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Constraint-induced movement therapy: A new

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Article  in  Rehabilitation Psychology · June 1998

DOI: 10.1037/0090-5550.43.2.152

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 Commentary

Rehabilitation Psychology devotes a section of each issue to commentary on recent

trends, concerns, or publications in rehabilitation psychology practice, research, and
education. Articles appearing in this section may contain comments in reaction to
specific pieces appearing in recent issues of the journal, and they may address
methodological, theoretical, educational, or professional concerns. Manuscripts
to be considered for this section should conform to the established editorial guidelines
for the journal and not exceed 15 pages in length. Manuscripts should be submitted to
the editor of the journal for processing, and authors should clearly indicate in a cover
letter that the submission is for the Commentary section. The submission and subse-
quent correspondence will then be handled by the associate editor in charge of the
section, Timothy R. Elliott, PhD, Department of Physical Medicine and Rehabilitation,
University of Alabama, 1717 Sixth Avenue South, Birmingham, Alabama 35233-7330.
Ideas and suggestions for topics and authors are welcomed.

Constraint-Induced Movement Therapy:

A New Approach to Treatment
in Physical Rehabilitation
Edward Taub, Jean E. Crago, and Gitendra Uswatte
University of Alabama at Birmingham

ABSTRACT. Constraint-Induced (CI) Movement Therapy is a new approach to the

rehabilitation of movement, based on research in neuroscience and behavioral
psychology, that has been shown in controlled experiments to greatly increase the
amount of use of an impaired upper extremity in chronic stroke patients in both the
laboratory and the real world. CI Therapy consists of a family of techniques that
induce stroke patients to greatly increase their use of an affected upper extremity for
many hours a day over 10 to 14 consecutive days. The signature technique involves
restricting the contralateral arm in a sling and training the affected arm. This
commentary reviews the animal and human research and the theoretical formulation
on which CI Therapy is based.

Rehabilitation Psychology, 1998, Vol. 43, No. 2, 152-170

Copyright 1998 by the Educational Publishing Foundation, 0090-5550/98/S3.00

152
Constraint-Induced Movement Therapy 153

Traditional neurorehabilitation interventions have not been demonstrated to be

effective in controlled studies. In a 1992 review of the stroke rehabilitation
literature, de Pedro-Cuesta, Widen-Holmqvist, and Bach-y-Rita wrote that "as
regards activities of daily life and motor function, differences between ...
rehabilitation in stroke units ... and non-rehabilitation ... were detected in
relatively few quality studies and remained particularly inconclusive insofar as
life in the home environment was concerned" (p. 433). In a 1997 review, Duncan
reported that "clinical research studies to support the efficacy of the interventions
are few" (p. 1). (See also reviews by Ernst, 1990, and Dobkin, 1989.)
The weak contribution from such basic sciences as behavioral psychology and
neuroscience to physical rehabilitation may account for the dearth of effective
interventions. Neuroscience, in studying the nervous system and its pathology,
focuses on the origin of dysfunction in neurorehabilitation patients. Operant
conditioning, a branch of behavioral psychology, studies how to systematically
modify behavior, which is the ultimate aim of physical therapy. These two
disciplines should arguably have been the parent sciences of physical rehabilita-
tion, but this has not been the case.
Neuroscience holds an important place in the curriculum of physical therapy
schools, but its influence has been largely didactic and has had little bearing on
clinical practice. Behavioral psychology has contributed much to the treatment of
chronic pain (e.g., Fordyce, 1991), but has had little or no place in the curriculum
of physical therapy schools or in developing treatments for movement disorders.
In other health-related fields, basic research has been of inestimable value in
enabling the development of new therapeutic approaches.
The limited practical influence of neuroscience on physical rehabilitation to
date may well be because the findings, until recently, have been restricted to areas
that are distant from obvious application to clinical practice. Recent discoveries
about the processes of injury and central nervous system recovery, such as
findings on nervous system damage in the early postinjury phase (reviewed in
Novack, Dillon, & Jackson, 1996), spinal cord regeneration (reviewed in Schwab
& Bartholdi, 1996), and cortical reorganization (Elbert, Pantev, Wienbruch,
Rockstroh, & Taub, 1995; Flor et al., 1995; Mezernich et al., 1984; Muehlnickel,
Elbert, Taub, & Flor, in press; Pons et al., 1991; Taub, Flor, Knecht, & Elbert,
1995), have generated considerable interest. It is hoped that these findings will
lead to new and effective rehabilitation interventions.
Behavioral psychology has had little impact on the rehabilitation of movement,
in part, because of the failure of biofeedback techniques to consistently effect
changes in functional activity when applied to the treatment of movement
disorders. In the 1960s, a strong interest developed in the application of operant-
conditioning techniques to the area of rehabilitation (Ince, 1969). Initial experi-
ments involving the application of biofeedback procedures as a type of operant
conditioning were promising; studies reported improvements in range of move-
ment, manual muscle-test scores, and muscle tension as measured by electromyo-
graphic techniques (Wolf, 1983). Later work, however, failed to show that these
physiological changes were persistent and related to changes in functional
154 Taub, Crago, and Uswatte

activity, so that biofeedback techniques came to be viewed as having questionable

clinical significance (Duncan, 1997; Wolf, 1983). The disappointment engendered
by the biofeedback research appears to have spread to all operant-conditioning
techniques. Consequently, there has been very little interest in the application of
operant-conditioning techniques to the rehabilitation of movement in recent
years.
Movement science, the study of motor learning and the kinetics and kinematics
of movement, has had a substantial influence on the practice of physical therapy.
However, it has not led to the formulation of effective interventions, probably
because early models of motor control, including reflex and motor hierarchy
theories, gave incomplete accounts of human movement. These incomplete
theories led to the facilitation approaches in physical therapy, which have proven
to be ineffective (Duncan, 1997; Horak, 1992; Shumway-Cook & Woollacott,
1995). Current models of motor control, which include systems, dynamical-
action, task-oriented, and ecological theories, provide more comprehensive expla-
nations of human movement than early models, but have yet to yield a large
enough body of knowledge to provide specific implications for clinical practice.
This problem is evident in the difficulty of operationalizing the task-oriented
approach to physical therapy (Horak, 1992; Shumway-Cook & Woollacott, 1995).
In addition, motor-learning research has been conducted largely with healthy
rather than neurologically impaired participants, has focused on artificial tasks,
and has used limited parameters of movement such as speed and error rate to
index the full range of use of an extremity in activities of daily living. As the work
herein described shows, findings based on such laboratory-based tasks and
outcome variables may not be applicable to the most salient targets of physical
therapy: functional activities in the home.
Constraint-Induced (CI) Movement Therapy is a new approach to the rehabili-
tation of movement (Taub, 1980), based on research in behavioral psychology and
neuroscience, that has been shown in controlled experiments to greatly increase
the amount of use of an impaired upper extremity in chronic stroke patients in
both the laboratory and the real world (Taub et al., 1993; Taub, Pidikiti, DeLuca,
& Crago, 1996; Taub & Wolf, 1997; Wolf, Lecraw, Barton, & Jann, 1989). CI
Therapy is made up of a family of treatments that involve focusing attention on
and repeatedly practicing use of the stroke-affected arm in the clinic and, in most
variants, constraining use of the unaffected arm both in the clinic and at home
(Morris, Crago, DeLuca, Pidikiti, & Taub, 1997). These treatments emerged
directly from basic research that used operant-conditioning techniques to change
the arm-use behavior of monkeys from whose forelimbs somatic sensation had
been surgically abolished (Taub, 1977). A major review of stroke-rehabilitation
interventions singled out CI Therapy as "the most promising" evidence that
motor recovery can be facilitated in stroke patients with some purposive move-
ment of the hand and as one of the few treatment modalities for which there is
sound evidence of transfer of therapeutic effect from the clinic to the life situation
(Duncan, 1997).
In this commentary, we review the animal research on which CI Therapy is
Constraint-Induced Movement Therapy 155

based, provide a model explaining its operation in terms of learning followed by

use-dependent cortical reorganization, summarize the research on the application
of CI Therapy to chronic upper extremity hemiparesis in stroke patients, and
suggest future applications. We also discuss principles that have emerged during
the course of this work that may enable the conversion of conventional physical
therapy, biofeedback, and other techniques into effective treatment modalities for
the long-term improvement of degraded motor patterns and functional activity.

AN ANIMAL MODEL OF LEARNED NONUSE

When a single forelimb is deafferented in a monkey, the animal does not make
use of it in the life situation (Lassek, 1953; Mott & Sherrington, 1895). However,
by restricting movement of the intact limb for several days, the monkey can be
induced to use the deafferented extremity permanently. Training of deafferented
limb use also proved to be an effective technique. Initially, conditioned-response
techniques were used to train limb use (Knapp, Taub, & Herman, 1958, 1963;
Taub, 1977; Taub, Bacon, & Herman, 1965; Taub, Ellman, & Herman, 1966;
Taub, Williams, Barro, & Steiner, 1978). Subsequently, it was found that shaping
techniques, which involve increasing behavioral requirements by very small steps
(Morgan, 1974; Panyan, 1980; Skinner, 1938, 1968), are considerably more
effective (Taub, 1976,1977).
Several converging lines of evidence suggest that nonuse of a single deaffer-
ented limb is a learning phenomenon involving a conditioned suppression of
movement (Taub, 1977,1980). The restraint and shaping techniques appear to be
effective because they overcome learned nonuse.
Substantial neurological injury usually leads to a shock-like phenomenon,
whether at the level of the spinal cord (spinal shock) or brain (diaschisis or
cortical shock). Deafferentation initially results in a reduction within the spinal
cord in the background level of excitation that keeps neurons ready to respond.
This effect is most marked in the deafferented segments of the spinal cord, where
the depressed condition of the motor neurons greatly elevates the threshold for
excitation necessary to produce movement. With time, recovery processes raise
the background level of excitability of motor neurons so that movements, at least
potentially, can be expressed. In monkeys, the period of spinal shock lasts from 2
to 6 months following forelimb deafferentation (Taub, 1977).
The inability of the monkeys to use the deafferented limb due to spinal shock
leads to conditioned suppression of use of that limb. Animals with one deaffer-
ented limb try to use that extremity in the immediate postoperative situation, but
they cannot. Attempts to use the deafferented limb often lead to painful and
otherwise aversive consequences, such as falls and loss of food. These failures in
use constitute punishments that suppress arm use (Kimble, 1961). Meanwhile, the
monkeys get along quite well in the laboratory environment on three limbs and
are therefore positively reinforced for this pattern of behavior, which as a result is
strengthened. These contingencies of reinforcement lead to a persistence of the
156 Taub, Crago, and Uswatte

nonuse of the affected extremity. Consequently, the monkeys never learn that,
several months after the operation, it had become possible to make use of the
limb.
The restraint of the intact limb several months after unilateral deafferentation
serves to overcome this conditioned suppression of movement or learned nonuse.
Restriction of the intact limb induces animals to use the deafferented limb or
forego feeding, locomotion, and other important daily activities with any degree
of efficiency. This change in motivation overcomes the learned nonuse of the
deafferented limb and consequently the animal uses it.
An experiment was carried out to test the learned-nonuse formulation directly
(Taub, 1977, 1980). Movement of a unilaterally deafferented forelimb was
prevented with a restraining device in several animals so that they could not
attempt to use that extremity for a period of 3 months following surgery. The
reasoning was that in preventing an animal from trying to use the deafferented
limb during the period before the spinal shock had passed off, one should thereby
prevent the animal from learning that the limb could not be used during that
interval. In conformity with this prediction, the animals were able to use their
deafferented extremity in the free situation after the restraint was removed.
Suggestive evidence in support of the learned-nonuse formulation was also
obtained during the course of deafferentation experiments carried out on the day
of birth (Taub, Perrella, Miller, & Barro, 1973) and prenatally (Taub, 1980; Taub,
Perrella, Miller, & Barro, 1975).

USE-DEPENDENT CORTICAL REORGANIZATION

Recent magnetic source imaging studies with humans, carried out by a group
of investigators including one of the coauthors (ET), and an intracortical micro-
stimulation (ICMS) study with monkeys suggest that cortical reorganization may
be associated with the therapeutic effect of CI Therapy. The human imaging
studies followed the seminal work of Merzenich and coworkers on use-dependent
cortical reorganization in monkeys (e.g., Merzenich et al., 1984), and showed that
the cortical somatosensory representation of the digits of the left hand was larger
in string players, who use their left hand in the dexterity-demanding task of
fingering the strings, than in nonmusician controls (Elbert et al., 1995). Moreover,
the representation of the fingers of blind Braille readers, who use several fingers
simultaneously to read, was found to be enlarged (Sterr et al., 1998). These
results, in conjunction with research on cortical reorganization in adult phantom-
limb patients (Flor et al., 1995), suggest that the size and nature of the cortical
representation of a body part in adult humans depends on the amount of use of that
part. The ICMS study demonstrated that in adult squirrel monkeys, who were
surgically given an ischemic infarct in the cortical area controlling the movements
of a hand, training of the affected limb results in cortical reorganization so that the
area surrounding the infarct not normally involved in control of the hand comes to
participate in that function (Nudo, Wise, SiFuentes, & Milliken, 1996). These
Constraint-Induced Movement Therapy 157

findings suggested the possibility that the increase in affected arm use produced
by CI Therapy results in a use-dependent increase in the cortical representation of
the affected arm, which provides the neural basis for a permanent increase in the
use of that extremity. This hypothesis has recently been confirmed in a transcra-
nial magnetic stimulation (TMS) study in which it was found that the cortical
region from which electromyographic responses of a hand muscle can be elicited
by TMS more than doubled after CI Therapy in chronic stroke patients compared
with the pretreatment period (Liepert et al., in press).

APPLICATION TO CHRONIC STROKE PATIENTS

Development of CI Therapy

Learned nonuse is hypothesized to develop in some humans after stroke by

similar mechanisms to those that operate after deafferentation in monkeys, with
the difference that the initial period of motor incapacitation would be due to
cortical rather than spinal shock. It was therefore felt that the techniques that
overcome learned nonuse in monkeys following unilateral deafferentation should
also constitute a potential treatment to increase the amount of limb use in chronic
stroke patients with upper extremity hemiparesis (Taub, 1980).
Ince (1969) and Halberstam, Zaretsky, Brucker, & Gutman (1971) carried out
the initial studies of the application of CI Therapy to humans. Ince transferred the
conditioned-response techniques used with the deafferented monkeys directly to
the rehabilitation of movement of the paretic upper extremity of 3 chronic stroke
patients. He tied the unaffected upper extremity of the patients to the arm of a
chair, while asking the patients to flex their affected arm to avoid an electric
shock. The motor status of two of the patients did not change; the third patient,
however, improved substantially in the training and life situation (Ince, 1969).
Halberstam et al. used a similar treatment protocol with a sample of 20 elderly
stroke patients and 20 age-matched controls. Treatment-group participants were
asked to flex their affected arm to avoid the electric shock and, also, to make a
lateral movement at the elbow to avoid shock; the unaffected arm was not tied
down. Most of the patients in the treatment group increased the amplitude of their
movements in the two conditioned-response tasks; some showed very large
improvements (Halberstam, Zaretsky, Brucker, & Gutman, 1971). There was no
report of whether this improvement transferred to the activities of daily life.
Steven Wolf and coworkers (Ostendorf & Wolf, 1981; Wolf, Lecraw, Barton,
& Jann, 1989) applied the unaffected-limb-constraint portion but not the affected-
limb-training component of Taub's (1980) treatment protocol to the rehabilitation
of movement in chronic neurologically impaired patients with a upper extremity
hemiparesis. The 1989 study included 25 stroke and traumatic brain injury
patients who were more than 1 year postinjury and who possessed a minimum of
10 degrees extension at the metacarpophalangeal and interphalangeal joints and
20 degrees extension at the wrist of the affected arm (minimum motor criterion).
75<S Taub, Crago, and Uswatte

The patients were asked to wear a sling on the unaffected arm all day for 2 weeks,
except during a half-hour exercise period and sleeping hours. The patients
demonstrated significant but small improvements in speed or force of movement,
depending on the task, on 19 out of 21 tasks on the Wolf Motor Function Test
(WMFT; Taub et al., 1993; Wolf, Lecraw, Barton, & Jann, 1989), a laboratory test
involving simple upper extremity movements. There was no report of whether the
improvements transferred to the life situation.
Taub et al. (1993) applied both the paretic arm training and contralateral arm
restraint portions of the treatment protocol (Taub, 1980) to the rehabilitation of
chronic stroke patients with an upper extremity hemiparesis in a study that used
an attention-placebo control group and emphasized transfer of therapeutic gains
in the laboratory to the life situation. Four treatment participants signed a
behavioral contract in which they agreed to wear a sling on their unaffected arm
for 90% of waking hours for 14 days. On 10 of those days, the treatment
participants received 6 hours of supervised task practice using then- affected arm
(e.g., eating lunch; throwing a ball; playing dominoes, Chinese checkers, or card
games; writing; pushing a broom, and using the Purdue Dexterity Board and
Minnesota Rate of Manipulation Test) interspersed with 1 hour of rest. Five
control participants were told they had much greater movement in their affected
limb than they were exhibiting, led through a series of passive movement
exercises in the treatment center, and given passive movement exercises to
perform at home. All experimental and control participants were at least 1-year
poststroke (mean = 4 years) and had passed the minimum motor criterion before
intake into the study. Treatment efficacy was evaluated using the WMFT, the Arm
Motor Ability Test (AMAT; Kopp et al., 1997; McCulloch et al., 1988), and the
Motor Activity Log (MAL; Taub et al., 1993), which tracks arm use in 14 ADL
through a semistructured interview. The treatment group demonstrated a signifi-
cant increase in motor ability as measured by both laboratory motor tests (WMFT,
AMAT) over the treatment period, whereas the controls showed no change or a
decline in arm motor ability. On the MAL, the treatment group showed a very
large increase in real-world arm use over the 2-week period and demonstrated a
further small increase in use when tested 2 years after treatment; the control
participants exhibited no change or a decline in arm use over the same period.
These results have since been confirmed in an experiment using unaffected arm
constraint and shaping of the affected arm, instead of task practice, with a larger
sample (20 participants) and a more credible control group (15 participants to
date). The shaping procedure involved selecting tasks that were tailored to
address the motor deficits of the individual patient, helping the patient to carry out
parts of a movement sequence if they were incapable of completing the movement
on their own at first, and providing explicit verbal feedback for small improve-
ments in task performance (Taub, Pidikiti, DeLuca, & Crago, 1996). Modeling
and prompting of task performance were also used. The control group was
designed to better control for the duration and intensity of the therapist-patient
interaction and the duration and intensity of the therapeutic activities. The
treatment participants signed a behavioral contract agreeing to wear a sling on
Constraint-Induced Movement Therapy 159

their unaffected arm for 90% of waking hours for 14 consecutive days and
received shaping of affected arm use for the 10 weekdays of that period. The
control participants received a general fitness program in which they performed
strength, balance, and stamina training exercises; played games that stimulated
cognitive activity; and practiced relaxation skills for 10 days. As in the first
experiment, the treatment group demonstrated a significant increase in motor
ability as measured by the WMFT over the intervention period, whereas the
control participants did not. On the MAL, the treatment group showed a very large
increase in real-world arm use from pretreatment to follow-up 4 weeks after
treatment; the control group did not exhibit a significant change over the same
period. The control subjects' answers to an expectancy and self-efficacy question-
naire about their expectations for rehabilitation prior to the control intervention
and their reported increase in quality of life after the intervention, as measured by
the MOS 36-Item Short-Form Health Survey (Ware & Sherbourne, 1992),
suggested that they found the control intervention to be credible.
Other experiments have indicated that there is family of techniques that can
overcome learned nonuse (Taub, Pidikiti, DeLuca, & Crago, 1996; Taub & Wolf,
1997). The other interventions that have been tested are: (a) placement of a
half-glove on the less affected arm as a reminder not to use it and shaping of the
paretic arm, (b) shaping of the paretic arm only, and (c) intensive physical therapy
(e.g., aquatic therapy, neurophysiological facilitation, and task practice) of the
paretic arm for 5 hours a day for 10 consecutive weekdays. Our laboratory
designed the half-glove intervention so that CI Therapy could be used with
patients who have balance problems and might be at risk for falls when wearing a
sling; this intervention expands the population of stroke patients amenable to CI
Therapy threefold. We currently use a "padded safety mitt" that leaves the
unaffected arm free, so as not to compromise safety, but that prevents use of the
hand and fingers in ADL. The shaping-only intervention was tested to evaluate the
relative importance of the constraint and task-practice components of the interven-
tion. The intensive physical therapy intervention did not involve physical con-
straint of the unaffected arm; however, the participants were requested to not
make use of their unaffected arm, and this regimen was monitored. To our
knowledge, such a concentrated application of physical therapy had not been
evaluated before this trial. All these groups showed very large increases in arm
use in the life situation over the treatment period equivalent to that observed for
the sling-constraint and task-practice and the sling-constraint and task-shaping
groups. Two years after treatment, however, these three groups showed some
decrement in arm use, whereas the sling-constraint and task-practice-shaping
groups did not. The sling-plus-shaping results have been replicated in full studies
in two laboratories (Kunkel, Kopp, Taub, & Flor, 1997; Sommer, Bauder, Miltner,
& Taub, 1997) and in pilot data elsewhere (Desai, 1991; Koelbel et al., 1997; G.
Lavinder, J. Charles, & A. Gordon, personal communication, June-August, 1997;
Tries, 1991). The sling-plus-task-practice results have been replicated in pilot
studies with subacute stroke patients who are 3-6 months poststroke (D. Nichols,
C. Giuliani, C. Winstein, S. L. Wolf, personal communications, September-
160 Taub, Crago, and Uswatte

December, 1997). Whether CI Therapy techniques will produce similar positive

results in acute inpatients remains to be determined.
The question arises as to the common factor or factors underlying the
therapeutic effect in these different interventions. Although most of the techniques
involve constraining movement of the less affected arm, the shaping-only and
intensive-physical-therapy interventions do not. There is thus nothing talismanic
about use of a sling or other constraining device on the less-affected extremity.
The common factors appear to be attention to the paretic limb and repeatedly
practicing use of the paretic arm. It is likely that it is these two factors that give
rise to the use-dependent cortical reorganization visualized by Liepert et al. (in
press), which is presumed to be the basis for the long-term increase in the amount
of use of the more affected extremity.

Lower Functioning Patients

Until recently, the patients we worked with all met or exceeded the minimum
motor criteria of 20 degrees of extension at the wrist and 10 degrees of extension
of the fingers. This represents a relatively high initial level of motor ability. It is
estimated that approximately 20 to 25% of the chronic stroke population meet this
motor criterion (Wolf & Binder-Macleod, 1983). However, current work with
lower functioning patients is proving to be very promising, suggesting that CI
Therapy may be applicable to up to 50% of the stroke population with a chronic
unilateral motor deficit. The minimum motor criterion for inclusion of lower
functioning patients into therapy is 10 degrees extension of the wrist, 10 degrees
abduction of the thumb, and 10 degrees extension of any two other digits. Eight
patients whose initial motor ability fell below the minimum motor criterion for the
higher functioning group and above the minimum criteria for the lower function-
ing group have been given CI Therapy to date. All eight of these lower
functioning patients exhibited substantial improvement. While the final level was
somewhat lower than that of the higher functioning patients, since the lower
functioning patients started from a lower initial level of motor ability, the relative
change was as large as in the higher functioning patients. These data suggest that
the motor capacity of chronic patients is modifiable in a larger percentage of the
population than our research originally indicated.

New Methods in Treatment-Outcome Measurement

CI Therapy successfully transfers improvement in the quality and amount of

arm use from the clinic to the life setting (Duncan, 1997; Taub et al., 1993). The
current consensus in the rehabilitation field, including the perspectives of patients,
researchers, clinicians, and health care payers, is that functional activity in the life
situation is the most important outcome to pursue and measure (Keith, 1995).
Physical-rehabilitation outcome-evaluation instruments, however, do not pro-
vide a direct measure of motor function in the real world (Uswatte & Taub, in
Constraint-Induced Movement Therapy 161

press). Traditional instruments in physical rehabilitation focus on measuring

strength, flexibility, and coordination in the clinic or laboratory situation (Smith &
Clark, 1995). More recent instruments measure functional ability in the home
indirectly by clinician observation of activities of daily living performed in the
laboratory or clinic (Baxter-Petralia, Bruening, Blackmore, & McEntee, 1990;
Cress et al., 1996; Holbrook & Skilbeck, 1983), but the relationship between
performance on these instruments and performance in the life situation has not
been rigorously tested (Keith, 1995). When investigators have attempted to
measure behavior in the home, they have relied on retrospective, self-report
questionnaires and focused on functional independence rather than extremity
function (Katz, Downs, Cash, & Grotz, 1970; Keith, Granger, Hamilton, &
Sherwin, 1987; Mahoney & Barthel, 1965). The experimental work conducted by
this laboratory and the observations of others (Andrews & Stewart, 1979) suggest
that laboratory motor tests indicate a rehabilitation patient's maximum motor
ability, but that patients frequently do not make full use of that ability in the life
setting. There is frequently a very large gap between the two.
Our laboratory, consequently, has developed new instruments, the MAL and
the Actual Amount of Use Test (AAUT), that measure upper extremity function in
the life situation (Uswatte & Taub, in press). The MAL (Taub et al., 1993; Uswatte
& Taub, in press) is a semistructured interview during which respondents are
asked to rate how much and how well they use their affected arm for 14 ADL in
the home over a specified period. The MAL is administered independently to the
patient and an informant. The tasks include such activities as brushing teeth,
buttoning a shirt or blouse, and eating with a fork or spoon. The AAUT (Taub,
DeLuca, & Crago, 1996; Morris, Crago, DeLuca, Pidikiti, & Taub, 1997; Uswatte
& Taub, in press) is an observational test that measures how much patients
spontaneously use their affected arm to perform a set of tasks in the laboratory. It
is administered on first entrance into the laboratory before pretreatment testing
and just prior to posttreatment testing. Patients are videotaped as they are
unobtrusively led through a standardized scenario of 20 tasks that they might
encounter in the clinic on a regular basis (e.g., remove coat, place project card in
wallet, fill out form). Patients are not told that they are being videotaped during
test administration; however, they gave informed consent to be videotaped prior
to entry into the CI Therapy trial. In addition, they are not prompted as to which
arm to use to accomplish the tasks or informed that they are being tested.
Clinicians who are unaware of the patients' treatment condition use the videotape
to rate the patients' behavior on the amount of arm use. The patients' performance
on the AAUT is believed to be more closely related to how much they actually use
their affected arms in their daily lives than their performance on laboratory tests of
motor ability where an experimenter specifically asks them to perform tasks with
their affected arm.
A third real-world outcome measure we are developing is the use of accelerom-
etry to measure arm use objectively and directly in the home (Uswatte & Taub, in
press). The accelerometers used in our laboratory are plastic units about the size
and weight of a large wristwatch that are based on piezoelectric crystal technol-
762 Taub, Crago, and Uswatte

ogy. When the piezoelectric crystal in the accelerometers is subject to accelera-

tion, it deforms and produces a charge. This charge is digitized, summed over a
user-specified epoch, and reported as a whole number each epoch (Computer
Science Applications, 1996; Tryon & Williams, 1996). We propose to have
patients wear accelerometers on each arm and the hip before, during, and after
treatment. Recordings from the affected arm unit will be compared before and
after treatment to evaluate the change in the amount of arm movement due to
treatment. Recordings from the unaffected arm unit during treatment will be used
to monitor compliance with the constraint protocol while recordings from the hip
unit before and after treatment will be used to assess the impact of the intervention
on general physical activity. Two initial experiments with college students in a
laboratory setting suggested that the accelerometers (a) provide reliable measures
of simple and ADL-like arm movement, (b) display high sensitivity to movement
parallel to the x and y axes of the units and low sensitivity to movement parallel to
the z axis, and (c) possess high sensitivity to changes in the duration and speed of
arm movement and low sensitivity to changes in distance (Uswatte et al., 1997).
We have also developed two tests of upper extremity motor ability in the
laboratory of specific value for evaluating the population of chronic stroke
patients we study. The WMFT was first developed in the laboratory of Steven
Wolf and has been modified by the current group (Taub et al., 1993). The WMFT
measures the ability of patients to perform 19 simple limb movements and tasks
with the affected arm. Two of the items measure strength and 15 items are timed
and scored by raters blinded to the pre- or posttreatment status of the patient. The
items include activities such as lifting the affected arm from the test table surface
to a box, extending the elbow past a line 40 cm from the initial position, turning
over playing cards, and picking up a pencil. The AMAT (Kopp et al., 1997;
McCulloch et al., 1988; Taub et al., 1993), measures the ability of patients to
perform 13 ADL with the affected arm. Each of the 13 tasks is a complete ADL
commonly carried out in the life setting, such as putting on a sweater, dialing a
telephone number, and unscrewing ajar cap.

FUTURE APPLICATIONS

The range of disorders for which CI Therapy might be an effective treatment

encompasses conditions in which motor disability is in apparent excess of the
underlying pathology. A possible explanation for the excess motor disability in
some of these cases might be that it is being maintained by learned nonuse (Taub,
1994). The research with deafferented monkeys suggests that learned nonuse is
established whenever (a) organic damage results in an initial inability to use a
body part so that an individual is punished for attempts to use it, and rewarded for
using other parts of the body, and (b) there is recovery from or healing of the
organic damage so that the person recovers the ability to use that body part, but
the suppression of use conditioned in the acute phase remains in force.
Some preliminary studies suggest that the range of disorders that meet these
Constraint-Induced Movement Therapy 163

stipulations is wide. Research with monkeys suggests that excess motor disability
can occur following pyramidotomy and other motor lesions (Chambers, Konor-
ski, Liu, Yu, & Anderson, 1972; Lashley, 1924; Ogden & Franz, 1917; Tower,
1940). The study in which Wolf et al. (1989) reported improved motor perfor-
mance in patients with a unilateral upper extremity hemiparesis after CI Therapy
treatment included traumatic brain injury patients. This suggests that excess
motor disability occurs after traumatic brain injury and can be overcome by CI
Therapy techniques. Positive results obtained with CI Therapy by Crocker,
MacKay-Lyons, and McDonnell (1997) with a 2-year-old with a hemiparesis due
to cerebral palsy and by our laboratory (DeLuca, Crago, & Taub, 1997) with a
teenager with a hemiparesis due to perinatal stroke suggest that excess motor
disability occurs in children with cerebral palsy. A case study by Birbaumer and
Taub (1994), which described restoring ambulation in a 29-year-old woman who
was 6 months post spinal cord injury using a CI Therapy approach, suggests that
excess motor disability in the lower extremities occurs after SCI. Our laboratory
has currently begun using a CI Therapy approach for improving ambulation in
chronic stroke. The first three patients have exhibited, if anything, greater
improvement than our patients treated for upper extremity motor deficit (Spear,
Yakley, & Taub, 1998). Given these results and theoretical considerations,
additional disorders where CI Therapy might prove effective include peripheral
nerve damage, unused or underused prosthetic limbs, broken hip, and arthritis
during periods of remission (Taub, 1980,1994).
Another area for future research is the prevention of learned nonuse. Prelimi-
nary magnetic resonance imaging (MRI) data collected by Chatterjee, Edwards,
Uswatte, and Taub (1997) suggest that in chronic stroke patients with an upper
extremity hemiparesis there may be an association between the locus of the infarct
and the affected arm motor ability. If the initial findings are confirmed, MRIs,
obtained after an infarct can be visualized in the scans in the early poststroke
period, could serve to identify patients who are likely to regain motor control of
their arm in the chronic phase and provide such patients with treatment in the
acute phase that prevents the development of learned nonuse (Uswatte & Taub, in
press).

IMPLICATIONS FOR THE DELIVERY OF PHYSICAL

THERAPY SERVICES

Conventional physical therapy is usually administered only once or twice per

week on an outpatient basis; but even when it is administered every day,
individual treatment sessions last just 0.5 to 1 hour each. When stroke survivors
are rehabilitation inpatients in the subacute period, they typically receive at least 3
hours of therapy daily. However, the treatments cover so wide a range of areas
(e.g., speech therapy; cognitive retraining; and therapy for the lower extremity, for
164 Taub, Crago, and Uswatte

the upper extremity, and for transfers) that repetitive practice is not given in any
particular type of motor function. As noted in the introduction, controlled studies
evaluating traditional physical therapy interventions, which typically involve
relatively little repetitive practice, have not yielded positive findings.
As described above, applying the family of CI Therapy techniques produces
very large increases in the amount of arm use of chronic and subacute stroke
patients in their daily lives. In addition, when conventional physical therapy is
administered for 6 hours/day for 10 consecutive weekdays, there is a similar
increase in arm use over the treatment period. This suggests that the factor
underlying the difference in results between CI Therapy and traditional tech-
niques does not reside primarily in the nature of the therapy, but rather in its
frequency of delivery. This conclusion implies that some chronic and subacute
stroke patients could benefit greatly from physical therapy if they received
treatment for multiple hours per day over consecutive days (Duncan, 1997; Taub
& Wolf, 1997). Although the motor-learning literature suggests that massed
practice has a neutral or negative effect on the learning of continuous tasks and a
variable effect on the learning of discrete tasks (Schmidt, 1988), recent studies
with neurologic patients from the laboratory of Mauritz, in which large therapeu-
tic effects for lower extremity function were obtained with repetitive concentrated
interventions (Butefisch, Hummelsheim, Denzler, & Mauritz 1995; Hesse, Bertelt,
Schaffrin, Malezic, & Mauritz, 1994), support the repetitive training model of CI
Therapy.
We recognize that it is difficult to alter customary methods of delivering
therapeutic services because of the tendency to remain with what is known, the
existence of administrative structures designed to manage the current model of
delivery efficiently, and the very real consideration of what services payment
agencies are willing to reimburse. However, none of these constitute insuperable
barriers. What is being proposed here is not a change in therapeutic practice per
se; very little that is used in conducting CI Therapy is unfamiliar to physical-
rehabilitation professionals. Instead, the proposal is to (a) identify, provide, and
reimburse treatment for subacute and chronic stroke patients who are amenable to
therapy involving repetitive practice and (b) change the schedule of treatment for
these patients so that they receive concentrated and repetitive training. The
suggestion is not to discard the "3-hour rule" and training in varied activities, but
rather to extend treatment for those patients who have the stamina to carry out
further therapeutic exercises. The additional time would be spent in repetitive
practice of specific types of movement and would continue until an apparent
plateau of function had been reached, at which point training would be switched
to another part of the body or motor function. If patients cannot tolerate more than
3 hours of therapy daily, it would be advantageous to defer inpatient treatment or
prescribe outpatient treatment when they gain the requisite stamina. The data
from the CI Therapy literature and other recent work speak very clearly on the
value of this approach.
Constraint-Induced Movement Therapy 165

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Acknowledgments. This research was supported by Grant HD34273-01 from the

National Institutes of Health, Grant 94-172 from the Retirement Research Foundation, and
a grant from the Center for Aging, University of Alabama at Birmingham, to Edward Taub
and Grants B93-629AP and B95-975R from the Rehabilitation Research and Development
Service, U.S. Department of Veterans Affairs, to Rama D. Pidikiti and Edward Taub.
We would like to thank the following collaborators: Rama D. Pidikiti, Anjan Chatterjee,
Stephanie C. DeLuca, David Morris, Sharon Shaw, Edwin W. Cook, Wolfgang Miltner,
Bruno Kopp, Maneesh Varma, Seth Spraggins, Scott Moran, Harrison Walker, Vinayak
Sharma, Jesse Calhoun, Kim Rudolph, David Edwards, Francilla Allen, Jennifer Glass-
cock, Louis D. Burgio, Donna M. Bearden, Thomas E. Groomes, William D. Fleming,
Cecil S. Nepomuceno, and Neal E. Miller. We would also like to thank Drs. Scott Richards,
Thomas Novack, and Jay Meythaler for then- critical reading of the manuscript and for their
helpful suggestions.

Offprints. Requests for offprints should be directed to Edward Taub, PhD, Department of
Psychology, University of Alabama, CH415, 1300 University Boulevard, Birmingham,
Alabama 35294-1170.

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