Ashan Weerakkody first wrote this blog post on behalf of the Australian Physiotherapy Association (APA) National Neurology Group, and it was published on the Stroke Foundation EnableMe platform.
Stroke can cause weakness, a loss of sensation, an increase in muscle tone (spasticity) or even affect your awareness of your arm (neglect/inattention). All of which can impair your ability to use your arm in daily tasks. This can make you more reliant on using your less-affected arm, which can hinder recovery of your stroke-affected arm.
The Stroke
L Foundation provides a strong recommendation for constraint-induced movement therapy (CIMT) to be provided to stroke survivors who have difficulty using their arm [1]. CIMT is the only arm therapy to receive this strong recommendation. This is based on numerous research studies that have shown CIMT is effective at improving arm use after stroke, and it’s important for stroke survivors to be offered this therapy if it’s appropriate for them.
What is CIMT?
CIMT is a program designed to motivate and encourage stroke survivors to use their stroke-affected arm more in their daily life [2]. Increasing the use of this arm in a range of activities can facilitate changes in the brain, known as neuroplasticity.
Generally CIMT programs go for 2 weeks, but some can go longer depending on the individual. There are 3 main components of the CIMT program:
a set of behavioural strategies to increase motivation to use the more-affected arm outside of scheduled therapy, known as the Transfer Package
intensive practice using the more-affected arm in specific and functional tasks, up to several hours a day
use of a restraint (such as a mitt) for defined periods of time, to prevent the less-affected arm from being used
The Transfer Package is a very important part of the overall CIMT program has a few components to it to:
A Behavioural Contract- which is an agreement you make to use your more-affected arm in particular tasks
Daily homework, which is logged using a diary and checked regularly by your physiotherapist or occupational therapist (to keep you accountable in your rehab)
Repeated use of the Motor Activity Log- this is a questionnaire that asks you how much and how well you think you use your arm for certain tasks
Support and problem solving with your therapist
The original CIMT program involved wearing a restraint or mitt for 90% of a person’s waking hours and training their affected arm for 6 hours a day. This is quite demanding for patients but it’s also really hard for physiotherapists and occupational therapists to provide in usual rehabilitation services.
Over the last 15 years, modified programs of CIMT (mCIMT) have been developed which are more feasible to adopt in the clinical setting. mCIMT programs vary in the number of therapy sessions, use of restraint and duration of the program. Interestingly, the research has found there isn’t a difference between traditional and modified versions of CIMT, which means more services are offering mCIMT without disadvantaging their patients [3].
Is this for me?
Whilst CIMT is an effective therapy for people with difficulty using their arm after stroke, it’s not for everyone [4]. You need to have some movement in your hand, particularly being able to grasp and release an object. It also helps if you have some movement at your shoulder and it’s not painful. Having the support of a family member or carer may be required for some people, but some stroke survivors are able to do the program without this support.
At Cortex Neuro Rehab, we can determine if CIMT is an appropriate therapy for you.
What if I don’t want to wear a restraint?
Many stroke survivors worry about wearing a restraint on their “good” arm. The focus of CIMT is to encourage you to exclusively use your stroke-affected arm as much as possible. Wearing a restraint, such as a mitt, can be a useful tool as a physical barrier from using your less-affected arm, or simply provide a visual reminder not to use that arm. That said, CIMT is more than just the mitt and some stroke survivors have had successful programs without wearing one. The decision to wear a restraint and for how long is made between you and your physiotherapist and/or occupational therapist at the start of your CIMT program.
What if it gets too hard for me?
There’s no sugar-coating it, CIMT can be challenging! It can be frustrating and you may find that it takes longer to do things using your stroke-affected arm. This is part of the process and it does get easier over the course of the program. At Cortex Neuro Rehab, we guide and support you through the CIMT program to ensure you have a positive and successful experience.
Ashan Weerakkody MACP
APA Neurological Physiotherapist
Cortex Neuro Rehab
1. Stroke Foundation, Clinical Guidelines for Stroke Management, N.S. Foundation, Editor. 2017.
2. Morris, D.M., E. Taub, and V.W. Mark, Constraint-induced movement therapy: characterizing the intervention protocol.Eura Medicophys, 2006. 42(3): p. 257-68.
3. Kwakkel, G., et al., Constraint-induced movement therapy after stroke. Lancet Neurol, 2015. 14: p. 224-34.
4. Fabbrini, S., G. Casati, and D. Bonaiuti, Is CIMT a rehabilitative practice for everyone? Predictive factors and feasibility. European journal of physical & rehabilitation medicine., 2014. 50(5): p. 505-14.
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