Who wouldn't be excited about a therapy that has proven benefits with the science to back it up.
Let's face it, in the field of neuromotor rehabilitation and childhood disability, almost ALL the research on therapies concludes that the research is well ...
inconclusive!
Many (many) years ago, when I first started hearing talk about Constraint Induced Movement Therapy, I can remember attending an NDT/Bobath workshop where the instructor discussed it. She said that in her opinion, we used CIMT in NDT treatment all the time when for example, you position a child in a way that restrains the good arm in order to facilitate activity in the more affected arm
Well that made sense at the time.
I think that many therapists believe that if you are restraining the good arm to get the affected arm to work, then you are doing CIMT and I was happy to go along with that for many (many more) years
until
I came across a brilliant series of podcast interviews with Dr Edward Taub, the man who brought us CIMT.
Which is why you should listen to podcasts people!
Now I am no expert on CIMT, but Edward Taub made it pretty clear that constraining the unaffected hand with a cast (or anything else) is an example of “forced-use” of the affected arm
and can not be called Constraint Induced Movement Therapy any more than say...
putting a child on a Bobath ball could be called Bobath Therapy.
So...
Today I'm sharing what I learned from listening to the Edward Taub interviews on the Brain Science Podcasts
which I highly recommend listening to - you'll find links to them at the end of this page
and my snow mountain analogy that I use to explain CIMT to parents
and some of the research that applies to CIMT in under two's
because that's where I've implemented it, so I'll share a bit of that with you too
Lets go...
To truly be doing Constraint Induced Movement Therapy, you need to include all four of these components:
1. Shaping
2. Intensive training
3. Transfer Package
4. Restraint
1. Shaping
Shaping is similar but not the same as grading.
Here's my definitions:
Grading is something a therapist does to increase competency with a new skill by breaking it down into manageable components, developing proficiency with the smaller tasks and then building the tasks up to successfully manage the more complex activity.
Shaping is the specific use of reinforcers to change (shape) an existing behavior so that it moves closer and closer to the desired response with the aim of producing a recognizable and repeatable behavior.
More on shaping later, but here's a top tip... if you want an excellent book on shaping, read
Not only will this teach you about shaping in a very practical, easy read, it will also teach you how to improve the behavior of
your animals,
your children and yes,
even your husband - I LOVED this book!
2. Intensive training
Everybody is talking about intensives and I think we all realize how important it is for neural plasticity, but the jury is not yet out on what intensive training actually entails. There is still uncertainty about
dosing - how much you need to do in a day / week / month / year
timing - when's the best time to start / how often and how soon should blocks of treatment be repeated
or duration - how long do you need to do it for in a day / for how many weeks at a time?
But we do know, that a large component of the success of CIMT can be boiled down to intensity (1).
We need repetition over sufficient periods for neuroplastic changes to be integrated
so best advice? Do lots, often, for long enough and look for the sweet spot by making it do-able for families and critically analyzing your outcomes.
3. The transfer package (TP)
The transfer package is basically a home program on steroids.
It's extremely structured and consists of systematic steps and behavioral techniques to ensure it’s efficacy (2). The impact of the transfer package is so important, that some studies have shown
NO sustained changes in grey matter
following CIMT without a TP.
In an adult study comparing two groups of patients who had had the same amount of CIMT, having a TP increased treatment effect size by 2.5 x
The group that had the TP also continued to show gains at 1 year post treatment whereas one can normally expect a drop of about 20% 1 year after treatment has stopped (3)
4. Restraint
Dr Edward Taub has said that
the one thing he regrets
is using the word Constraint in the name of the therapy approach (4) .
Keep in mind that Dr Taub comes from a background of behavioral psychology and CIMT was initially developed with monkeys where operant conditioning was used to train the monkeys to reuse their de-afferented arms.
Dr Taub has written that we
* ie us members of the rehabilitation field *
have poor understanding of Behavioral Therapy where constraint is used to describe a way of training behavior through shaping to achieve a desired outcome.
We have confused constraint with restraint
Which is easy to do really when the most visually obvious part of the therapy is the cast or mit. (5)
In adults, where self-suppression of behavior and deferral of reinforcement is possible, there is evidence to show that restraint is not necessary or even important for optimal treatment effect in CIMT. Adults are often able to access their own "internal restraint".
Which is how they've used the principles of CIMT to develop Constraint Induced Language / Aphasia Therapy - because you don't need to put a cast on the tounge - you just need to tell adults that certain practiced behaviors are not allowed during the therapy and the adults then apply their own restraint as the speech therapist provides the appropriate stimuli to shape new behaviors that lead to improved skill and function with speech.
In terms of restraints however, Dr Taub makes a clear statement (5), that in monkey’s and young children,
*now I am sure he is not implying anything here*
restraint is needed!
Although it is the least important component in terms of treatment efficacy, restraint is the key to accessing the other components effectively where the patient does not have the capacity for internal restraint.
So let's put this all together on top of a snowy mountain peak
Because I like to think in Pictures...
Imagine the brain as a snow mountain, with action potentials (APs) sliding down axons like kids on sleds down a deep snowy track. A neurological insult, like an avalanche, covers most of the tracks, maybe leaving only the oldest and deepest (like our primitive reflexes and mass movement patterns?).
With options limited, the AP starts out on an available axon that looks right, but lands up wrapping around the mountain and going the wrong way. The AP's sled has no breaks and the harder and more often the little AP tries to ride this axon to achieve the goal, the deeper the track becomes,
until it becomes inconceivable that there is any other way to go,
and the bottom of the mountain becomes an unreachable goal.
The pattern is entrenched and learned non-use is established.
(practice makes permanent not perfect – Karen Pape, MD)
In CIMT, we use a restraint, like a boulder in the middle of the track, to block this
deeply entrenched pathway and give the AP time to find another way before he slips around the other side of the mountain.
We use constraints, like the flags in the picture, to mark out the correct pathway, and over time we gradually shape the path to lead directly to the goal.
If we encourage the APs to slide down the new path often enough, a strong pathway is formed, like a deep track in the snow,
but if we remove the constraint to soon, the track won't be deep enough to easily switch tracks, which is why intensity AND duration matter for neural integration.
If our AP doesn't have a good enough reason to practice using this new path, it'll easily get lost in the new snow that falls, which why the Transfer Package is so important!
So we know CIMT work, it started in monkeys, moved to adults; there's been loads of research in children with hemiplegia, but
Is it safe to do in babies?
What of the Impact of restraint on the development of the coritcospinal tract?
and does it affect normal development of the restrained side at a time when practice is vital to improve proficiency?
How does it affect bilateral hand function development?
And what about the other components of CIMT?
Does the intensity of treatment conflict with an infants need for sleep and what is the impact of intensive training on other care needs such as breastfeeding?
Is it feasible to do therapy 3 hours a day for 3 weeks – how long can an infant effectively concentrate?
What of changing developmental skills? Does previous CIMT lessen the effect size of subsequent interventions?
These are some of the questions and criticisms that have been raised for Baby CIMT. A search for literature turned up a few studies on Baby CIMT (ie CIMT in under two's) which go someway to addressing these concerns and
Most of the baby CIMT studies describe a modified version of CIMT, where components are adapted or added to address the unique needs of babies, as well as mitigate the above concerns that have been rightly raised about possible negative consequences of CIMT on a very immature nervous system (6-12).
access a summary of the different approaches used and their outcomes here
The most obvious modification was restraint time, which varied between 30 minutes a day for 6 weeks to 24 hours a day for 3 weeks. In the study by Pax Lowes et al (2014) when infants aged 7 - 16 months were restrained using a bivalved cast for 24 hours over 4 weeks, researchers implemented intensive bimanual training for 4 days after the restraint was removed to mitigate the effect on the restrained limb. They found no deficits in arm function tests 1 month later.
Just a quick note on Bimanual Training...
Bimanual Training mimics the intensity and shaping aspects of Constraint Induced Movement Therapy with better outcomes for bimanual tasks and carry-over.
It may be better for children who can’t tolerate restraints or are less affected, but requires more one:one therapy expertise as the therapist needs to be able to anticipate difficulties or compensations and shape the environment to prevent these. In the paper that compared CIMT to Bimanual training(6), the authors concluded, especially in older children, that ingredients (unilateral vs bimanual) were not as important as intensity of practice. They recommend doing both in therapy.
All the Baby CIMT studies I found showed impressive gains and positive parent's experience. It was noted in one study that a 13 month old would even initiate therapy herself by bringing the restraint mitten to her parents to put on. Parents in different studies commented that use of the restraint led to an increased awareness that lasted for most of the day after the restraint was removed.
These comments certainly mirror my experience of using baby CIMT.
I am lucky enough to work in a child development service where early referrals are common place and I've been able to introduce baby CIMT from around 6 months of age, with results that continuously amaze me!
My approach has been more in line with a soft restraint, worn predominantly during active therapy times. My recommendations have been to restrain the good arm for 10 or 15 minutes, 3 - 5 times a day and plan the times and activities based around normal care schedules with feeding, nappy changes and play time. As the babies get a bit older, it has been useful to use a molded, removable arm splint that our hand therapist makes. We aim for 40% of awake time with the cast on, with some structured activities and some free play during this time.
It's been really interesting to see that the frequent result of this early start is a willingness to use the affected arm in activities with only verbal reminders by the time the children get to kindergarten. This means that we don't need a restraint unless we are working on particularly challenging or complex activities.
Joel is one of the children that I have seen from 6 months of age. His parents were happy for me to share his story as a case study,
You can access the full story with photos and a video here
Joel experienced a peri-natal infarct secondary to a traumatic birth, resulting in loss of both grey and white matter in the right temporal and posterior frontal lobes. He started therapy at 6 months of age, which included CIMT as described above.
Our goal for Joel at the beginning of this year was to be able to climb using both hands.
This month he aced it!
And managed to hang from the monkey bars for 30+ seconds, which was his own goal!
I'm sorry not to sound terribly professional here...
but his progress blows me away!
Way to go Joel!
For more brilliant insights into applying Constraint Induced Movement and Bimanual therapy, listen to this interview with Dr Brian Hoare (Occupational Therapist)
Links to Edward Taub Interviews
on Brain Science with Ginger Campbell, MD
Joel's Case Study can be accessed in the wiredON Development's Clinical Corner.
This is space for sharing knowledge, case studies, insights and learnings. It is free and open to clinicians who are registered with a professional governing body. Registrations are verified to ensure a private space to share clinical case studies and have open discussions about topics.
If you're not already signed up, click on the above link to join us.
References
1. Kolobe et al. Research summit III proceedings on dosing in children with an injured brain or cerebral palsy: executive summary. Physical Therapy (2014) vol. 94 (7) pp. 907-20)
2. Taub and Uswatte. Importance for CP rehabilitation of transfer of motor improvement to everyday life. Pediatrics (2014) vol. 133 (1) pp. e215-7).
3. Taub et al. Method for enhancing real-world use of a more affected arm in chronic stroke: transfer package of constraint-induced movement therapy. Stroke (2013) vol. 44 (5) pp. 1383-8)
4. Wilson, Heather. "Parent Information - CIMT for Children at Ranken Jordan ." YouTube. April 4, 2011. https://www.youtube.com/watch?v=lQTEPoVMIVk (accessed June 13, 2016)
5. Taub, Edward. "The Behavior-Analytic Origins of Constraint-Induced Movement Therapy: An Example of Behavioural Neuroscience." The Behavior Analyst 2, no. 35 (2012): 155-178
6. Gordon, AM. "To constrain or not to constrain, and other stories of intensive upper extremity training for children with unilateral cerebral palsy." Developmental Medicine & Child Neurology (2011) vol. 53 pp. 56-61 53 (2011): 56-61
7. DeLuca, SC, K Echols, SL Ramey, and E Taub. "Pediatric constraint-induced movement therapy for a young child with cerebral palsy: two episodes of care." Physical Therapy 83, no. 11 (2003): 1003-13 -12
8. Fergus, A, J Buckler, J Farrell, M Isley, M Mcfarland, and B Riley. "Constraint-induced movement therapy for a child with hemiparesis: a case report." Pediatr Phys Ther 20, no. 3 (2008): 271-83
9. Coker, P, C Lebkicher, L Harris, and J Snape. "The effects of constraint-induced movement therapy for a child less than one year of age." NeuroRehabilitation 24, no. 3 (2009): 199-208
10. Pax Lowes, L, et al. "Pilot study of the efficacy of constraint-induced movement therapy for infants and toddlers with cerebral palsy." Physical & Occupational Therapy In Pediatrics 34, no. 1 (2014): 4-21
11. Eliasson, AC, L Sjöstrand, L Ek, L Krumlinde-Sundholm, and K Tedroff. "Eliasson et al. Efficacy of baby-CIMT: study protocol for a randomised controlled trial on infants below age 12 months, with clinical signs of unilateral CP." BMC Pediatr. 141. Vol. 14. 2014
12. Nordstrand, L, M Holmefur, A Kits, and AC Eliasson. "Improvements in bimanual hand function after baby-CIMT in two-year old children with unilateral cerebral palsy: A retrospective study." Research in Developmental Disabilities 41-42 (2015): 86-93
