Therapists working in neurology have an approach which can change lives and is becoming increasingly popular.
Constraint Induced Movement Therapy (CIMT) is best known as a treatment intervention for people following stroke (1). Its use with people with conditions such as multiple sclerosis and incomplete spinal cord lesion is documented in only a handful of papers (2,3). These groups of patients may present with impairments in both arms, with one arm often more affected than the other, creating a particular challenge to recovery of upper limb function.
Will suffered an incomplete spinal cord injury following a pushbike accident. His experience is typical of many with bilateral arm involvement following neurological injury.
“The natural thing is to use your leading hand. My right hand has always been better than my left but the left hand keeps getting left out because I’m always using my right, more and more and more. There’s always been quite a big difference between the left and the right since my injury, but the gap’s getting bigger. I can’t close the gap”.
Will’s description perfectly illustrates the vicious cycle of learned non-use of a weaker arm that people with bilateral arm weakness often develop, and which can lead to further complications such as stiffness and pain in the weaker arm.
Will suggested he needed a ‘boot camp’ for his left arm to re-involve it in his day-to-day activities. The boot camp was in the guise of a 2 week CIMT programme. For 6 hours a day, Will trained his weaker arm through intensive exercise and task practice, and wore a mitt on his less affected right arm for 90% of the waking day for 2 weeks. His therapist visited three times a week for an hour to progress exercises and provide encouragement and positive reinforcement. The programme wasn’t easy.
“I could have quite easily given up and caught a bus into town on bad days but the schedule, the exercises – meant I had to stick to it” Will commented during the programme.
Will’s tenacity and the regime provided by CIMT, paid off.
“I feel like we’ve closed the gap” was Will’s summary following the programme on reflecting on his previous discrepancy in arm use.
Will has since begun a new career as a picture framer, something that had seemed impossible following his injury and the loss of his job as a precision engineer. CIMT arguably acted to reverse learned non-use of Will’s weaker arm, and his return to bimanual work has ensured retention of arm use on a long term basis.
Will’s story serves as an example of the potential benefits of CIMT for those with bilateral arm involvement and continued learned non-use, whatever the cause. CIMT programmes have now become more feasible with evidence suggesting that 3 hours of daily training can be as effective as 6 hours(4).
Annie Meharg MSc MCSP and Jill Kings MSc DipCOT have authored ‘How to Do Constraint-Induced Movement Therapy – a practical guide’, edited and published by Harrison Training, to provide an easy to read guide to getting started with CIMT in practice. An essential read for those therapists working in neurology, it can be purchased from the Harrison Training website www.harrisontraining.co.uk at a costs of £24.
- Wolf S, Winstein C, Miller P et al (2006). Effect of Constraint-Induced Movement Therapy on upper extremity function 3-9 months after stroke. The EXCITE randomised clinical trial. The Journal of the American Medicine Association 2961 (17) pp2095-2104.
- Kim Y-J Kim JK, and Park SO (2015) Effects of modified constraint-induced movement therapy and functional bimanual training on upper extremity function and daily activities in a patient with incomplete spinal cord injury: a case study – J Phys Ther Sci. Dec; 27(12): 3945–3946
- Mark VW, Taub E, Bashir K (2008) Constraint-Induced Movement therapy can improve hemiparetic progressive multiple sclerosis. Preliminary findings Mult SclerAugust 2008 14 no. 7992-994
- Lum PS, Taub E, Schwandt D et al (2004) Automated Constraint-Induced Therapy Extension (AutoCITE) for movement deficits after stroke. J Rehabil Res Dev May; 41 (3A): 249-58