This Constraint Induced Movement Therapy edition of Brain Injury Professional was guest edited by Dr. Joan Carney and Teressa Garcia Reidy. Joan Carney, EdD, is the Assistant Vice President of Clinical Programs at the Kennedy Krieger Institute and an Assistant Professor, Physical Medicine and Rehabilitation at the Johns Hopkins University School of Medicine. Teressa Garcia Reidy, MS, OTR/L is a Senior Occupational Therapist in the Specialized Transition Program at Kennedy Krieger Institute.
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Message from Guest Editors:
A patient who was told she would never use her hand in a meaningful way opened a zip top bag with two hands and ate a snack by herself. How would that make you feel as her therapist? As her caregiver? Constraint Induced movement therapy has given this family the gift of independence and the patient the gift of self-efficacy. We thank the editors in chief for inviting us to share our experiences and insights from working in this area of clinical practice for more than 15 years. We were pleased to invite many of our colleagues who have contributed to the evolution of this treatment for patients with strokes, traumatic brain injury and cerebral palsy.
The primary features of Constraint Induced Movement Therapy (CIMT) involve high intensity focused use of the affected upper extremity with progressively more challenging tasks and some type of constraint to restrict use of the dominant extremity. With CIMT many families and patients are for the first time finding a treatment that focuses not on compensatory techniques to cope with disability but true remediation of upper extremity deficits. As rehabilitation professionals treating patients with a variety of etiology for their upper extremity motor impairments, constraint provides an option to maximize the movement available. It also uncovers strategies to use two hands in a functional, common sense way that can be life altering for those with hemiplegia. Our CIMT program at Kennedy Krieger Institute has been in existence since 2004 as a part of our intensive day neuro-rehabilitation program. It has evolved with the ever-increasing body of literature on this topic. Trialing this intervention, that had case study level evidence at the time, was innovative and experimental. What started as a few test patients evolved and blossomed to a continual stream of children receiving intensive, evidence-based intervention with a focus on gaining function and bimanual coordination. Our team committed to staying current with the literature and adapted the newly established clinical protocol as new evidence became available.
Rapidly, that promising case level evidence materialized into RCTs and multi-site RCTS. Something that, in the rehabilitation world, was exciting and rare. Pioneers Deluca, Ramey and Wolf describe this evolution in detail in the feature article. Blending the art and science of rehabilitation with protocol-based intervention was a welcome challenge. For one of the first times in many of our therapists’ careers there was a shift to a manualized, protocol driven treatment for hemiplegia. CIMT had its beginnings in the treatment of adult stroke but, as we are reminded in the article describing stroke across the lifespan, children are at risk too. In fact, perinatal stroke is one of the most common causes of cerebral palsy. Readers of this issue will find examples of the use of CIMT with both adult and pediatric populations who have experienced stroke or other neurological insult or injuries resulting in hemiplegia.
Whether an adult or a pediatric client, Naber and Andrejow offer considerations that can guide decision-making when planning to incorporate CIMT in a plan of care. Beyond the decisions regarding dosage, setting, and choice of constraint, patient goals and priorities figure prominently. Readers will likely find the decision tree offered a useful tool. For the youngest patients, Tanner and colleagues describe their clinical coaching model and report creating and delivering a protocol requires constant reflection, program evaluation and improvement plans to ensure best practice. The advent of more widespread use of telehealth has had appropriate application in CIMT. As Gauthier and colleagues inform, motor-practice self-managed at home with gaming can be both more engaging and allow the therapist to focus on behavioral intervention to reinforce habitual use of the paretic upper extremity. Trapp reviews other applicable technologies such as considering robotic-assisted CIMT. Although, as new technologies they are being welcomed into clinics providing intensive rehabilitation models, interventions with robotic assistance present concerns both in availability and evidence to support the efficacy of their use.
CIMT has a fairly long history in the United States and research is continuing to refine the evidence to guide its use. Still, many clinicians have not been formally trained in its use and some remain hesitant. Coker-Bolt and DeLuca present a framework of how to build capacity in low and middle resource countries such as Vietnam and Ethiopia. Their work demonstrated a model to improve the quality of rehabilitation to children with disabilities and their families across international boundaries.
What do patients and their caregivers think about their experience with CIMT? Interviews with participants give the readers of this issue a unique perspective of the benefits and challenges that come along with being the recipient of CIMT. The interviewees give their unabridged advice. These interviews give great insight to any clinician considering CIMT in their practice. We hope you find this issue both informative about the evolution of this evidence-based intervention and that it provides practical direction for your clinical practice.
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Table of Contents:
- How Constraint-Induced Movement Therapy Changed Rehabilitation and the Science that Guided It – Stephanie C. DeLuca, PhD, Sharon Landesman Ramey, PhD, Steven L. Wolf, PT, PhD, FAPTA
- A Brief Introduction to Stroke across the Lifespan – Danielle Ploetz, PhD, ABPP, Kelly Jones, PhD, ABPP
- Functional and Clinical Considerations of Intensive Upper Extremity Therapy Models – Erin Naber, PT, DPT, Nicole Whiston Andrejow, MS, OTR/L
- Constraint-Induced Movement Therapy via Telehealth Builds Client Autonomy – Lynne V. Gauthier, PhD, Rachel Proffitt, OTD, OTR/L, Alexandra Borstad, PT, PhD, Kristina M. Kelly, PT, DPT, EdM
- Robotic Assisted Constraint Induced Movement Therapy – Stephen K. Trapp
- Successful Implementation of Pediatric CIMT in International Settings – Patty Coker-Bolt PhD, Stephanie C. DeLuca, PhD
- Designing and Implementing an Evidence-Informed CIMT Program for Infants Using Principles – Sara O’Rourke, MOT, OTR/L, BCP, Nancy Batterson, OT/L, SCFES, CLC, Kelly Tanner, PhD, OTR/L, BCP
- Group Based Protocols in Constraint Induced Movement Therapy – Nicole Whiston Andrejow, MS, OTR/L, Erin Naber PT, DPT