Constraint-Induced Movement Therapy for Restoration of Upper-Limb Function: Introduction







Grade 2 (mild to moderate limitation)

MAL < 2.5 for AS and HW scale

Flexion and abduction ≥ 45°

Extension ≥ 20° from a 90° flexed starting position

Extension ≥ 20° from a flexed starting position

Extension of all MCP and IP (either PIP or DIP) joints ≥ 10° from a flexed starting position; may be assessed by attempting to pick up and drop the tennis ball

Extension or abduction of thumb ≥ 10° from a flexed starting position

Grade 3 (moderate limitation)

MAL < 2.5 for AS and HW scale

Flexion and abduction ≥ 45°

Extension ≥ 20° from a 90° flexed starting position

Extension ≥ 10° from a flexed starting position

Extension of MCP and IP (either PIP or DIP) joints of at least two fingers ≥ 10° from a flexed starting position; may be assessed by attempting to pick up and drop a washcloth

Extension or abduction of thumb ≥ 10° from a flexed starting position

Grade 4 (moderately severe limitation)

G4/5 MAL < 2.5 for AS and HW scale

Flexion and Abduction ≥ 45°

Extension ≥ 20° from a 90° flexed starting position

Extension ≥ 10° from a flexed starting position

Extension of at least two fingers > 0° and < 10° from a flexed starting position; may be assessed by attempting to pick up and drop a washcloth

Extension or abduction of thumb ≥ 10° from a flexed starting position

Grade 5 (severe limitation)

G4/5 MAL &lt; 2.5 for AS and HW scale
Subclass A
Flexion, abduction, or scaption ≥ 30°

Initiation of extension and flexion at the elbow

Must be able to either initiate extension of the wrist or initiate extension of any digit

Subclass B
Flexion, abduction, or scaption ≥ 30°

Extension ≥ 20° from a 90° flexed starting position

No active movement required for the wrist, fingers, or thumb

For classification in this system, individuals with hemiparesis are assessed by the therapist to determine the amount of AROM at each joint of the more-affected UE. Each joint movement must meet minimal AROM requirements and be performed three times in a minute in order to meet the criteria for a specific grade. Classification of UE movement of an individual also depends on deficit of use of the more-affected UE as determined by the MAL or G4/5 MAL mean score. Individuals that meet the criteria for grade 2 movement, but score higher than a 2.5 mean on the MAL, would be determined to have grade 1 UE movement. Individuals who are unable to meet the minimal movement requirements for either subclass of grade 5 movement would be classified as grade 6

The original CIMT protocol has also been modified and extended to individuals with TBI (Shaw et al. 2005); multiple sclerosis (Mark et al. 2008); focal hand dystonia (Candia et al. 1999); lower extremity paresis following stroke, spinal cord injury , and multiple sclerosis (Taub et al. 1999; Mark et al. 2013); aphasia (CIAT and CIAT II; Johnson et al. 2013; Pulvermüller et al. 2001; Taub 2002); or cerebral palsy (pediatric CIMT;Taub et al. 2004, 2007, 2011).

In addition to the UE AROM criteria, selection of research participants has taken into consideration postural balance, cognitive integrity, presence of pain that might interfere with administration of the therapy, and illness chronicity, to ensure homogeneous populations. However, in clinical practice, greater flexibility may be appropriate to treat clients with learned nonuse (Mark and Taub 2004).

Stroke chronicity of > 1 year was used for most research studies, but preliminary evidence suggests that clients in the acute to subacute phases may also benefit (Nij-land et al. 2011; Wolf et al. 2006)

The use of the AROM criteria assists the therapist with selecting the appropriate CIMT protocol. Clients with mild or moderate UE paresis are usually treated for 3.5 h/day for 10 consecutive weekdays, while clients with more severe UEs paresis are usually treated 3.5 h/day for 15 consecutive weekdays (Mark and Taub 2004).


The prevalence of stroke-associated disability in the general population has been reported to range from 173 to 200 per 100,000 (SASPI Project Team 2004), while the estimated proportion of stroke survivors who are dependent in their activities of daily living (ADL) ranges from 30 to 50 % (Carroll 1962; Gresham et al. 1975).

Seventy percent of chronic stroke survivors are estimated to have motor deficit (Anderson et al. 2004). Studies have not yet determined what proportion of adult stroke clients with an acute hemiparesis in a subacute or chronic stage will meet inclusion criteria for CIMT.

In a prospective study, 41 out of 87 people suffering from a stroke had moderate-to-severe hemiparesis in the acute phase of recovery (Prabhakaran et al. 2008). The great majority of these 41 clients (83 %) recovered to at least 70 % of the maximum motor gain possible by 3 months after stroke onset. Another longitudinal study found that of stroke patients presenting with acute hand impairment, 65 % remained impaired by 18 months poststroke onset, including 43 % with at least mild–moderate difficulty (Welmer et al. 2008). Together, these findings suggest that an appreciable number of acutely hemiparetic stroke clients eventually regain substantial movement ability that would appear adequate for training tasks. However, further research is needed to determine what proportion of stroke patients in the subacute or chronic stage have persistent learned nonuse and motor deficits of the paretic UE, and therefore would be recommended to undergo CIMT.

Individuals with diagnoses other than stroke , such as TBI , cerebral palsy , and multiple sclerosis , who meet the AROM criteria, may also be appropriate for CIMT.


Research, to date, indicates that CIMT is well suited for implementation among outpatient and in-home health settings. Studies have suggested that CIMT in an acute inpatient rehabilitation setting may be efficacious (Nijland et al. 2011).

The Role of the Occupational Therapist

CIMT may be conducted by an occupational therapist (OT) or a physiotherapist (PT). The role of the therapist in CIMT is to ensure the integrity of the standard intervention while focusing on the unique needs and goals of each client. The OT may be required to adopt a variety of roles, including evaluator, tester, trainer, coach, problem solver, and encourager. Therapists must employ therapeutic skills in observation, listening, problem solving, behavioral management, task analysis , strategy development, safety awareness, and risk assessment, especially with regard to appropriate mitt use. Splinting, adaptive equipment selection, adaptive strategy development, and other interventions are also employed with clients during CIMT.

In the clinical application of CIMT for clients with different grades of motor deficit severity, it is imperative to replicate the procedures that were used in the research protocols for that grade of motor deficit. Employing a treatment protocol, designed for a patient with grade 2 or mild–moderate deficit, with a client who does not meet the minimal movement requirements for the grade 2 protocol, may lead to poor results as well as frustration on the part of both the therapist and the clients. Therapists also need to recognize the importance of close adherence to all four of the components of the CIMT protocols in order to achieve the best results with clients as measured by the Motor Activity Log (MAL; Uswatte et al. 2006b). If the MAL is not selected by the treating therapist, as at least one of their outcome measures for CIMT, then the therapist must realize that the central construct addressed in CIMT consisting of real-world use of the more-affected UE is not being determined. CIMT protocols always need to have a measure of real-world use, as an outcome measure like the MAL; otherwise, measurement of the outcome of this behavioral approach to rehabilitation of the more-affected arm will not assess the most important aspect of its treatment effect.

It should be noted that many procedures in CIMT are not typically employed in conventional rehabilitation. In our experience, therapists have often voiced their unfamiliarity with the types of procedures utilized in CIMT, particularly with the techniques of the transfer package. It is important that therapists who plan to implement CIMT should first be adequately trained.

At the University of Alabama at Birmingham, CIMT training consists of a semiannual 5-day continuing education course that includes 2 days of a hands-on lab practicum accompanied by a feedback on performance of procedures to ensure proper administration of the CIMT treatment.


Clinical Application

CIMT consists of four main components:

  • Repetitive, functionally relevant, and task-oriented training of the more-impaired limb.

  • Training by the behavioral technique termed shaping.

  • Employment of a set of behavioral techniques known as the transfer package that are designed to facilitate carryover of gains made in the research laboratory or clinic to the generalized life situation.

  • Procedures to constrain use of the more-affected extremity, including physical restraint of the less-affected arm (Taub et al. 1993; Uswatte et al. 2006a, Fig. 40.1).


    Fig. 40.1
    An example of administering two of the four components of CIMT known as shaping with a client who had suffered from a stroke. The mitt on the less-affected hand reminds the client to use only the more-affected hand for each task and greatly reduces the ability to use that extremity

Shaping (Taub et al. 1993, 1994), one of the primary training technique employed, is a systematic behavioral procedure whereby progress is achieved in small steps by successive approximations throughout multiple trials that use frequent detailed feedback and encouragement. With adults, the shaping process is usually broken up into blocks of ten trials each, and the repetitions of the task are timed or the number of repetitions completed in a set timed period (e.g., 30 s). The data from each trial are recorded and reported immediately to the client. Progression of the shaping task requires consistent improvement in the previous performance.

The transfer package (Taub et al. 2006a, 2013) utilizes selected behavioral techniques: home diary, behavioral contract, home skill assignment, daily administration of the MAL (Uswatte et al. 2006b), problem solving, and maintenance of a daily schedule. In the transfer package, protocol adherence is bolstered by maximizing client accountability, engaging the client in problem solving, and prompting the client to use the more-affected limb during occupational performance. The transfer package makes compliance with the CIMT protocol the responsibility of the client; therefore, the functional achievements are his own.

A signature feature of CIMT protocols is the use of a padded safety mitt on the less-affected hand as a physical restraint. The mitt is worn for a target of 90 % of waking hours during the therapy period and is removed during personal hygiene and where safety might be compromised through its use. Mitt use is only one way of constraining the adult client’s behavior to increase the use of the more-affected UE and is not the most important feature (Uswatte et al. 2006a). Recent research findings in this laboratory indicate that in randomized controlled trials, the more significant component in adult CIMT is the use of the transfer package. (Gauthier et al. 2008; Taub et al. 2013) The largest gains in use of the more-affected UE in the life situation and in structural brain change were found when participants received all of the components of the CIMT including the transfer package (Fig. 40.2).

May 21, 2017 | Posted by in GENERAL | Comments Off on Constraint-Induced Movement Therapy for Restoration of Upper-Limb Function: Introduction
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