Higher Efficacy of
Modified Constraint Induced Movement Therapy
versus
Conventional Rehabilitation Therapy
in
Acute Stroke Patients
• Annually, there are approximately 15 million people
worldwide suffering from cerebrovascular stroke.
• Of these, 5 million are permanently disabled
• Thus stroke represents one of the leading causes of
disability among all CNS disorders .
• One of the disabling consequences of cerebrovascular
stroke is functional impairment of the affected upper
extremity since its recovery is often delayed than that
of the lower extremity .
Rehabilitation Options For Individuals
With Acute Stroke
• Most rehabilitation strategies of acute hemiplegic patients focus on
compensation rather than restoration of upper extremity function
since patients use the unaffected upper extremity for activities of
daily living.
•
Recently, new treatment strategies were introduced that might
be more effective than conventional rehabilitation treatment.
Promising approaches include practice with robotic devices or use
of a virtual environment with electrical stimulation to increase cortical
excitability during training. One potential method to improve
sensorimotor recovery after acute stroke is constraint induced
movement therapy (CIMT) , often labeled “forced use” treatment
which is a currently popular therapy with a sound theoretical
foundation. Many reports are available about its effectiveness on
cortical reorganization and there is mounting evidence for the
efficiency of CIMT protocols.
•
• CIMT is a behavioural approach in neurorehabilitation
based on the principle of ‘learned non-use’. The term is
derived from studies of non-human primates in which
somatosensory deafferentation of a single forelimb was
performed, after which the animal failed to use that limb.
The major components of CIMT include: intense,
repetitive (task oriented) training and behavioral shaping
of the impaired limb with immobilization of the
unimpaired arm. Intensive CIMT involves constraint of
the unaffected arm for at least 90% of the waking hours
whilst modified CIMT (m-CIMT) consists of constraint of
the unaffected arm with a padded mitt or arm sling for a
minimum of 6 hours per day .
• In contrast to conventional therapy in acute stroke, CIMT
discourages the use of the unaffected extremity and
encourages the active use of the hemiplegic arm in order
to restore the motor function16. CIMT can be thought to
exert an indirect effect on the paretic limb use by
preventing compensatory use of the less-affected limb
for some tasks. On the other hand, the task-specific
training with the paretic limb can be thought to exert a
direct effect on paretic limb use. There are numerous
studies that have suggested that CIMT can lead to
considerable improvement in hand function which lasts
for more than a year after training .
identification of the patient potentials for motor
recovery is important in order to avoid
“learned disuse’’ and to be able to initiate
appropriate therapy with realistic goals
Recovery is due to brain plasticity which occurs through
cortical reorganization.
Three major mechanisms for this plastic reorganization:
1. unmasking of existing but functionally inactive
pathways,
2. sprouting of fibers from surviving neurons and
3. formation of new synapses and redundancy of CNS
circuits allowing alternative pathways to take over
functions
• An essential question is "Does modified
constraint induced movement therapy has
higher efficacy than conventional rehabilitation
therapy in management of acute stroke
patients?".Consequently , in this article, the
authors assessed functionally and
neurophysiologically the efficacy of modified
constraint induced movement therapy on
functional recovery of upper extremity (UE) in
acute stroke patients, as compared to
conventional therapy with the same total
rehabilitation peroid. .
Objective
To assess the efficacy of
modified CIMT on functional
recovery of upper extremity (UE)
in acute stroke patients, as
compared to conventional
rehabilitation therapy
Methodology
• This study included twenty six acute stroke
patients.
• Inclusion criteria included the following: patients
within two weeks from the onset of stroke,
persistent hemiparesis leading to impaired upper
extremity function, evidence of preserved
cognitive function and a minimum of 10 degrees
of active finger extension and 20 degrees of
active wrist extension.
• Exclusion criteria included the following:
intracerebral hemorrhage, previous stroke
on the same side, presence of neglect or a
degree of aphasia impeding understanding
of instructions and patients with conditions
that limit the use of the upper limb before
the stroke.
• .
• The patients were divided into two groups.
• Group A: 13 patients were given a
conventional rehabilitation program for two
weeks.
• Group B: 13 patients were subjected to the
modified CIMT for two consecutive weeks.
Total treatment time was kept identical in
both groups
• Patients were assessed by BrunstromFugl Meyer test Motor Assessment test
(FMA), Action Research Arm Test (ARAT)
and Motor evoked potentials (MEPs)
recorded from the abductor pollicis brevis
of the affected hand. The clinical and
neurophysiological tests were performed
pre and post rehabilitation
FMA
upper extremity motor section
of Brunstrom-Fugl Meyer
Assessment (FMA) to evaluate
motor performance and
function of the upper extremity
where 0= cannot perform and
2= can perform fully
It includes: Reflex activity , flexor
synery, extensor synergy,
combining synergies, out of
synergy, wrist, hand, coordination
ARAT
):
quantitative test for the upper extremity function. There are four subsets:
Grasp, Grip, Pinch and Gross movement. Items in each are
ordered in such a way that if the patient performed the most difficult item
(the first item of each subscale), then this predicts success with all less
difficult subscale items. Thus, the patient is scored with the maximum score
for that subscale for that limb. On the other hand, failure with the easiest
item (the second item of the first three subscales and the first item of the
fourth subscale) predicts failure with all items of greater difficulty on that
subscale and the patient is scored zero and again no more tests needed to
be performed in that subset. Otherwise the patient needs to complete all
tasks within the subset.
Materials needed to perform the test: Wood blocks, a ball, a stone, two
different sizes of alloy tubes, a washer and bolt, two glasses, a marble and
a 6-mm ball bearing.
Scoring: The test is a four point scale ranging from 0 to 3 with maximum
score =57.
0= Can perform no part of the test.
1= Perform test partially.
2= Complete test but takes abnormally long time or has great difficulty.
3= Perform test normally.
Items of the Action Research Arm Test.
• 1- Grasp subscale.
Grasp and lift blocks, a ball and a
stone from one shelf of a table
to another.
i– Pick up a block wood of 10 cm
diameter (if score =3, total = 18
and go to grip).
ii– Pick up a block wood of 2.5 cm
diameter ( if score =0, total =0
and go to grip).
Iii– Pick up a block wood of 5 cm
diameter.
iv– Pick up a block wood of 7.5
cm diameter.
v– Pick up a ball of 7.5 cm
diameter.
vi– Pick up a stone 10X2.5X1 cm.
• 2- Grip subscale.
• i– Pour water from glass to
another (if score =3, total=12
and go to pinch).
• ii– Displace an alloy tube
(diameter 2.5 cm) from one
side of the table to the other (if
score = 0, total =0 and go to
pinch).
• iii– Displace an alloy tube
(diameter 1 cm) from one side
of the table to the other.
• iv– Put washer over a bolt.
• 3- Pinch subscale.
• Pinch and lift the ball and block
from one shelf of a table to
another (lift over 37 cm).
• i– Ball bearing of 6mm
diameter between 3rd finger
and thumb (if score =3, total =
18 and go to gross movement).
• ii– Marble bearing of 1.5 cm
diameter between first finger
and thumb (if score = 0, total =
0 and go to gross movement).
• iii– Ball bearing between 2nd
finger and thumb.
• iv– Ball bearing between 1st
finger and thumb.
• v– Marble bearing between 3rd
finger and thumb.
• vi– Marble bearing between
2nd finger and thumb.
• 4- Gross movement
subscale.
• i– Place hand behind
head (If score =3, total=9
and finish), (If score = 0,
total = 0 and finish).
• ii– Place hand on top of
head.
• iii– Hand to mouth.
Neurophysiological evaluation
•
•
•
•
•
Transcranial magnetic stimulation (TMS) was used as a diagnostic tool for
estimation of resting motor threshold (RMT), motor evoked potential (MEPs)
amplitude, central motor conduction time (CMCT)). TMS was performed
initially and repeated after completion of the rehabilitation program. The
clinical neurophysiologist was masked to the results of the clinical
assessments.
A Dantec keypoint EMG was utilized to collect the signal. Maglit Model 200
stimulator with 90 mm a figure of 8 coil. Stimuli were given on the infarcted
side. Coil placement was performed as described by Malcolm et al.39 Motor
response was recorded by surface electrodes placed over contralateral
abductor pollicis brevis (APB). After recording RMT, the stimulus intensity
was increased until potentials with the largest amplitude and shortest
latency were obtained. The stimulus intensity was increased to the
maximum before a response was considered absent.
Resting motor threshold was defined as the lowest intensity necessary to
produce motor evoked potential> 50 uV in at least 5 out of 10 consecutive
stimulations. 40
The motor evoked potential amplitude was determined as peak to peak
amplitude (mV). MEPs were considered absent if no response could be
obtained with 4 stimulations at maximum intensity.41
CMCT was calculated as the latency difference between responses to
stimulation of the motor cortex (TMCT) and the cervical ventral roots
(peripheral latency). 41
Schematic representation of the calculation of CMCT.
A- Motor evoked potential induced by TMS, TMCT is calculated (T1).
B- MEP after cervical spinal root stimulation, peripheral latency is
calculated (T2).
CMCT= T1-T2
• Recording: from the abductor pollicis brevis
muscle by surface electrodes using Dantec
keypoint EMG apparatus.
• Resting motor threshold: is defined as the
lowest stimulus intensity evoking a MEP> 50 uv
recorded from thenar muscle after magnetic
stimulation of the motor cortex.
• MEP amplitude: peak to peak amplitude (mV).
• CMCT: latency difference between responses to
stimulation of the motor cortex (TMCT) and the
ventral roots (peripheral latency).i.e. subtracting
peripheral latency from TMCT
MEPs were considered absent if no response could be
obtained with 4 stimulations at 100% intensity.
III) Medical treatment according to the guidelines of the Ain
Shams University stroke group.
IV) Rehabilitation program
Group A, the patients were subjected to a standard
conventional one to one rehabilitation program for
two hours per day, 5 days per week for 2
consecutive weeks. The prescription of the program
was tailored according to each patient’s clinical and
functional assessment and modified according to
the development of his condition. It included
traditional positioning, management of spasticity,
standard occupational therapy, compensatory
techniques in activities of daily living (ADL),
strengthening exercises and range of motion
exercises..
• Group B, the patients were subjected to CIMT. CIMT
consisted of 2 main elements; movement restriction and
shaping: Restriction of movement of the unaffected extremity
was achieved by asking the patient to wear a mitten on the
unaffected hand for at least 6 hours per day during the 2 week
treatment period. Onsite training of the affected arm was done
in the rehabilitation outpatient department by a procedure
termed "shaping" for two hours per day, 5 days per week for 2
consecutive weeks. Shaping (adapted task practice) is a
method in which motor task difficulty is adjusted in small steps
to the patient motor capabilities. Shaping was carried out for
various tasks related to (ADL) and routine home activities.
Task objects frequently used were children’s toys (e.g.
building blocks, marbles) . A formal behavioral contract with
the patient was set up detailing the agreed-upon activities the
patient would carry out alone, after the session in hospital or
at home, with the mitten on.
Results
Table 1: Demographic data of all patient
groups
Age
Disease
duration
Range
Mean ± SD
Range
Mean ± SD
Group A
43-74
53.90 ±
10.87
5-11
8.60±2.71
Group B
49-70
55.70 ± 6.58 5-12
P. value
>0.05
>0.05
9.00 ± 2.67
Table 2: Baseline assessment between both groups
Group A
Group B
P value
FMA
35.70 ±9.44
34.30 ±10.37
>0.05
ARAT
29.3 ±10.32
30.20 ±10.54
>0.05
RMT (% of
output)
70.1±9.93
69.80±12.38
>0.05
Amplitude of
MEPs (mV)
0.64±0.41
0.63±0.32
>0.05
CMCT (msec)
9.65±1.96
10.82±1.71
>0.05
Table3: Comparison between clinical assessment
.
scales in both groups before and after rehabilitation
Group
Before
After
Mean ±SD
Mean ±SD
FMA
A
B
35.70 ±9.44 36.78±9.18
34.30±10.37 51.20±6.83
>0.05
<0.05*
ARAT
A
B
29.3 ±10.32 32.80±9.46
30.20±10.54 48.00±6.34
>0.05
<0.05*
Table (4 ): Comparison between both groups as
regards FMA & ARAT scale mean improvement in each
group after end of rehabilitation therapy
Group A Group B
Mean ±SD
Mean ±SD
Z-test)
Sig.(p )
FMA
.Change
1.08±0.21
16.90±9.93
-4.322
<0.05
ARAT
.Change
3.50±1.22
17.80±6.75
-3.723
<0.05
figure (1): Comparison of Fugel Meyer assessment scale
between both groups before and after therapy
36.7
after therapy
51.2
35.7
34.3
60
50
40
before therapy
30
group B
20
groupA
10
0
figure (2): Comparison of action research arm test
between both groups before and after therapy
32.8
after therapy
48
29.3
before therapy
30.2
60
50
40
30
group B
20
groupA
10
0
Table 5: Comparison between MEPs
parameters in both groups before and after
rehabilitation
MEP
Parameter
Group
Before
Mean ± SD
After
Mean ± SD
RMT (% of
output)
A
B
70.1±9.93
67.82±5.74
69.80±12.38 62.80±11.85
>0.05
0.008*
Amplitude
of MEPs
(mV)
A
B
0.64±0.41
0.63±0.32
0.96±0.36
1.25±0.53
>0.05
0.000*
CMCT
(msec)
A
B
9.65±1.96
10.82±1.71
9.38±2.44
8.91±2.30
>0.05
0.000*
P value
MEPs after cortical and cervical motor root stimulation of both sides in a patient with left cerebral infarction.
Affected side CMCT=26.7 -15.6 =11.1 msec (C &D) and normal side CMCT=22-14.1=7.9 msec (A & B).
(A) TMCT of normal side
(C) TMCT of affected side
(B) Peripheral latency of normal side
(D) Peripheral latency of affected side
Conclusion
• On the contrary to conventional
rehabilitation therapy, the modified CIMT
revealed a significant functional
improvement in acute stroke patients
denoting that m-CIMT might be a more
efficient treatment strategy.
• Furthermore, improvement of MEP
parameters reflects the impact of training
on cortical plasticity.
Thank you