Modified Constraint-Induced Therapy

Modified Constraint-Induced Therapy
Steve Page, Ph.D.
Departments of Rehabilitation Sciences,
Physical Medicine & Rehab., Neurosciences;
Greater Cincinnati/N. Kentucky Stroke Team;
University of Cincinnati Academic Medical Center

If you are a stroke patient…
And I asked you to reach for something, with
which hand would you be more likely to
perform the task; the affected or unaffected
hand
Unaffected
Why
– Learned Nonuse – a behavioral suppression of
movement (not biologically based)
– Operant conditioning
Success/punishment-operant conditioning
-therapy/compensation

So, recovery isn’t t just “in the brain”…

Practice, Plasticity and Stroke
Pt exhibits learned
nonuse
– Easier to use less
affected than more
affected
Training =>Use-
induced brain
reorganization
– Changes in cortical
motor area sizes in the
damaged hemisphere in
abductor pollicis brevis
(APB) muscle before
and after training
Liepert et al., 1999

Constraint-induced induced therapy is
born…
2 components to induce
repeated practice with the
affected limb
– Pts. Participate in 6 hour training
sessions on 10 consecutive
weekdays
– Wear sling 90% of all waking
hours during same 2 weeks
Increases more affected limb
use & function in acute &
chronic CVA pts.
Repeated practice => brain
reorganization => improved
motor function

Lots and lots of studies support
“Lots and lots of practice”
Teasell; EBRSR

ExCITE Trial

VECTORS TRIAL (2007) – is
earlier and more intensive better
Very Early Constraint-
Induced Therapy for
Recovery from Stroke
CI Therapy no better
than regular therapy
When more is given,
worse outcomes
Buttressed by several
animal studies
(Schallert et al)
Supported by other
clinical data (Boake et
al., 2007, Neurorehab
Neural Repair)

But are we really here yet
CONSTRAINT-
INDUCED
THERAPY FOR SALE

Drug development
Appropriate dosing is established early on in drug
development process

Timing, Intensity, and Duration of
Rehabilitation for Hip and Stroke Fracture
NIH, 2001
“Current medical practice has
been heavily influenced by
reimbursement rules, with
comparatively little empirical
research on optimal treatment
schedules.”
In other words:
We still don’t know the optimal
duration with which stroke
rehabilitation should be delivered
It also may differ from one
technique to another.

Some recent studies showing that
task specific trainingg => plasticity:
Do you really need “lots and lots”
“any technique that induces a patient to use an affected limb…should be
considered therapeutically efficacious. This factor is likely to produce the
use-dependent cortical reorganization.”
Taub; J Rehabil Res Dev 1999: p. 243.
Non-disabled humans
Classen et al; J Neurophysiol 1998
– “15 or 30 min of continuous training (finger tapping) were required ed in
most of the subjects and, on two occasions, as little as 5 or 10 minutes”
Humans with stroke
Butefisch et al; J Neurol Sci 1995
– 15 min./day; 2 times/day
Dean & Shepherd; Stroke 1997
– 30 min/day; 10 weekdays over a 2 week period
Luft et al; JAMA 2004
– 1 hour, 3 times a week, for 6 weeks
Motor learning evidence – distributed practice > massed practice (clumping)

Modified constraint-induced induced therapy:
Translating “basic research” to care
Therapy 3 times/week for ½
an hour
Practice with the more
affected arm 5 hours/day 5
days/week
– Tasks pts. choose
Reimbursable
Not taxing
What patients are used to
(i.e., consistent w. OP tx
regimen)

Study Criteria That We Typically Use:
Inclusion Criteria:
1. hx of no more than one stroke;
2. ability to selectively actively extend at least 10° at the
metacarpophalangeal and interphalangeal joints and 20° at the
wrist;
3. stroke experienced > 12 months prior to study enrollment;
4. > 69 on the Modified Mini Mental Status Examination
5. age > 18 < 80 years;
6. more affected arm nonuse, defined as a score < 2.5 on the
Motor Activity Log.
Exclusion Criteria:
1. excessive spasticity, (> 3 on Modified Ashworth Spasticity
Scale);
2. > 4 on a 10-point visual analog scale;
3. still enrolled in any form of physical rehabilitation;

Results
Action Research Arm
Test (primary
outcome measure)
(functional limitation)
– mCIT = +10.8
– TR = +3.00
– CON = +0.90
– ARA (F {3, 31} =
13.14, p < .0001)
60
40
20
0
Fine Motor Skill Improves for mCIT; Changes are
Nominal for Others
PRE-1 PRE-2 POST
mCIT
TR
CON
Page et al., Phys Ther; 2008

Repeatable
These findings are…
– mCIT used in several clinical sites across US
– Subacute stroke (< 1 year post CVA)
Page, S.J., Sisto, S.A., Johnston, M.V., Levine, P.,
Hughes, M. Modified constraint induced therapy: A case
study. Arch Phys Med Rehabil 2002; 83 (2): 286-90.
Page, S.J., Sisto, S., Johnston, M., Levine, P. Modified
constraint-induced induced therapy after subacute stroke: A
preliminary study. Neurorehabil Neural Repair 2002; 16
(3): 223-28.
28.
Page, S.J., Sisto, S., Johnston, M.V., Levine, P. Hughes,
M. Modified constraint induced therapy: A randomized,
feasibility and efficacy study. J Rehabil Res Dev 2001; 38
(5): 583-590.
590.

These findings are repeatable…
– Chronic stroke (> 1 year post CVA)
Page SJ, Sisto SA, Levine P. Modified constraint-
induced therapy in chronic stroke. Am J Phys Med
Rehabil 2002 Nov;81(11):870-5.
– Acute stroke
• Page SJ, Levine P, Leonard AC. Modified
constraint-induced induced therapy in acute stroke: a
randomized controlled pilot study. Neurorehabil
Neural Repair. 2005 Mar;19(1):27-32.
– Mechanism
Szaflarski JP, Page SJ, et al. Use dependent cortical
organization following mCIT. Arch Phys Med Rehabil
2006.

There are other efficacious dosing
strategies too (and I don’t t care
which you use)
3 Hours/day (Sterr et al, 2002, Arch Phys
Med Rehabil)
2 Hours/day (Wu et al 2007; Arch Phys
Med Rehabil; ; Wu et al 2007; Neurorehabil
Neural Repair)
1.5 hours/day (Taub et al, CSM
conference, 2007)

Some tips for administering mCIT
Inclusion/Exclusion – how do you MEASURE if
someone is eligible
“I I know my intervention works.” Really! How if
you don’t t measure outcomes
– Amount of active movement
– Amount of affected arm use
– Spasticity
Behavioral Contract
Doing the Therapy
– Sling Use
– Therapy

Flowchart for patient screening
Affected limb nonuse
(< 2.5 on Motor Activity Log)
Active extension in affected wrist & fingers
"Good" ROM in other joints,
Subluxation or other comorbidities
No cognitive deficits (MMSE)
Things that MAY exclude patients:
Ambulation
Family support
Others

How much movement is
needed to start mCIT

Minimum Motor Criteria
1. Extension of the hemi wrist
greater than 10°
2. Some active ABDuction of the carpal
metacarpal joint of the thumb
3. 10° of active extension in, at least, 2
additional digits.
(Should be able to do the movement 3x in 1 min.)

Practical Application:
Motor Criteria: What You Look For on the Phone
Able to actively lift hand from a
drooped position and raise thumb and
at least two fingers. (EMORY)
Roughly enough finger extension to
release a tennis ball (Taub, higher
functioning group)
The ability to lift a wash rag off a tabletop using
any type of prehension they could manage, and
then release the rag. (Taub, lower functioning
group)
Movement should be enough to pick up and
release a washcloth. (U. OF OREGON)

CIT
There are some studies showing
CIT/mCIT efficacy outside of
“established” motor criteria
– Taub et al: “lift a wash rag off a tabletop using any type of prehension they
could manage, and then release the rag” (Taub E, E Uswatte G, G Pidikiti R. R
Constraint-Induced Movement Therapy: a new family of techniques with
broad application to physical rehabilitation--
--a a clinical review. J Rehabil Res
Dev. 1999 Jul;36(3):237-51. )
– Patients who initially exhibited no isolated wrist movement, reporting some
motor changes but no functional benefits (Bonifer N, Anderson KM.
Application of constraint-induced induced movement therapy for an individual with
severe chronic upper extremity hemiplegia. Phys Ther 2003; 83(4):384
:384-98.)
mCIT
– Page & Levine, 2007; Phys Ther
– 4 patients who experienced stroke > 1 year prior to study entry (mean age =
60.25 + 1.98 years; mean time since stroke = 37.5 + 23.2 months
– individuals who could barely lift a washrag off a tabletop, as described d
above.
– rendered increased affected arm use and function, and increased ability to
perform SOME valued activities

Affected Limb Use- Motor
Activity Log

Why does the MAL matter
Quantitative measure of affected limb use
– Is the patient re-integrating the affected limb in
ADLS as a result of mCIT
Want to make sure nonuse of affected limb is
being “turned around”
– PRACTICE=>PLASTICITY=>MOTOR FUNCTION
Identifies activities that patient is doing at home
– Relevant activities for “practice/homework”
Patient can self-administer so no sweat!

Motor Activity Log
(Amount of Use)
Caveat: mCIT is based on increasing
functional use of the limb – need to be able to
quantify that before and after
MAL Amount of Use score - < 2.5
0 – Not Used
1 – Very rarely used (occasional effort)
2 – Rarely used (sometimes but most with less
affected arm)
3 – Half Prestroke
4 – ¾’s s Prestroke
5 – Same as Prestroke

Flowchart for Intervention (cont’d)
Patient Deemed "Eligible"
(Previous talk)
Ashworth
(Spasticity)
Physiatrist - spasticity mgt.
(Spasticity meds w/wout therapy, estim)
(e-STIM)
(other)
HIGH (> 3 on MAS)
Within Desirable Limits
mCIT
Behavioral Contract
Individualized Task Selection
Task Analysis

Modified
Ashworth
0 = No increase in
muscle tone
1= slight ‘catch’ at end
of ROM
1+ =‘catch=
catch’ followed by
minimal resistance
(< ½ ROM)
2 = ‘catch’ followed by
minimal resistance
(> ½ ROM)
3 = PROM difficult
4 = rigid

Behavioral contract

mCIT Behavior contract
Always put therapist expectations
first!
– Puts patient at ease – lets them know
that this is an investment for you as well.
Therapy
– Set up therapy schedule, location, and
what happens during tx
– Patient expectations for attendance,
advanced notice of missing sessions
– Patient bring sling/mitt
Home exercise/ “homework”
– Schedule, example activities/exercises
Consequences for noncompliance
– Therapy
– Homework

How do I start What do I do the first day
(Not written in stone)

mCIT: The First Day of Treatment
– Time “PRE” task attempt
– Videotape “PRE” task attempt
– Note quality of movement
– Other measures, i.e.: MAL, ROM, activity
monitors
– Behavior contract

mCIT: The First Day of Treatment
Time before and after
Video before and after
Activity monitors
– Objectively, quantitatively
determine amount of use.
– Patient takes home and
wears for one week.
– Easy to use – put into tray
and tables come out (right).
– Can be used as an outcome
measure for therapy
– www.theactigraph.com/

Scheduling
Donning / Doffing of Mitt and or Sling

Picking the Tasks…
Tasks should be one or more of the
following:
–Important to the patient (motivating)
(What truly motivates)
–Challenging Fun, interesting,
engaging
–Necessary (feeding)
–We use the COPM, MAL

Other easy therapies that can be
integrated with mCIT concept
With Botox (Page et al., 2003; Am J Phys Med Rehabil)
With internet via netwellness.com
– One of the country’s s largest “ask an expert” websites administered
through UC
– Videos of different skills administered in learning modules over
Netwellness
– Therapist supervision with cameras, Skype software
With E-stim, E
either:
– E-stim
before/as a gateway (Page et al., 2006; Arch Phys Med
Rehabil)
– E-stim
during/task specific, repetitive e-stim e
(Bioness device) (Page et
al., submitted)
Imagery/mental practice + mCIT
– Page, et al in press

Contact info:
Steve Page, PhD
Stephen.Page@uc.edu
513-558
558-2754