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)
Experiment:
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)
Experiment
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"
