CIMT: Constraint-induced movement therapy -- My research and our experience - Cerebral Palsy Message Board

09-26-2006, 09:17 AM

I posted this on another board in response to a question about using CIMT with children with CP, but thought I should post here, too, since it seems like a lot of parents come here for information about their children. I would welcome any questions/clarifications.

We did CIMT with our 2-year-old son with mild hemiparetic primarily hypotonic CP with good results.

09-26-2006, 09:19 AM

My research on CIMT:

Definition: “Constraint-induced movement therapy (CIMT) and forced use therapy refer to restraining the unaffected arm of people with hemiplegia to “force” the affected arm into use….[usually] accompanied by intensive therapy (massed practice) to facilitate function in the affected arm. The underlying rationale for CIMT is that ‘forcing’ use of the affected arm reverses the learned non-use of the limb.”

The effectiveness of CIMT, particularly when used for children with cerebral palsy, is under debate. Many studies have shown positive results, but there is criticism of the clinical rigor of the studies.

Like most therapies for CP, CIMT does not claim to cure the underlying physical problem. CIMT is really just an intensive period of training and habituation of using the more-affected limb by forcing disuse of the less-effected limb, under the basic theory that skill building and more “practice” will lead to better dexterity in the more-effected limb.

It is also thought to increase the child’s awareness of the more affected hand/arm. In my own experience with my son’s CIMT, I believe that it was not only the actual skill training that improved the dexterity in the more-affected hand and arm, but also even the very basic daily reinforcement for him of the IDEA that he can use his right arm to eat, throw a ball, turn a page, etc. was very beneficial.

The underlying neurological theory (as I understand it) is that constraint of the less-affected limb combined with intensive “training/practice” with the more-affected limb “rewires” the brain, rebuilding/strengthening the neural pathways relating to usage patterns in the more-affected limb.

A positive-bias overview (with an excellent, brief summary of the theory behind CIMT and the questions yet to be answered) from the CanChild Center for Childhood Disability Research:
[url]http://www.canchild.ca/Default.aspx?tabid=1374[/url]

A negative-bias overview from Aetna (insurance)’s clinical policy bulletin on CIMT, which it approves as “medically necessary” for (certain) stroke patients but not for children with cerebral palsy:
[url]http://www.aetna.com/cpb/data/CPBA0665.html[/url]

(Note: For more information about CIMT and the brain plasticity of adults, the website of Dr. Taub, the developer of CIMT, has a good overview of the research in that area as it relates to CIMT: [url]http://www.psy.uab.edu/taub.htm[/url].)

* CIMT is one of the major areas of current research by the (U.S.) United Cerebral Palsy Foundation.
[url]http://www.ucpresearch.org/activeresearch.htm[/url]

* CIMT is commonly accepted in traditional medical circles and by most insurance companies as a legitimate therapy for stroke victims to regain use of their more affected hand/arm.

09-26-2006, 09:20 AM

Permanent vs. removable restraints

As far as I know, there are two main kinds of CIMT for pediatric patients. In the kind used with my son, they cast the child's entire arm from shoulder to just past their fingertips (bent slightly at the elbow), in our case for 21 days. The other main method uses a temporary sling or other restraint that is removed when the child is not receiving direct therapy, or at night.

My (parental) concern with the latter method is my fear that after the child has had a few sessions with the sling, the next time the parent or therapist tries to put the sling on, the child would resist (especially a younger child to whom you can't really explain why you’re doing what you’re doing).

With my son, I was also worried that he would not like having the cast on, and knew it would break my heart if he cried in frustration, asking me to take it off. I was also very concerned because he could not walk independently, and crawling was his main means of mobility. Neither I nor his therapists knew whether or not he would be able to learn a way to crawl with the cast on during the therapy, and I knew it would be very frustrating for him if he couldn't. (It turned out not to phase him at all; he returned to crawling without a pause.)

The biggest benefit of the full-time full casting vs. a removable cast or sling, in my opinion, is that the child is naturally forced to use their more affected arm for daily tasks, from playing to feeding. My layman/parent's opinion is that this is a better method for young children than a removable splint or cast, since the cast becomes not something that is "forced" on the child by the parent or therapist again and again, but just becomes a given that the child has to deal with. Since it can't be taken off, it's not a negotiation or an option when it gets frustrating. Of course, older children in particular might complain about it, but just as if you would if you’d broken your arm, if you have a cast on your "good" arm and need to brush your teeth, you "have to" use the more affected arm.

(As a side note, what they did at the center, and I'm sure is common, is they put on a regular cast, then using a method to protect the child's arm, they cut one long path through the cast and remove it all the way. Then they put it back on and wrap it with 2-3 inch-wide medical tape, which, although I can't explain it properly, makes the wrapping and cast seem "permanent," however, they did tell us that if there was any problem or if he seemed very distressed about it, we could easily have removed it ourselves.)

Perhaps not every child will adjust as well as mine did to having the cast on, but once it's there as a (semi-)permanent condition, I believe it's easier for the child to accept its presence.

09-26-2006, 09:26 AM

My son was exactly 2 years old when he did CIMT. His left arm does not seem to have any clinical impairment, while his right arm is hypotonic (has low tone).

I started to notice just after his first birthday that he greatly preferred to use his left hand over his right hand. Asymmetrical hand/arm movements and fisting had been observed by a pediatric neurologist when he was only a few months old.

Before the CIMT, He COULD use his right hand, it was just less efficient for him. He would try to do something with his right hand (eat, throw a ball, turn a dial, etc.), and when it wasn't easy for him, he would transfer the item to his left and and find it much more efficient.

Therefore, he was getting himself stuck in a cycle; the right arm and hand were more affected by his CP, so it was "mechanically" less efficient to begin with; learning this, he chose to do almost everything with his less-affected hand.

This increase in usage of his left hand increased the efficiency of the that hand, while the lack of usage of the more-effected hand lead to a lack of skill gains in that hand. Particularly since he is only 2 years old, this is normally a time period of constant testing, experimenting, learning and improvements in hand dexterity, so the gap in dexterity between his left and right hands was growing and it seemed like it would only continue to increase over time.

My personal estimate was that he was using his left hand 90% of the time vs. 10% for his right hand, even though we were making a conscious effort to encourage the use of his right hand. He had gotten to the point where if he were sitting with an open box on his right side, and I stood on his right side and handed him a block so that he had to reach for it with his right hand, he would take the block in his right hand, and instead of putting it in the box just a few inches away from that hand, he would transfer it to his left hand, put his right hand on the floor, and twist his body around, crossing his left hand over his body to put the block in the box with his left hand.

When I was considering this therapy, I was concerned that he might react negatively to having the cast on, which made me question whether or not the negatives would outweigh the positives for him. The thought that convinced me to go ahead with the therapy was that, considered separately from the possible benefits that he could receive, if he had actually broken his arm, of course I wouldn't have questioned putting his arm in a cast for however long the doctors told me to.

We took him to the Oregon Health Science University's Child Development and Rehabilitation Center at Doernbecher Hospital in Portland, Oregon, where they are doing a CIMT study. ([url]http://www.ohsu.edu/cdrc/clinical/portland/cimt/[/url])

We did was a pre-evaluation, 3 weeks of the CIMT including 2 PT and 2 OT sessions/week (1 hour each) and 2 hours of home therapy ("easy" things like playing with Play-Doh, Duplos, etc., spread throughout the day), then a final evaluation.

My son passed the pre-evaluation with flying colors, frustratingly for me (because it didn't reflect his daily habits); instead of transferring everything to his left hand and being less efficient with his right, he worked with everything they gave him in his right hand and even managed to build a 4 or 5 block tower with just his right hand! (They did notice a clinical difference; I was just frustrated because he didn’t replicate the behaviors I saw on a daily basis). However, since they knew his medical history (including his CT scans and MRI), diagnosis, and my descriptions of his daily usage, they let us proceed.

He didn't like the actual casting process, naturally (the setting of the cast, which required him to sit still while they wet-bandaged his arm and it dried), but he surprised me with how quickly he seemed to accept and forget the fact that his arm was suddenly in a cast. Immediately following his casting, when we got home, I had to put him down on the floor for a minute to get him a drink. I was very nervous about the fuss I was sure would start when he tried to crawl and discovered that his arm in the cast made it harder (or even impossible). It didn't even phase him for a second, however. He just crawled around as though nothing had changed. Didn't even pause for a second.

He never seemed bothered by his cast, and never complained about it or asked to have it removed. Coincidentally, it was the exact shade of red as his favorite Teletubbies character, Po, so we played up that connection quite a bit, which he liked.

The resulting improvement in my son's usage of his right arm and hand was dramatic once the cast was removed. During the time the cast had been on, he had learned to feed himself with his right hand, to throw a ball, manipulate objects, twist a dial, etc.

For the first several weeks following the therapy, his arm usage was at least 50/50. (I wish I had made a better observation, but we were just thrilled to see how well he was using his right arm).

It has now been 4.5 months since his CIMT, and while the gap in dexterity between his left and right hands is much smaller than it was before the therapy, it has definitely widened since the end of the therapy.

Since the therapy, we have tried to balance:
* Allowing him natural opportunities to choose which hand to use, particularly in play,
* Encouraging the use of his right hand/arm, and
* Encouraging bilateral hand movements.

It’s hard for me, now, to put a percentage use on his hand preference. He chooses to draw and throw a ball with his left hand 90% of the time, but will use both hands in independent play, and will often finish eating a meal with the spoon in his right hand (as we’ve given it to him). He does automatically use his left arm whenever he senses that a task is going to be difficult.

One of the issues I’m investigating more now and will bring up at our next visit is the issue of natural hand preference. Prior to the CIMT, there were clinically observed effects of his CP on his right hand and arm from several months of age (corroborated by CT and MRI scans), but it’s also possible that in addition, he’s just meant to be left-handed anyway! So we need to be careful not to over-correct.

Overall, our experience has been positive, and I would make the same decision. I do need to follow up with his developmental pediatrician and his therapists about his current situation, however, I think that the CIMT dramatically improved the dexterity and frequency of use of his more-affected hand and arm. Some of the increase in the gap in dexterity between his hands may also be due to the fact that at his age, the typical development of his left hand would include rapidly increasing dexterity, so it makes sense that his right hand would be "falling behind" again in the newer skills, and that he's learning again that it's less efficient.

A final note:

Since my insurance does not cover CIMT for use with children with cerebral palsy, the therapists were happy to bill it as "regular" PT and OT sessions (which they were, for his right hand!). The riskiest part of CIMT in terms of getting it covered by insurance is the pre- and post-evaluations by PT and OT. If we'd participated in the actual study, my son would have had 3 evaluations each by PT and OT within a 3-month period, which the insurance company might have questioned.

From my layman's perspective, if a family could not participate in a rigorous CIMT protocol, they could still replicate much of the therapy in conjunction with their regular therapists.