
3.1
4.4
2.6
2.6
3.6
0.5
0.9
1.5
2.1
2.0
1.1
1.4
2.4
1.8
0.6
0.9
1.0
0.5
2.7
0.6
0.4
1.0
1.0
1.1
2.1
1.3
0.8
1.5
2.2
1.8
3.1
1.7
2.2
3.3
3.6
2.7
2.4
3.0
4.0
3.7
1.9
1.7
2.5
2.0
4.0
2.8
2.6
3.0
1.9
2.7
3.9
2.6
2.8
3.3
3.3
3.5
3.7
1.8
1.3
1.8
3.4
2.3
2.1
2.9
4.0
2.3
4.0
1.4
3.1
4.4
3.8
3.0
4.1
3.1
1.7
2.4
MAL- MALAOU AOU
post 6 mo
23
12
16
4
11
16
5
6
3
38
41
46
11
5
12
19
15
7
14
4
5
5
16
4
8
5
9
7
8
3
7
4
4
3
3
15
31
29
8
3
4
7
15
6
4
3
4
3
6
3
5
3
29
20
11
3
5
10
5
5
3
4
4
5
3
3
2
3
5
10
12
2.5
2.4
2.5
3.5
2.5
2.7
2.6
3.3
4.1
2.3
2.2
1.7
2.6
3.8
2.6
2.5
3.0
2.7
2.5
3.8
3.7
2.9
2.3
2.9
2.8
3.3
3.2
2.6
2.7
4.0
3.0
3.1
3.4
3.8
4.2
2.9
2.4
2.3
2.8
3.7
3.1
3.1
3.0
3.0
3.0
4.2
3.9
3.4
2.9
3.4
3.7
4.6
2.7
2.3
2.9
4.1
2.9
3.3
3.0
3.3
4.3
3.5
3.2
3.2
4.5
4.4
3.6
3.3
3.1
2.5
3.1
WMFT- WMFT- WMFT- WMFT- WMFT- WMFTsec
sec
sec
FA
FA
FA
FAT
pre
post
6 mo
pre
post
6 mo pre
2
0
2
4
1
4
5
4
5
0
0
0
0
5
1
1
3
1
3
5
2
5
2
3
3
3
FAT
post
3
0
4
5
2
5
5
5
5
2
1
0
1
5
3
3
4
2
3
5
5
5
4
4
4
5
FAT
6 mo
2
1
3
4
2
5
4
4
5
5
3
4
5
5
5
5
3
0
2
NHPT
pre
1
3
2
13
1
0
1
6
13
0
0
0
0
13
3
0
14
4
2
12
8
6
1
14
5
9
NHPT
post
0
4
3
19
5
0
6
10
17
0
0
0
1
17
5
0
19
8
5
18
7
12
2
19
4
9
NHPT
6 mo
0
3
6
19
4
2
4
10
14
14
9
5
17
9
19
17
5
0
0
1
2
1
1
2
2
2
2
2
1
1
2
2
1
2
1
2
1
1
2
2
2
1
2
2
2
Therapy
Single/
Paired
Pat = patient number according to time point of inclusion. Patients 6,8,11,18,20,21,22,24, and 26 are listed separately because of different results in follow-up. For all tests: pre = before therapy; post = after 2 weeks of therapy; 6 mo = during follow-up after 6 months. MAL-QOM = Motor Activity Log Quality of Movement; MAL-AOU = Motor Activity Log Amount of Use; WMFT-sec
= Wolf Motor Function Test in seconds; WMFT-FA = Wolf Motor Function Test–Functional Ability; FAT = Frenchay Arm Test; NHPT = Nine Hole Peg Test (total number of pegs in 50 seconds).
Therapy Single/Paired: 1 = individual therapy; 2 = paired therapy. Bold numbers indicate a deterioration compared to previous scoring.
2.9
2.2
2.2
2.0
3.3
2.6
2.5
1.6
2.4
2.0
3.5
2.6
2.5
3.0
2.6
2.2
3.1
1
2
3
4
5
7
9
10
12
13
14
15
16
17
19
23
25
Pat
MALAOU
pre
Individual Test Results
MAL- MAL- MALQOM QOM QOM
pre
post 6 mo
Table 2.
Individual Factors in CIMT
Table 3.
Group Results
Test
Pre Mean (SD) Post Mean (SD) 6 Months Mean (SD) Pre-Post
MAL-QOM
MAL-AOU
WMFT-FA
WMFT-sec
FAT
NHPT
2.65 (0.47)
1.4 (0.73)
2.84 (0.58)
13.6 (11.74)
2.46 (1.79)
5.04 (5.18)
3.13 (0.48)
2.88 (0.72)
3.29 (0.58)
7.6 (7.39)
3.46 (1.66)
7.31 (6.90)
3.28 (0.56)
2.78 (0.98)
3.33 (0.62)
7.5 (6.86)
3.53 (1.54)
8.26 (6.62)
**
**
**
**
**
**
Pre-6 Months Post-6 Months
**
**
**
*(P = 0.008)
*(P = 0.007)
**
Ø
Ø
Ø
Ø
Ø
Ø
(0.35)
(0.54)
(0.84)
(0.45)
(0.73)
(0.37)
Note: MAL-QOM = Motor Activity Log Quality of Movement; MAL-AOU = Motor Activity Log Amount of Use; WMFT-FA = Wolf Motor
Function Test–Functional Ability; WMFT-sec = Wolf Motor Function Test in seconds; FAT = Frenchay Arm Test; NHPT = Nine Hole Peg
Test (total number of pegs in 50 seconds.)
*P < 0.01. **P < 0.001. Ø = not significant.
Table 4.
Individual Factors
Pre-Post
Categorical Factors
Male > Female
Affected hemisphere
Right > left
Left > right
Hemorrhagic > ischemic
Communication disorder > normal
Composite MAL above 2.5 > below 2.5
Sensibility normal > pathologic
SEPs normal vs. pathologic
Married vs. single
Therapy size
Correlational factors
Age
Chronicity
Spasticity
Previous rehab therapy
Ambulant therapy
Pre-6 Months
Ø
MAL-QOM (P = 0.005) MAL-AOU (P = 0.036)
Ø
NHPT (P = 0.039)
MAL-QOM (P = 0.039)
FAT (P = 0.024)
WMFT-sec (P = 0.028)
WMFT-sec (P = 0.046)
Ø
Ø
Ø
FAT (P = 0.045)
Ø
Ø
Ø
Ø
Ø
Ø
Ø
Ø
MAL-QOM (P = 0.003)
Ø
Ø
Ø
Ø
Ø
Ø
Ø
Ø
Ø
Pre-Post = comparison between score before therapy and after 2 weeks of therapy; Pre-6 Months = comparison between score before
therapy and during follow-up after 2 months. MAL-QOM = Motor Activity Log Quality of Movement; MAL-AOU = Motor Activity Log
Amount of Use; WMFT-sec = Wolf Motor Function Test in seconds; FAT = Frenchay Arm Test; NHPT = Nine Hole Peg Test (total number
of pegs in 50 seconds). SEPs = sensory-evoked potentials; Ø = not significant.
However, in 2 tests that are commonly used to
monitor improvement after stroke (FAT, NHPT),
patients improved significantly in all comparisons.
It could be argued that those 7 patients who did
not show up for follow-up did so because they had
deteriorated to pretherapy levels and were disappointed. However, this hypothesis is improbable,
because 6 of them (1 patient had suffered another
disabling stroke) ensured during telephone contact that they still profited from the therapy in daily
life but that the effort of travel was too much
because they lived too far away.
We chose to use a nonparametric analysis
because we could not assume that our recruitment
method would lead to a normal distribution. Also
the fact that CIMT is a relatively new therapy, com-
pared with traditional ones like Bobath, Vojta, or
PNF, could have had an influence. Motivation of
hopeful patients could be higher, and it is also possible that therapists were motivated above average. Only a direct comparison between CIMT and
other therapies can give an answer to these
questions.
Influence of Individual Factors
There was no statistical difference between categorical and individual factors in more than 1 comparison, except for 2 tests (both parts of MAL) in 1
categorical factor. Although this confirms the general applicability of CIMT, a more detailed look at
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245
M. Rijntjes and others
those tests that did show a difference, as well as
those with negative results, might be worthwhile
because of the implications on the underlying
theory.
In the MAL (AOU and QOM), male patients valued their improvement higher than female patients
(Table 4). On average, male patients were older
than female patients, 7 male patients being over 60
years of age, and maybe they noticed it more when
they increased their contribution to household
tasks. The fact that this gender difference was only
noticed after 6 months, when patients had
returned to their household settings, would support this explanation.
All patients except for 1 were right-handed and,
like in a previous study, the affected hemisphere
did not influence results in MAL and WMFT.23 Also
in a study that compared the amount of use of the
affected hand with the quality of movements, there
was no such influence.3 Other tests seem to give
contradictory results. Patients with left-hemisphere lesions improved more in the NHPT after
therapy, patients with right-hemisphere lesions
more in the FAT after 6 months. However, the
NHPT puts more demands on spatial orientation
and could be more demanding for patients with
right-hemisphere lesion. On the other hand, even
if we excluded patients with severe communication disorders, there was a difference in FAT where
p at ie n t s wit h o u t c o m m u n ic at io n d is o r d e r
improved slightly more (P = 0.046) than the others.
From the tests we used, FAT has the most elaborate
instructions, and it could be that patients in this
group who still had light aphasia were at a
comparative disadvantage here.
It is interesting to note that patients with hemorrhagic infarction improved as well as patients with
ischemic infarction, with even a better result in one
test (MAL-QOM). Even if only 4 patients with hemorrhagic infarction showed up for follow-up, there
was no significant difference after 6 months.
Although previous studies did sometimes include
patients with hemorrhagic infarctions,23,25 and 1
study showed an improvement in 2 patients with
bleeding,9 this is the 1st time that it is shown
directly that these patients can profit from CIMT at
least as well as patients with ischemia.
Patients who lived alone did not fare differently
from patients with a partner at home. One possibility could be that patients living alone had adapted
better to their situation, another one that the presence of a stimulating partner at home can be a beneficial factor.
246
Clinical examination of sensory disturbance
correlated well with SEPs in 15 patients for which
both data were available, except in 1 patient (no.
16), where SEPs were pathological but clinical
examination was normal. The presence of pathological SEPs did not influence the improvement of
patients, except in 1 test (WMFT-sec) that just
reached a level of significance. Also patient 21,
who needed continuous visual feedback for any
movement he made, improved by CIMT. In 1 other
study, where patients with sensory defects
improved slightly more than those without, sensory disturbance was 1 of only 2 factors identified
that showed a significant difference in outcome.25
However, this significance was found in comparison with another treatment (bimanual training),
and it was not reported in that study whether
patients within the CIMT group with sensory disturbances profited more or less than those without. Maybe the compensation for proprioceptive
deficits is not the only factor in CIMT and patients
with intact sensibility could be at a better starting
position. In 1 test (WMFT-sec), patients with intact
sensibility did improve stronger in the present
study.
It is advised not to include patients with a MAL >
2.521,24,26 because the potential for improvement is
considered too low with this therapy, because
there is not enough learned nonuse to be overcome by CIMT. However, it is not always clear
whether “MAL” means AOU, QOM, or both. In 1
study, no correlation with initial level of motor disability in MAL-QOM (included until 3) and outcome was found.23 In the present study, 2 patients
(nos. 5 and 25) with scores higher than 2.5 on MALAOU did improve markedly and those 6 patients
with Comp-MAL > 2.5 improved more than those
with lower scores in the WMFT-sec test. It is therefore conceivable that other, aspecific effects play a
role in this intensive therapy.
One interesting finding is that patients
improved, regardless whether they were treated
individually (10 patients) or in groups of 2 (16
patients). There was no significant correlation with
any of the tests we applied. It could be expected
that the division of available time over 2 patients
might produce worse results in each of them. Also,
in a modified CIMT paradigm, patients who
received 3 h of CIMT per day did improve, but not
as much as those with the “classic” concept of 6 h
per day.33 However, in our experience, patients
motivate each other in a competitive way, and a
small improvement in one patient stimulates the
other one to try even harder, especially when they
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Individual Factors in CIMT
are working on the same task. Whether groups can
be enlarged more, however, is doubtful. In 1 study,
when patients were treated in groups of 4, supervised by 1 or 2 therapists, they showed only a
minor improvement compared to a group treated
with standard therapy.25 From the other side,
recent reports show that also a structured outpatient treatment can be effective,34,35 so the amount
of therapy that is necessary to overcome learned
nonuse will need further investigation.
From the correlational factors, only age showed
a significant correlation in only 1 test (Table 4).
Because the age range of the patients was rather
close, this finding was surprising. One explanation
could be that everyday life in older patients is less
demanding and that even small changes are more
noted, which would be reflected in the self-assessment on the MAL-QOM scale.
Our data show that the presence of spasticity, as
long as it is not higher than 3 on the Ashworth scale
in any of the joints of the affected arm, does not
influence the effect of therapy. Even patient no. 4
with a high average score on the Ashworth scale
improved well after 2 weeks. Thus, spasticity
should not a priori preclude application of CIMT.
There was no test that showed a correlation
with the other factors investigated. Especially
interesting was the lack of correlation between
effectiveness of CIMT and the time passed since
stroke occurred, which was also found in a previous study.23 The main reason that CIMT is applied
in patients at least half a year after stroke is not
only that ongoing spontaneous recovery may
interfere with the effects of therapy but also
because learned nonuse, by repetitive negative
reinforcement, is an essential part of the theory on
which CIMT is based. There are some interesting
recent reports that CIMT can also be effective
when applied starting within 2 weeks after acute
stroke.11,36 The explanation given in those reports
was that nonuse might be prevented, but it is also
possible that some other, aspecific effects play a
role in CIMT.
Also the number of months spent in a rehabilitation clinic and the number of hours of ambulant
therapy received did not influence the degree of
improvement, as was found before.23 We were not
able to assess which kind of therapy was applied to
individual patients, but the results are in line with
previous studies that show the effectiveness in
general in chronic stroke patients who have tried
several different therapies before with limited success. Even if these factors did not influence the
results of CIMT in the comparison before treatment
and follow-up, we found in the post hoc analysis
that those patients who had received more therapy
before starting CIMT had a stronger deterioration
in 3 or 4 of the 5 tests during follow-up, compared
to posttherapy. We did not inquire about the
ambulant therapy after our 2-week program of
CIMT, but future studies should examine whether
continuous therapy, even if not on the basis of
CIMT, could still be helpful for reminding patients
of their improved function and preventing the
recurrence of learned nonuse.
General Considerations
With 14 cofactors, it must be assumed that some
have interacted. For example, younger patients
with a hemorrhagic lesion might profit more from
CIMT when they have no communication deficits
and are living alone, but only when the right hemisphere is affected. Statistical power in 26 patients is
not sufficient for such an analysis, and a much
larger group would be necessary to exclude such
interactions.
One possibly decisive factor was not investigated in this study because of lack of information.
The motor system is hierarchically organized,37,38
and learning in healthy subjects involves different
components of this system over time, depending
on the task.39,40 Because CIMT is in essence a
relearning therapy, the localization of the lesion
could be an essential factor. Imaging studies have
shown that the pattern of reorganization in the
motor system in patients recovering from
hemiparesis after stroke depends greatly on the
site of the lesion. Different patterns are found
depending on the involvement of the posterior
part of the internal capsula,41 the primary motor
cortex,42,43 and the premotor cortex.10 In those
studies on CIMT where approximate localization
of lesion is given,23 or where reorganization has
been shown with imaging techniques4,7,10 and
TMS,5,6 details about localization of the lesion are
missing. Future clinical studies should therefore
include precise information of the cortical and
subcortical areas involved. Also, individual patterns of reorganization induced by CIMT should be
compared with the site of the lesion. It would be
especially interesting to see whether this aspect
could be a factor in the relative deterioration in
some patients in follow-up.
Several arguments in the present data indicate
aspecific effects of CIMT. Especially in those factors where an enhanced effect might be expected
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247
M. Rijntjes and others
on the basis of the learned nonuse theory (time
since stroke, previous ambulant therapy, sensory
deficit, living situation, MAL before therapy), no
influence on outcome was found. Intense attention to the affected hand may already have been a
beneficial effect, in that this in itself increases
activity in the contralateral hemisphere44 and in
imaging studies, even of the motor cortex.45
Still, the results of the present study confirm the
general effectiveness of CIMT in a large group of
patients with chronic stroke and clinically different
symptoms, with the effects lasting at least 6
months. Patients should have a relatively high
level of performance, but the absolute number of
patients in this situation is large.
Also patients who are less affected (MAL > 2.5)
and those with hemorrhagic lesions profit from
CIMT. The finding that patients treated pairwise do
as well as patients treated individually could have
practical and financial relevance.
9.
10.
11.
12.
13.
14.
15.
16.
ACKNOWLEDGMENTS
We thank the patients for their participation and
V. Schoder from the Department of Biometry and J.
Gläscher, Neuroimage Nord, Dept. of Neurology,
both from the Universitätsklinikum HamburgEppendorf, for assistance with statistics.
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