Constraint-Induced

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)

• 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"