Bridging the Gap

Striving for Intensity with CIMT

There is a growing movement in the application of constraint-induced movement therapy (CIMT) at rehabilitation hospitals nationally. The University of Florida Health Shands Rehabilitation Hospital (SRH)  in Gainesville has become a leader in incorporating CIMT into the daily schedules of neuro patients. To provide a quick refresher, CIMT training involves forced task shaping and repetitive functional training with the affected upper extremity after stroke. In typical practice patients will attempt use of the affected upper extremity for 5-6 hours daily to drive neuroplasticity. We know from previous research such as the EXCITE trial headed by Steven Wolf in 2006 that CIMT can significantly increase upper extremity function and use of the affected limb (Wolf, 2006).

In modern rehab we are faced with a question:
How do we implement these programs and provide carryover in our own hospitals as OTs? 

A group of therapists from SRH have identified this problem and implemented a number of  task-oriented groups and treatment sessions into patient schedules. Groups typically contain 4–6 patients and last an average of 30 minutes per group session. Therapists in the program have also implemented CIMT over individualized patient ADL sessions in an attempt to increase Functional Independence Measure (FIM) scores (Walker, 2017). Induction of a modified CIMT program requires communication and carryover across all disciplines during the day as well as caregiver training to achieve the desired 5-6 hour treatment window. A treatment schedule can be implemented by the primary occupational therapist and individualized to promote a client-centered, motivating and occupation-based program. 

CIMT is relatively inexpensive to implement, in fact, oven mitts can be used as a form of 'constraint' on the unaffected UE. Functional task-oriented movements can be honed-in on (ie: feeding tasks, buttoning) as well as traditional fine motor and sensory integration tasks. 

While CIMT therapy has been proven extraordinarily valuable in the pursuit of functional gains in neurorehabilitation, there are some limitations. In order to effectively participate stroke patients must have some (may it be limited) active movement in the upper extremity as well as the ability to follow one to two-step commands. 

Could robotic therapy bridge the gap for earlier application of CIMT? 

Robot-assisted therapy devices offer the opportunity for intensive task shaping and repetitive motor movements with the affected upper extremity in and out of a muscle synergy pattern earlier in the rehabilitation process. The BURT device allows patients with limited to no active movement autonomy to start perform motivating task-oriented activities with graded robotic assistance. Robotic therapy has the capability of helping to integrate forced use of the affected upper extremity earlier in the game to maximize functional gains and upper extremity function. Could robotics be the missing link in our CIMT programs? With robot-assisted therapy perhaps we can jump-start proximal initiation of the shoulder complex and elbow early on in the rehab process to increase distal movement and motor function.

To read more about CIMT therapy check out the articles below!

Authored by Holly Mitchell, MOT, OTR/L

Clinical Manager, Barrett Technology

References

Walker, L. (2017). Group Discipline: Incorporating Evidence-Based Modified Constraint-Induced Movement Therapy in an Inpatient Rehabilitation Facility. OT Practice 22(10), 18–21.

Wolf et al., (2006). The EXCITE Trial: Predicting a Clinically Meaningful Motor Activity Log Outcome. Neurorehabilitation and Neural Repair 22(5), 486 - 493.