Efficacy of Constraint-Induced Movement Therapy in Early Stroke Rehabilitation

The reason you don't do early CIMT is that there is no way to posit whether spontaneous recovery caused the changes or CIMT. Thus this research is practically useless.
http://nnr.sagepub.com/content/29/6/517.full

A Randomized Controlled Multisite Trial

1. Gyrd Thrane, MSc1,2
2. Torunn Askim, PhD3,4
3. Roland Stock, MSc5
4. Bent Indredavik, MD, PhD5
5. Ragna Gjone, MSc6
6. Anne Erichsen, MSc7
7. Audny Anke, MD, PhD1,2

1. ¹UiT The Arctic University of Norway, Tromsø, Norway
2. ²University Hospital of North Norway, Tromsø, Norway
3. ³Norwegian University of Science and Technology, Trondheim, Norway
4. ⁴Sør-Trøndelag University College, Trondheim, Norway
5. ⁵Trondheim University Hospital, Norway
6. ⁶Vestfold Hospital Trust, Norway
7. ⁷Oslo University Hospital, Norway

1. Gyrd Thrane, MSc, Department of Health and Care Sciences, University of Tromsø, Faculty of Health Sciences, NO-9037 Tromsø, Norway. Email: gyrd.thrane@uit.no

 

Next Section

Abstract

Background. There is limited evidence for the effects of constraint-induced movement therapy (CIMT) in the early stages of stroke recovery.  

Objective. To evaluate the effect of a modified CIMT within 4 weeks poststroke.  

Methods. This single-blinded randomized multisite trial investigated the effects of CIMT in 47 individuals who had experienced a stroke in the preceding 26 days. Patients were allocated to a CIMT or a usual care (control) group. The CIMT program was 3 h/d over 10 consecutive working days, with mitt use on the unaffected arm for up to 90% of waking hours. The follow-up time was 6 months. The primary outcome was the Wolf Motor Function test (WMFT) score. Secondary outcomes were the Fugl-Meyer upper-extremity motor score, Nine-Hole Peg test (NHPT) score, the arm use ratio, and the Stroke Impact Scale. Analyses of covariance with adjustment for baseline values were used to assess differences between the groups. Results. After treatment, the mean timed WMFT score was significantly better in the CIMT group compared with the control group. Moreover, posttreatment dexterity, as tested with the NHPT, was significantly better in the CIMT group, whereas the other test results were similar in both the groups. At the 6-month follow-up, the 2 groups showed no significant difference in arm impairment, function, or use in daily activities.  

Conclusions. Despite a favorable effect of CIMT on timed movement measures immediately after treatment, significant effects were not found after 6 months.

Introduction

Constraint-induced movement therapy (CIMT) is designed to improve upper-extremity motor function after stroke and consists of 3 key components: (1) repetitive, task-oriented training; (2) adherence-enhancing behavioral strategies (transfer package); and (3) constraining the use of the less-affected arm, usually by wearing a mitt.^1,2 The original protocol was developed for patients with chronic stroke and included 10 days of therapy for 6 h/d and constraining the less-affected arm during 90% of the time awake.³

There is a critical window for neuroplasticity and ability to relearn impaired activities within the first weeks after stroke.^4,5 Modified forms of CIMT have already been tested in the early stages of stroke rehabilitation (<10 weeks).⁵ In 2000, Dromerick et al⁶ published the results from a small-scale trial of 23 patients and reported that a 2-hour/10-day CIMT program was associated with less arm impairment at the end of treatment. Another study of 23 patients by Boake et al⁷ reported trends favoring a 3-hour/10-day CIMT program over standard therapy of equal duration. However, their only significant finding was improved Fugl-Meyer assessment scores immediately after treatment; no long-term effects were found. In the VECTORS study,⁸ 3 groups of stroke patients received 10 days of treatment within 4 weeks after stroke. The low-intensity CIMT group (2 h/d, 6-hour constraint) had significantly better improvement in the Action Research Arm test (ARAT), whereas the high-intensity CIMT group (3 h/d, 90% constraint) scored significantly worse than the control group. Yet another modification of CIMT was reported by Page et al,⁹ who reported increased use of the affected arm and improved motor impairment after 0.5 hours of training, 3 d/wk for 10 weeks of CIMT in a sample of 10 patients. In summary, the existing evidence on the effect of CIMT in the early stages of rehabilitation is limited to 5 trials that included 64 CIMT patients and 41 controls.¹⁰ These 5 trials included at least 3 different protocols and reported wide confidence intervals and large variations in treatment effects. Of particular concern are the negative results of the VECTORS trial.⁸ Because of the limited data and diversity of the results between previous trials, the effect of CIMT in the early stroke rehabilitation is still uncertain.

The aim of the present study was to assess the effect of a modified CIMT protocol in the early phase of rehabilitation after stroke. The primary hypothesis was that patients who completed a modified CIMT protocol in the early phase after stroke would have better arm motor function measured with the Wolf Motor Function test (WMFT) 6 months after the intervention compared with patients who received the usual care. The secondary aims were to evaluate the effect of CIMT on arm motor impairment, dexterity, arm use in daily activities, and overall health status after stroke. 

More at link.