CNS damage patients regain the use of affected limbs by forcing the patient to use the affected limb by restraining the unaffected one. The affected limb is then used intensively and as a result of the patient engaging in repetitive exercises with the affected limb, the brain grows new neural pathways and movement and function in the affected limb is proved. CLINICAL USES
CIMT has been used in
-Stroke -TBI -Cerebral palsy -Focal hand dytonia BASIS FOR CIMT
Two different but linked mechanisms are
considered to be responsible for increased use of the more affected extremities as a result of CIMT. 1. Overcoming learned non use or developmental disregard 2. Inducing use dependent cortical re- organisation. How it works
The treatment is thought to work because it
overcomes a strong tendency not to use the weaker arm(learned non-use) that develops early after stroke. CIMT produces a large “rewiring” of the brain, that is , after treatment more of the brain works to move the weaker arm than before the therapy. Cortical re-organisation
After CIMT, area surrounding the infract
(usually not used for hand control) get recruited. These are synapses in the brain that are previously not used for a particular function, but have the potential for activation after the usually dominant system has failed. Such neurons get utilized and , by repetition and practice, can be set into constant use. 1. Overcoming learned nonuse or developmental disregard
CIMT is based on two fundamental principles-
(a) The constraint of the non affected limb
(b) Mass practice of activities with the affected limb
Forced use of the affected limb through CIMT program,
removes the need for persistent prompting and may be a more effective way of improving the outcome. CIMT attempts to change the contigencies of behavioural reinforcement so that the learned non use or developmental disregard of the more affected limb is conditioned or lifted. Despite the conceptual difference in behavioural adaptation (learned non use vs developmental disregard) as a result of an acquired condition (stroke) compared with the congenital condition(CP), the components of CIMT program including restraint and mass practice, aim to reverse the behavioural suppress of movements in the affected limb. The consequent increase in the use of the more affected limb induces expansion of the contralateral cortical area controlling movement of the more affected limb and recruit new ipsilateral areas. This is proposed as the neural basis for the permanent increase in use of affected limb following CIMT. 2. Inducing use of dependent cortical re-organisation
CIMT improves motor function in the affected
extremity of patients with hemiplegia and results in cortical changes in adults with stroke. One of the mechanisms associated with improved motor ability through CIMT is NEURO PLASTICITY. CIMT produces functional changes in brain meatbolism, blood flow and electric excitability. These changes demonstrate that plastic changes of the motor network occur as a neural basis of the improvement subsequent to CIMT following brain injury. TYPES OF RESTRAINT
1. Holding a child’s arm
2. Glove or mitt 3. Forearm splints 4. Slings 5. Short arm casts 6. Long arm casts COMPONENTS OF RETRAINING PROGRAM
Classic constraint induced training defines two
types of training:
(a) Shaping or adaptive task practice
(b) Standard task practice (a) Shaping or adaptive task practice
It derives its name from behavioural training technique.
It is a form of operant conditioning in which the probabilities of individual determined behaviours are elicited through reinforcement(reward or punishment). Learner is passive in the process while performance is progressively shaped as the behavioural objective (task goal) is approached in small steps through reinforcement or reward(positive feedback). Using this approach a motor objective(task goal) is approached in small steps by successive approximations (part of the task), the task is made more difficult in accordance with motor capability or the speed of the performance is progressively increased. Typically each functional activity or its part is practised for a set of 10trials and explicit feedback is provided regarding the participants performance with each trial. Shaping involved presenting intresting and useful activities to the patient in ways that provide immediate, frequent and repetitive rewards(primarily verbal praise, smiles and supportive gestures) for the patients efforts and increasingly functional use of the impaired extremity. Tasks such as reaching, grasping, holding, manipulating an object, bearing weight on the arm and making hand gestures are derived into their small component skills are worked on individually and later chained together to comprise a target activity. When the patient demonstrates a new movement skill, the therapist proceeds to shape this by increasing the demands for more precision, strength, fluency, automaticity and functional versatality. The therapist also incorporates everyday tasks(dressing, eating, bathing and grooming) in the therapy sessions. Shaping tasks are selected by considering- Family and patients goal Intrinsic motivating properties of an activity. Promotion of independence by acquisition of appropriate self help skills. The movement that therapist believe has the greatest potential for improvements. When patents show signs of fatigue, frustration or reduced interest, the therapist adopts the activities but does not cease the therapy.Rest interval should be given as needed. Intensive training is by far the more important component of treatment procedure. (b) Standard task practice- It is less structured than shaping procedures. tasks are not set up to be carried out as individuals trials of discrete movements. They involve functionally based activities performed continuously fro a period of 15-20 minutes (setting the table, wrapping a present).
Progression- in successive periods of task practice, the spatial
requirements of the activity or other parameters(such as duration)can be changed to require more demanding control of the limb segments for task completion. Feedback about overall performance is provided at the end of –min period.
Efficacy of Different Approaches On Quality of Upper Extremity Function, Dexterity and Grip Strength in Hemiplegic Children: A Randomized Controlled Study