Constraint Induced Movement Therapy Increases Functionality

and Quality of Life after Stroke

,
Larissa Salgado Oliveira Rocha,* † Geisa Crissy Bandeira Gama,*
,
Rodrigo Santiago Barbosa Rocha,* † Letícia de Barros Rocha,*
,
Caroline Prudente Dias,* Luciane Lobato Sobral Santos,* †
M
arcio Clementino de Souza Santos,*
Maria Imaculada de Lima Montebelo,† and Rosana Macher Teodori,†

This blind randomized clinical trial evaluated the effect of CIMT on the functional-
ity and quality of life (QOL) of chronic hemiparetics. Thirty volunteers were
divided into two groups: Control (CG) and CIMT (CIMTG); evaluated before and
after 12 and 24 intervention sessions. The scales used were: adapted Fugl-Meyer
Motor Assessment (FMA), Modified Ashworth, Stroke Specific Quality Of Life (SS-
QOL) and the Functional Reach Test (FRT). The scores for all FMA variables in the
CIMTG increased until the 24th session, differing from the pre-treatment. In the
CG, the scores increased for pain, coordination/ speed and sensitivity. In the FRT
there was an increase in the scores in both groups; after the 12th and 24th sessions,
the result of the CIMTG was superior to the CG. For the SS-QOL in the CIMTG, the
general score and most of the variables increased, as well as in the CG. Muscle tone
in CIMTG was lower compared to CG after 24 sessions. Both protocols used in the
study were effective, the CIMT protocol showed benefits in recovering the function-
ality of the paretic upper limb, in the functional range and in reducing muscle tone,
with a consequent improvement in quality of life.
Key Words: Upper extremity—Paresis, stroke—Neuronal plasticity—
Physiotherapy
© 2021 Elsevier Inc. All rights reserved.

Introduction The disuse is stimulated by the potentiation of afferent

information to the sensorimotor cortex when the non-
The paretic and spastic brachial condition causes the
paretic limb is functional and its action inhibits the use of
learned non-use, also known as disuse; the individual
the affected limb, resulting in loss of sensorimotor mem-
expresses difficulty in using the compromised upper limb
ory and generating asymmetric and spastic patterns.6
and develops compensatory mechanisms that prioritize the
Thus, due to limited bimanual activities, these individuals
use of only the unaffected extremity, triggering the poor
use only the unaffected limb and result in daily difficulties
adaptation of neuroplasticity, which is the ability to recover
resulting from paresis of the upper limb,16,38,39 observing
a nerve function through behavior change strategies.25,35
the learned non-use, characteristic of poorly adaptive
plasticity after stroke.35
From the *Physiotherapy Course at the State University of Par

a; Constraint Induced Movement Therapy (CIMT) plays
Bel
em, Brazil; and †Postgraduate in Human Movement Sciences at
an important role in inhibiting maladaptive plasticity in
the Methodist University of Piracicaba; Piracicaba, Brazil.
Received December 10, 2020; revision received March 15, 2021;
hemiparetic patients by being characterized by the restric-
accepted March 22, 2021. tion of the unaffected upper limb associated with an inten-
Clinical Trials Number: NCT02932631 sive motor activity training program applied to the paretic
Ethics Committee number: 987.298 upper limb, with aim of improving or reestablishing
Corresponding author. E-mail: lari1980@gmail.com.
motor function, promoting movement with adequate
1052-3057/$ - see front matter
© 2021 Elsevier Inc. All rights reserved.
speed, precision and smoothness.1,19,40
https://doi.org/10.1016/j.jstrokecerebrovasdis.2021.105774

Journal of Stroke and Cerebrovascular Diseases, Vol. 30, No. 6 (June), 2021: 105774 1
2 L.S.O. ROCHA ET AL.
However, the time required to execute the protocol pro-
posed by Taub et al.,36 during 6 hours of supervised training
of the paretic limb daily, 90% of the time with the restricted
non-paretic limb and performed for 14 consecutive days, is
extensive and the treatment is expensive, not adapting to
the reality of the clinic. Therefore, adapted protocols have
been adopted with variation in the number of sessions and
the restriction or training time, varying from 30 minutes to
3 hours daily, as well as only the use of the restriction with-
out additional treatment with forced use pointing out bene-
fits for the functionality of the system. Paretic upper
limb.9,17,22,23,28,41 However, the impact of CIMT after stroke
in relation to the stage for starting treatment,5,17
intensity2,31,32 and long-term effects34 is still controversial,
with the need to implement an ideal protocol.10,29
The present study proposes a 1-hour / session CIMT pro-
tocol to assess functionality and quality of life in chronic
hemiparetic patients, time conventionally available in clini-
cal practice for physical therapy care, without requiring a
daily post-treatment restriction period. This protocol favors
adherence to treatment, in addition to being physically and
mentally less tiring compared to other protocols.
Methods
This is a randomized, blinded, prospective and quanti-
tative clinical trial, approved by the Ethics Committee in
Research with Humans of the University of the State of
Par
a (opinion number 987.298), registered in the Clinical
Trials (NCT02932631) and carried out in the Physiother-
apy Sector of university.
Seventy volunteers were screened with the following
inclusion criteria: age group 45 to 80 years old, both sexes,
clinical diagnosis of stroke, time of injury above six
months, hemiparesis with brachial predominance, who
presented at least 20° of passive extension of wrist and
10° metacarpophalangeal and interphalangeal and 20°
elbow extension considering the 90° position of elbow
flexion16 and a score above 24 points in the Mini State
Exam Mental or considering the score used for illiterate
(20 for illiterate; 25 for one to four years of schooling; 26.5
for five to eight years; 28 for nine to 11 years and 29 over
11 years of schooling).
The volunteers were randomized by a researcher
blinded by drawing a paper contained in an envelope in
two groups of equal number: Control Group (CG) made
up of hemiparetic individuals submitted to a conventional
physiotherapy protocol and Group of Constraint Induced
Movement Therapy (CIMTG) made up of hemiparetic
individuals submitted to a CIMT protocol.
The paretic upper limb was evaluated in three
moments, using the Modified Ashworth Muscle Tone
Scale, allowing the quantification or degree of spasticity
from the passive stretching of the musculature, being
graded from 0 to 4;4 no study considered the group of
muscle flexors as wrist flexors and brachial biceps.
The assessment of paretic upper limb functionality was
performed using the Fugl-Meyer Motor Assessment Phys-
ical Performance Scale (FMA Scale), which includes six
aspects: passive movement and pain, motor function, sen-
sitivity, balance, coordination and speed. An ordinal line
of 3 points is applied to each item where: 0 = cannot be
performed; 1 = performed partially and 2 = performed
completely, totaling 100 points for normal motor function,
and in this study only the upper limbs section of the scale
was selected (Maki et al., 2006).
The functional reach test (FRT) was performed with
each volunteer, in sedation in a chair without armrests for
the upper limb, positioned laterally to the wall, with the
shoulder 15 cm away from it without touching her, feet
parallel in a comfortable position, keeping the shoulder
close to the wall and flexed at 90°. A measuring tape
(CIRCULOÒ ) was fixed parallel to the floor, positioned at
the height of the acromion. The volunteer was instructed
to lean forward as much as possible and the displacement
was measured on the tape measure, with three attempts
at functional reach, then obtaining the average of the three
repetitions of the paretic limb, where the increase in the
mean score represents improved functional range.42
The Stroke Specific Quality Of Life scale (SS-QOL) was
used, composed of 49 items subdivided into 12 domains:
energy, family role, language, mobility, humor, personality,
self-care, social role, reasoning, function upper limb, vision
and work/ productivity. In each item there are five answer
options with a minimum score = 49, which means greater
dependence and difficulty in daily tasks, and a maxi-
mum = 245, which means better perception of quality of life.16
The evaluations took place in three moments: in the
pre-treatment period; 24 h after the 12th session and 24 h
after the 24th session (post treatment), with a total inter-
vention time of 24 sessions (three weekly 60 min sessions
on alternate days).
Subsequently, the volunteers designated to compose
the CG were submitted to the conventional physiotherapy
protocol and performed activities divided into three
stages: stretching (finger flexors, wrist, flexor carpi ulna-
ris, elbow flexors, shoulder flexors and internal shoulder
rotators - 30sec, 2 repetitions, 1 set); strengthening and /
or mobilization of the same muscle groups (10 repetitions
and 3 sets) and functional training of the affected muscles
with the following tasks performed for 3 min each: Make
balls with a newspaper sheet opposing all fingers, move
objects in sequence over the markers positioned on the
table, forming squares and diagonals, stacking acrylic
cups, using a spoon to transfer beans from one container
to another, attaching clothespins to a rope that were
repeated sequentially, in specific series and repetitions
lasting 60 minutes in total session. The speed of move-
ment during functional activities increased from the
beginning to the end of each functional activity.
The volunteers allocated to the CIMTG performed the
CIMT protocol (60 minutes each session), which was
CONSTRAINT INDUCED MOVEMENT THERAPY AFTER STROKE
based on the study by Rocha et al.,25 which was also
developed to carry out functional activities.
When applying the CIMT protocol, the volunteers had
previously made a positioning orthosis for the healthy
upper limb with plastered bandage and adhesive tape, with
the orthosis positioned on the limb in a neutral position.
Then, the paretic limb was stimulated to perform tasks that
involved activities of daily and/ or daily life, with the volun-
teers being seated, ergonomically and with the material used
for the activities positioned on a table. The healthy upper
limb was supported on the table, while the paretic per-
formed the activities; the researcher remained at the volun-
teer's side to control the performance of exercises that
consisted of functional activities in the following sequence
Fig. 1. Flowchart of the sample selection process.
3
of execution: threading containers of different sizes, opening
and closing locks, reaching for a 500 ml jar and pouring 5
glasses, taking a glass and take it to the mouth, pick up a
spoon and take it to the mouth, perform the hair combing
movement, clean the table with a sponge in circular move-
ments, perform activities with fitting games, place marbles
and clips in a container, turning playing cards, bouncing a
ball on the floor, painting vertical lines.
Each task was performed for 5 min, totaling 60 min of
therapy, with the degree of difficulty of each task pro-
gressively increasing, such as distance, size, weight and
material of the objects. In addition, the tasks performed
in the intervention protocol included the use of all the
joints of the upper limb and, as they were right-handed,
4 L.S.O. ROCHA ET AL.

the activities were dynamic, with prehension being
encouraged.
For statistical analysis, the Stastical Package for Social
Science for Personal Computer software (SPSS/ PCÒ ver-
sion 20.0) was used and the Shapiro-Wilk test was applied
to analyze the data normality. For the nominal variables
of sex, the Binominal test was applied in two proportions
and for the variables age and time of injury, the T test
sample data was used. For the analysis of muscle tone,
the Cochran Q Test was used for k paired samples in the
intra-group analysis and for the evaluation between
groups, the McNemar-Bowker test was applied.
For comparative analysis of the FMA Scale, SS-QOL
and the functional range test between groups at different
times, the ANOVA_F repeated measures test was used.
Identifying significance in ANOVA, the Bonferroni test
was used to analyze intra-group differences. It was also
possible to calculate the influence of treatments using an
effect size to compare the CG with the CIMTG. For this,
the Cohen’s d pooled method was used. This analysis was
performed by the “Effect Size Generator” application, ver-
sion 2.3 (Swinburne University of Technology, Center for
Neuropsychology, Melbourne, Australia).
Results
70 volunteers were selected, 40 of whom were excluded.
Thus, 30 volunteers were randomized to compose the GC
and CIMTG groups. The volunteer selection process was
described in Fig. 1.
The values regarding the characteristics of the sample
between the groups studied regarding age were
59.8 § 9.59 years for the CG and 59.66 § 10.04 years for
the CIMTG, the highest incidence of males for the CG in
11 individuals and 10 for the CIMTG and time of injury
on average of 3.32 § 2.00 years for the CG and
3.81 § 2.94 years for the CIMTG, verifying that there was
no statistical difference for these variables (p > 0.05). In
addition, all volunteers in both groups had ischemic
stroke and right handedness (100%); as for the affected
cerebral hemisphere, it was verified in percentage values
in CG and CIMTG greater impairment in the right hemi-
sphere with 60% and 53.33% respectively, being the skills
affected in the left hemibody in most of the volunteers.
In the analysis of Muscle Tone intragroups in the differ-
ent periods of evaluation, it was observed that the muscle
tone of each individual did not differ between the periods
pre-treatment, 12th session and 24th session in the groups
CIMTG (p = 0.97) and CG (p = 0, 99). In the intergroup
analysis, a difference was observed only in the 24th ses-
sion (p = 0.004), in which the CIMTG showed a more evi-
dent decrease in muscle tone than the CG.
Table 1 shows the average values and standard devia-
tions for each variable on the modified FMA scale and the
FRT at different times, for each group.
In the comparison between the pre-treatment period
and the 24th session in the CG, the passive movement
(S = -0.24) and joint pain (S = -0.26) variables had little
effect, whereas the other variables had an effect insignifi-
cant (S < -0.13). On the other hand, the CIMTG showed a
medium effect on the passive movement variables (S = -
0.53) and motor function of the upper limb (S = -0.57) and
a small effect on joint pain (S = 0.39), sensitivity (S = -0.26)
and coordination / speed (S = -0.22). Such analyzes point
to a better effect of the protocol used in the CIMTG in rela-
tion to the CG.
In assessing the size of the treatment effect for FRT
between the periods in the CG between the pre-treatment
period and the 24th session, a medium effect (S = -0.69) was
observed and in the CIMTG, a small effect was observed

Table 1. Mean values § SD of the variables of the modified Fugl-Meyer Motor Assessment Scale (FMA) and Functional Reach Test
(FRT) in the Control (CG) and Constraint Induced Movement Therapy (CIMT) groups at different times of assessment.

Variables of FMA Groups Pre 12th 24th Group x intervention

and FRT time/p-value
Passive movement CG 21.2 § 1.01 21.6 § 0.82 22 § 0.65 F(2,56) = 21.44; p < 0.01
CIMT 17.26 § 3.59z 20.86 § 2.72* 22.93 § 1.75*,y
Joint Pain CG 19.4 § 3.90 21.6 § 0.82* 22 § 1.13*,y FGG(1,13;31,57) = 2.51;p = 0.11
CIMT 17.33 § 4.13 21.26 § 1.83* 22.06 § 1.90*,y
Sensitivity CG 11.6 § 0.82 11.6 § 0.82 12 § 0.65*,y FGG(1,26;39,82) = 5.64; p = 0.017
CIMT 10 § 2.59z 11.06 § 1.86* 11.8 § 0.86*
Motor function CG 52 § 3.64 53.8 § 7.09 54.4 § 7.79 FGG(1,27;35,55) = 16.46;p < 0.001
of the upper limb CIMT 43.2 § 11.4z 52.4 § 7.67* 58.6 § 2.05*,y,z
Coordination/speed CG 4.8 § 0.41 4.6 § 0.82 5 § 1.13y FGG(1,62;45,34) = 8.69; p = 0.001
CIMT 3.53 § 1.18z 4.2 § 1.26* 4.6 § 1.18*,y
FRT (cm) CG 96.8 § 4.18 104.2 § 4.76* 110 § 5.41*,y FGG(1,3, 36,43) = 4.5; p = 0.031
CIMT 96.37 § 13.26 110.84 § 10.10*,z 116.22 § 9.76*,y,z
Pre: Pre-treatment; 12th: 12th session and 24th: 24th session
*It differs from the respective pre-treatment;
†
It differs from the respective 12th session;
‡
Differs from the respective CG, difference between CG and CIMT.
CONSTRAINT INDUCED MOVEMENT THERAPY AFTER STROKE 5

Table 2. Mean values § SD of the general score and variables of the Stroke Specific Quality of Life scale (SS-QOL) in the Control
(CG) and Constraint Induced Movement Therapy (CIMT) groups at different times of assessment.

Variables SS-QOL Groups Pre 12th 24th Group x intervention

time/p-value
Energy CG 10.6 § 3.11 13.4 § 1.40* 13.4 § 1.54* FGG(1,12; 31,35) = 4.80; p = 0.32
CIMT 9.46 § 3.35 14.13 § 1.24* 14.66 § 1.04*,z
Family roles CG 11.2 § 2.95 13.2 § 1.01* 14.4 § 0.82*,y FGG(1,39; 38,95) = 0.75; p = 0.47
CIMT 10.13 § 3.48 12.6 § 2.02* 14.26 § 0.88*,y
Language CG 19 § 5.51 21.2 § 2.73* 24.2 § 0.77*,y FGG(1,33; 37,22) = 0.79; p = 0.45
CIMT 20 § 6 22.86 § 5.23* 24.2 § 24.2*,y,x
Mobility CG 20.8 § 4.82 23.4 § 4.22* 24.6 § 5.53*,y F(2; 56) = 11.32; p < 0.001
CIMT 20.33 § 4.45 24.8 § 4.70* 27.73 § 2.81*,y,z,x
Humor CG 20.4 § 3.37 23.2 § 1.20* 23.8 § 1.20*,y FGG(1,14;31,94) = 1.058;p = 0.32
CIMT 19.33 § 7.03 22.46 § 2.19* 24.73 § 0.79*,y,x
Personality CG 13.8 § 2.48 14.4 § 1.24 14.4 § 1.24 FGG(1,17;32,68) = 3.94; p = 0.05
CIMT 12.26 § 3.30 14.26 § 1.27* 14.8 § 0.77*
Self-care CG 17.2 § 3.83 18.8 § 3.89* 21.2 § 5.0*,y F(2; 56) = 4.6; p = 0.01
CIMT 20.6 § 3.43 24.53 § 1.24* 24.6 § 0.73*,y,z,x
Social roles CG 17.8 § 3.29 20.8 § 2.30* 21.4 § 3.62* FGG(1,16;45,04) = 6.58;p = 0.003
CIMT 16.46 § 5.80 20.6 § 3.99* 23.93 § 1.53*,y,x
Memory/Concentration CG 11.6 § 1.40 12.4 § 1.40 13.2 § 1.78*,y FGG(1,21;33.97) = 6.17;p = 0.01
CIMT 10.33 § 3.59 13.66 § 13.66* 14.33 § 1.23*,y,z
Upper limb function CG 19.4 § 2.41 19.8 § 2.21 21 § 3.76 FGG(1,36;38.07) = 19.83;p = 0.003
CIMT 16.8 § 16.8 21.46 § 21.46* 24.13 § 1.59*,y,z,x
Eyesight CG 13.6 § 1.24 13.2 § 1.65 13.2 § 1.65 FGG(1,01;28.51) = 4.93;p = 0.03
CIMT 14.13 § 1.92 14.53 § 1.55 14.6 § 1.54,z
Work/Productivity CG 10.6 § 1.24 10.6 § 1.80 11.6 § 3.68 FGG(1,21;34.031) = 13.97;p < 0.001
CIMT 9.53 § 1.76 12.46 § 1.30* 14.06 § 1.53*,y,z,x
General score CG 186 § 16.56 204.4 § 16.18* 216.4 § 24.65*,y FGG(1,54;43.26) = 19.19;p < 0.001
CIMT 179.4 § 17.42 218.4 § 9.52* 236.06 § 10.61*,y,z,x
Pre-treatment; 12th: 12th session and 24th: 24th session.
*Intragroup Analysis: It differs from pre-treatment;
†
It differs from the 12th session (p  0.05).
‡
Intergroup Analysis: Difference between pretreatment and the 12th session of the CG;
§
Difference between the 12th session and the 24th session of the CG (p  0.05).

between the pre-treatment period and the 24th session (S = -
0.43), which shows that although conventional physical
therapy has shown a superior effect, CIMT has also brought
about an improvement in functional range.
Table 2 expresses the mean values and standard devia-
tions of the general score and of each SS-QOL variable at
different times for each group.
The size of the treatment effect for the SS-QOL variable in
the comparison between the pre-treatment period and the
24th session in the CG showed that the variables energy
(S = -0.30), family roles (S = -0.42), language (S = -0.41),
humor (S = -0.37), self-care (S = -0.23), social roles (S = -0.26)
and memory / concentration (S = -0, 25) and the general
score of the scale (S = -0.37) had little effect. On the other
hand, in the CIMTG there was a great effect on the general
score of the scale (S = -1.01), medium effect on the variables
energy (S = -0.59), mobility (S = -0.51), roles (S = -0.51), upper
limb motor function (S = -0.73) and work / productivity
(S = -0.69) and small effect for family roles (S = -0.47), lan-
guage (S = -0.23), humor (S = -0.34), personality (S = -0.31),
self-care (S = -0.48) and memory / concentration (S = -0.41).
Such analyzes point to a better effect of the protocol used in
the CIMTG in relation to the CG.
Discussion
In the present study, the evidenced motor deficits
related to the learned non-use characterize a functional
impact because when the injury occurs in the right hemi-
sphere, as in most volunteers, it causes damage to the
body image, neglect of the extracorporeal space and
injury and visuomotor impairment, with greater weight
unloading in the non-affected hemibody and impaired
postural alignment,14 considering that patients learn not
to use the compromised limb due to repeated failure in
the attempt of using it during the acute phase, triggering
an application and negative view of the use of the paretic
arm and stimulating the use of the unaffected limb
(dominant37,38,b;41).
However, the non-use learned may have been reduced
in the present study at CIMTG due to the fact that the pro-
tocol emphasizes mostly more dynamic activities than
6 L.S.O. ROCHA ET AL.
postural ones specifically, being worked on unilateral
reach and grips with an emphasis on postural alignment
as a way of learning the task once that the compromised
hemisphere was the right, despite the fact that they had
dominance on the right.
The injury time in the study that addresses the chronic
phase is due to the fact that in the acute or subacute stage,
depending on the intensity of the proposed therapy, there
may be a negative effect of the intervention, resulting in a
marked increase in neuronal injury, growth impairment
dendritic and axonal sprouting due to excitotoxicity
caused by increased use-dependent cortical activity. Fur-
thermore, intense exercise can influence the temporal
expression of the profile of various molecules involved in
synaptic plasticity, such as synapsin I, insulin growth fac-
tor type I, CREB transcriptional protein and brain-derived
neurotrophic factor (Brain Derived Neurotrophic Factor-
BDNF), responsible for brain remodeling and neuronal
survival after stroke, generating too much increase in hor-
monal stress by increasing corticosterone, which can
reduce the expression of these proteins, impairing synap-
tic plasticity,8,24 as well as effects of therapy in the acute
phase are confused with spontaneous changes that occur
in motor function and cortical organization.3
The results on muscle tone in this study showed that, at
the end of the intervention period, CIMT promoted a sig-
nificant reduction in tone compared to conventional phys-
iotherapy. These results found in relation to tone
reduction are in agreement with Siebers, Oberg € and
Skargren,27 who submitted chronic hemiparetics to CIMT
(6 hours daily, 5 days a week, for two weeks, with restric-
tion of the healthy limb 90% of the waking time) and eval-
uation of spasticity and functional use of the upper limb
affected by the modified Ashworth scale, mal and joint
range of motion (ROM). There was a reduction in spastic-
ity and an improvement in the ROM of elbow and wrist
extension. The authors suggested that this improvement
may be due to the specific training of CIMT tasks, which
involved exercises in strength, coordination and speed of
repetitive movements.
Thus, the control of spasticity in this study seems to be
the result of factors inherent to the chosen technique and
the protocol performed, since the proposed activities stim-
ulated the action of the extensor and abductor muscles of
the upper limb in order to inhibit the predominant flexor
and adductor pattern. With repetitive and intense stimu-
lation during the application of the CIMT, there seems to
have been activation of the physiological mechanism of
reciprocal inhibition, compromised by the injury, since
the proposed tasks had a movement pattern antagonistic
to that presented by the paretic upper limb, facilitating
the inhibition of muscle tone abnormal and facilitating
functional recovery.
Concomitant with the results of muscle tone in the pres-
ent study, the results of the functional reach test showed a
progressive increase in each of the groups during the
periods of analysis, however, the CIMTG had greater
interaction; a hypothesis that can justify is the repetition
of each task for 5 minutes associated with verbal feedback
in order to stimulate the correct performance of the move-
ments or self-correction, by perceiving the activities dur-
ing the service, preventing compensations, which resulted
in greater postural control with consequent improvement
of the motor function of the upper limb in the CIMTG,
while in the CG the time for each task was longer.
Although the functional reach test evaluates postural
control, it was used due to the influence of the trunk on
the grip, since the movement of the trunk ensures the
reach of the hand to the object as well as helps with the
grip, even when deficits are present, as the trunk has com-
pensatory action. The justification is based on the study
by Michaelsen et al.,20 who evaluated the hand, arm and
trunk movements of 19 chronic hemiparetic patients and
7 healthy individuals through kinematic analysis during
reaching and grasping a cylinder. They found that the
hemiparetics oriented the hand more frontal to grab and
used more displacement or anterior rotation of the trunk
to reach the hand on the target compared to healthy indi-
viduals, as well as the size of the grip opening, the tempo-
ral coordination between the manual reach and the
opening of the hand and the opening time for grasping
were mostly preserved.
Lin et al.18 justify this benefit of CIMT by the intense
practice of functional tasks, which stimulates propriocep-
tive information to develop internal models of movement
control. The feedforward mechanisms assist in the correc-
tion of movements, favoring the execution of tasks with
greater precision, as is necessary in the movements of
reaching and grasping objects. In this study, activities of
precision and dexterity during the CIMT protocol were
emphasized to encourage adjustments of movement cor-
rection by verbal feedback and self-perception in the repe-
tition of functional tasks, which promotes the inhibition of
learned non-use.
Considering the results found in the present study,
using CIMT protocol or conventional physical therapy,
both techniques contributed to the improvement of func-
tionality, however, the FMA scale showed that the
CIMTG showed a more notable recovery, probably due to
the repeated training of functional activities with progres-
sive increase in difficulty; the motor function of the upper
limb would have been favored by improved perception,
manipulation of objects and possible reduction in pain.
These results can be related to the protocols used in the
present study for both groups because despite the same
intervention time, the CIMTG was performed increasing
the levels of difficulty and the use of the transfer package
as recommended by the therapy and the CG continued
maintaining the proposal from the beginning to the end of
the service according to the study by Gaspar, Hotta and
Souza11. These authors proposed this protocol of conven-
tional physiotherapy compared to a protocol of mirror
CONSTRAINT INDUCED MOVEMENT THERAPY AFTER STROKE
therapy + conventional physiotherapy during 20 sessions
of 1 hour performed twice a week and observed that both
groups showed functional improvement.
The assessment of passive movement and pain, individ-
ually, by the FMA, showed more effective results with the
CIMT protocol, which can be explained by the training of
functional activities, such as picking up and taking a glass
and spoon to the mouth and even combing the hair,
which favor the combined movements of flexion, abduc-
tion at 90 °, lateral and medial rotation of the shoulder,
flexion and extension of the elbow, wrists and fingers and
supination and pronation of the forearm, which differs
from the conventional protocol, where functional training
did not emphasize abduction exercises and lateral shoul-
der rotation. In addition, such activities carried out at the
CIMTG are based on the CIMT shaping and task practice,
where there is a repetition of the task and a progressive
increase in the difficulty in carrying out the tasks,21 pro-
viding functional movement and reducing the staff pain.
Another relevant data that showed effectiveness of the
CIMT and conventional physical therapy protocols in the
present study was the improvement in the AMF sensitiv-
ity variable, however what could justify the superior
result of the CIMT in relation to the sensitivity would be
the training of the activities “cleaning the table with
sponge in circular movements” and “bounce the ball on
the floor” which provided proprioceptive stimulation and
contact with texture material in the paretic limb, since the
impairment of somesthetic sensation occurs in 37% of
patients with injuries of the right hemisphere33 and this
change can give rise to the learned non-use mechanism.30
Thus, in this study, the involvement of the right hemi-
sphere, in most volunteers, suggests a tendency of neglect,
which favors disuse. However, with the TCIM there was
an improvement in sensitivity, which reflected in the
improvement of the motor function of the paretic upper
limb.
In addition to improving sensitivity, the coordination/
speed variable also improved in the same period of analy-
sis, which can be justified by the fact that the proposed
activities promoted reaching and grasping objects with
greater dexterity due to sensory improvement and
sequenced repetition tasks. However, despite this
improvement being more noticeable in the CIMTG, the
CG showed an increase in the speed in carrying out func-
tional activities, identified by the greater number of news-
paper balls produced or the greater number of clothespins
placed on the rope during the performance of tasks dur-
ing of appointments within three minutes.
The results of sensitivity, pain and coordination/ speed
may have reflected directly on the responses of the motor
function of the upper limb of the FMA, given that in the
analysis between the groups there was an improvement
in the motor function variable, being more noticeable in
the CIMTG. Despite the improvement in both groups, the
CIMTG had its motor behavior changed from moderate
7
to light, which did not occur with the CG, which main-
tained its motor behavior throughout the intervention
process. Israely, Leisman and Carmeli13 mention that
with the improvement of spasticity the range of motion is
facilitated and that the pain is caused by the immobility of
the segment with spasticity. Therefore, it is considered
that as the activities proposed in the CIMTG promoted
improvement in spasticity, which allows greater ROM,
the inhibition of immobility in the affected segment may
have contributed to the improvement of pain.
Another discussion that may support these results of
the motor function of the upper limb is that after the
stroke there is a reduction in the dorsolateral descending
stimuli, modifying the activity of the distal muscles of the
upper limb, such as the flexors and extensors of the wrist
and, as a consequence, compensation of the shoulder and
elbow muscles occurs because the ventromedial descend-
ing pathways are intact and show greater activity. This
condition is verified clinically by the flexor and extensor
synergies through combined movements of the paretic
upper limb.7 However, in the present study, some activi-
ties were requested with combined movements in order
to develop a more selective movement and greater activ-
ity in the extremities.
The FMA scores in this study increased progressively
during the intervention with CIMT, which reaffirms the
effectiveness of the method and its role for a possible cor-
tical reorganization, as according to Gauthier et al.12 and
Mark, Taub and Morris (2006), CIMT promotes functional
changes in brain metabolism, blood flow and electrical
excitability, with consequent alteration of the structure
and function of the nervous system, as well as Di Filippo
et al.,8 stated that it can influence the reorganization of the
cortical representation maps, inducing a functional con-
nection of neurons that are in a quiescent state, that is,
pre-existing, functionally silent synapses around the
lesion are unmasked and these neuronal networks are
progressively activated. Such plastic changes, according
to Lima et al.,16 may be due to intensive and repeated
training of activities with progressive difficulty, which act
to inhibit learned non-use.
In this study, a direct assessment of neural plasticity
using brain imaging techniques was not performed. How-
ever, the functional results constitute a form of indirect
assessment of this process and show that both CIMT and
conventional physiotherapy apparently stimulated neural
plasticity in the study volunteers, with advantages for
CIMT.
In the present study, in relation to the results of the
evaluation of the total score of the SS-QOL scale, there
was a progressive improvement for each of the groups
analyzed between the times, and the CIMTG presented
better results than the CG in the 12th and 24th sessions,
the which reflects an improvement of 9.89% in the 12th
session and 16.34% in the 24th session for the CG and
21.73% and 31.58%, respectively, for the CIMTG. The size
8 L.S.O. ROCHA ET AL.
of the treatment effect reaffirms that in CIMTG the result
was better in all periods evaluated.
Although both protocols were efficient, it is suggested
that in CIMTG the use of shaping and the task practice
favored the learning of activities that were carried out
during one hour and that they were similar to the tasks
tested in the evaluation of the SS-QOL scale, as well as
stimulating the relearning of the combined movements in
the three planes, differently from what happened in the
CG, in which part of the therapy was aimed at stretching
and mobilization and, afterwards, the practice of func-
tional activities in less time.
Lima et al.,15 evaluated the quality of life of hemiparet-
ics who did not undergo any intervention. The study
pointed out that the stroke affects several dimensions of
QOL, being able to change personal and family relation-
ships and restrict the social participation of the affected
people. Similar results were found in the CG of this study
for the SS-QOL domains in the pre-treatment, where the
variables personality, MS function, vision and work /
productivity had similar scores in the 12th and 24th ses-
sions in relation to the pre-treatment period. In the
CIMTG, all domains showed a gradual improvement
between the periods evaluated, with the exception of
vision, which reaffirms the benefits of CIMT, since in the
pre-treatment the volunteers had lower scores, indicating
altered personal and family relationships due to injury.
In this study, in the pre-treatment period, scores for
mobility and motor function are reduced and it is
assumed that they are related to the reduction in serum
BDNF levels, common after stroke. BDNF plays an impor-
tant role in sensory and motor recovery, facilitating neu-
ronal interconnections and generating the process of
synaptic plasticity. Santos et al.26 state that BDNF levels
tend to be lower in chronic hemiparetic patients when
compared to healthy individuals and that these low con-
centrations impair functional and structural recovery.
Conclusion
Both protocols used in the study were effective, how-
ever, the CIMT protocol can be beneficial in recovering
the functionality of the paretic upper limb, in the func-
tional range and in reducing muscle tone, with a conse-
quent improvement in quality of life.
Declaration of Competing Interest
There is no conflict of interest regarding the manuscript
or the materials of this study.
Funding: This research did not receive any specific grant
from funding agencies in the public, commercial, or not-for-
profit sextos.
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