Movement Therapy (CIMT):
Strong Evidence Supportive of
the Habit Retraining Model
E. Taub et al (1999). Constraint-Induced Movement Therapy: A New Family of Techniques with Broad Application to Physical Rehabilitation - A Clinical Review. Journal of Rehabilitation Research and Development, Vol. 36, No. 3, July, 1999, pages 237-251
- Controlled experiments document efficacy of CIMT in producing large improvements in limb use in real-world environments after CVA
- CIMT involves constraining movements of the less-affected arm with a sling for 90% of waking hours for 2 weeks, while intensively training use of the more-affected arm
- CIMT induces concentrated, repetitive practice of more-affected limb
- Neuroimaging and transcranial magnetic stimulation studies show massed practice of CIMT produces a massive use-dependent cortical reorganization that increases the area of cortex involved in the innervation movement of the more-affected limb
- To date, used effectively for:
- Upper limb of Chronic and subacute CVA
- Upper limb of Chronic TBI
- Lower limb of CVA patients
- Focal hand dystonia of musicians
- Phantom limb pain
- Derived from non-human primate experiments
- Cf. Carl Lashley and equipotentiality
- Several converging lines of evidence indicate that Nonuse of a single deafferented limb results in learning that represents a conditioned suppression of movement
- Substantial neurologic injury --> depression in motor and/or perceptual function that is greater than will be the case after spontaneous recovery of function takes place
- Initial depression of activity lasts 2-6 months following forelimb deafferentation; afterwards progressive regaining of movement ability takes place
- Animal with one deafferented limb attempts to use it postoperatively, but cannot
- Animal begins to function adequately with 3 limbs, reinforcing 3 limb function
- Continued attempts to use deafferented limb produces failure, pain, incoordination, falling, etc., resulting in punishment of attempts, and suppression of efforts.
- Nonuse response tendency persists, preventing monkeys from learning that after several months, the limb is potentially usable
- Conclusion: the animals never learned they could eventually use the limb (Learned Nonuse; cf. Learned Helplessness)
- Movements of a deafferented limb were prevented with restraining device for 3 months.
- After restraint removed, animal used limbs as predicted
- Conclusion: Animals never learned they couldn't use limb (Learned Nonuse)
- In utero deafferentation of limb
- In utero is a movement restricted environment (i.e., restraint)
- At birth, purposive use of limb is present, with progressive improvement to normal when mature
- Use Dependent Cortical Reorganization
- Five TMS, EEG, MEG studies with humans, and one study of monkeys indicate:
- Cortical reorganization is associated with therapeutic effect of CIMT. After use training:
- Area surrounding the infarct (usually not used for hand control) was recruited
- Ipsilateral hemisphere limb control area was recruited
- Mechanism of Action
- (1) By changing learning contingencies, reinforces use learning, blocking nonuse learning
- (2) Sustained, repeated practice of functional arm movements induces expansion of contralateral cotical area controlling movement and recruiting new ipsilateral areas.
- Andrews and Stewart (1979): Stroke Recovery: He can, but does he?
- ADL's performed less well at home vs hospital in 25-45% of cases
- Learned Nonuse? (Taub et al., 1999): "Most patients, despite exhibiting a pronounced motor deficit, probably have a considerable latent capacity for motor improvement"