Medical Policies - Therapy
Constraint Induced Movement Therapy (CIMT)
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Constraint-induced movement therapy (CIMT) is considered experimental, investigational and/or unproven for the treatment of motor disorders including but not limited to those resulting from stroke, traumatic brain injury, or congenital motor disorders including but not limited to cerebral palsy.
Constraint-induced movement therapy (CIMT), also known as constraint-induced therapy (CIT) or forced-use movement therapy is a therapeutic approach to rehabilitation of movement after stroke or other neurological events. CIMT has been used to improve motor function in patients following a cerebrovascular accident (CVA). The intensity and schedule of delivery of CIMT is different than that of traditional physical therapy. CIMT involves a technique of restraining the unimpaired limb and forcing use of the impaired limb during normal daily activities and rehabilitation exercises. The non-affected upper extremity is secured in a sling for 90% of waking hours, while the affected arm receives intensive training in a variety of tasks six hours per day for two to three weeks.
CIMT has been used in patients with:
• Chronic and subacute CVA,
• Chronic brain injury,
• Incomplete spinal cord injury,
• Cerebral palsy,
• Fractured hip,
• Phantom limb pain, and
• Musicians with focal hand dystonia.
The exact mechanism by which CIMT produces its therapeutic effect is not known, but imaging studies suggest that use-dependent cortical reorganization may occur after CIMT therapy.
This policy was originally developed in 2006 and has been updated with searches of scientific literature through July 2018. The following is a summary of the key literature to date.
Although there are preliminary reports that CIMT is effective in improving motor ability of patients after stroke or brain injury, there are no multi-center trials, only a few studies of randomized patients. Fewer studies employed a separate control group and the researchers used patients as their own control group. In a randomized study (n=66), van der Lee et al. (1999) reported a small improvement in motor impairment in patients with chronic hemiparesis treated with CIMT. However, the improvement was judged to be of potential clinical significance only in patients with sensory loss or neglect. In another randomized study (n=20), Dromerick et al. (2000) found that CIMT resulted in a marked improvement in motor impairment. The outcome measure was determined only at the end of the 14-day treatment, and the differences in motor impairment did not clearly translate into improvements in the function of activities of daily living. Thus, randomized controlled trials showing the effectiveness of CIMT are unconvincing.
Bonifer and Anderson (2003), in a study on the use of CIMT in the treatment of severe chronic upper extremity hemiplegia, found that the increased outcome scores were not maintained over the long term and that CIMT did not result in improved functional ability. The authors concluded that further investigation of CIMT is warranted.
Boyd and associates (2001), in a review on the management of upper limb dysfunction in children with cerebral palsy, concluded that there are a small number of randomized clinical trials evaluating the effectiveness of various management options including CIMT.
In a randomized controlled study, Taub et al. (2004) evaluated the applicability of CIMT to young children with cerebral palsy (n=18, aged 7 to 96 months). Patients were randomly assigned to receive either pediatric CIMT or conventional treatment. Pediatric CIMT involved promoting use of the more affected arm and hand by intensive training (using shaping) of the more-impaired upper extremity for six hours/day for 21 consecutive days coupled with bi-valved casting of the child’s less-affected upper extremity for that period. Patients were followed for six months. The authors found that pediatric CIMT produced major and sustained improvement in motor function in the young children with hemiparesis. The results of this trial are promising, but its finding needs to be validated by studies with larger sample size and longer follow-up to ensure that gains that might occur persist for over two years as proposed by Winstein et al. (2003).
Pierce et al. (2004) examined the effectiveness of a program of traditional outpatient neurological rehabilitation that included home forced use. In total, 17 patients with chronic stroke and one patient with subacute stroke (mean time post stroke = 27.6 months) completed an individualized program consisting of seven 2-hour treatment sessions composed of one hour of occupational therapy and one hour of physical therapy. Therapy sessions were completed over a two to three-week period with instruction on the use of a restraining mitt at home during functional activities. The authors stated that the preliminary results suggest that the forced-use component of CIMT may be effective when applied within a traditional outpatient rehabilitation program. Additional investigation is required to examine the effectiveness of using forced use within typical outpatient rehabilitation under more experimentally controlled conditions.
Siegert et al. (2004) considered some issues surrounding CIMT, such as its theoretical basis, effectiveness, utility and composition. The authors stated that considerable evidence from case studies and case series has accumulated but only a limited number of randomized controlled trials exist. The two most positive studies represent a combined 15 people undergoing CIMT. There is a need for replication by groups not already associated with CIMT. CIMT may hold promise, but independent, large-scale, multi-centered studies comparing its effectiveness with conventional therapy of equal intensity are required
Van der Lee (2003) reviewed the findings of four randomized clinical studies on CIMT, and stated that although the investigators of all four studies reported positive results, when the statistical variance of the randomized studies was calculated, they yielded no significant differences. In one of the studies, a differential effect was found for patients with sensory disorders and hemi-neglect, leading to the hypothesis that learned non-use may be primarily related to afferent impairments. The author concluded that the learned non-use theory requires further exploration and that the evidence regarding the effectiveness of CIMT is not yet conclusive. This is in agreement with the observation of Bonifer and Anderson (2003) who stated that further investigation of CIMT, as well as investigation of CIMT in combination with other motor recovery interventions is warranted. Well-designed studies with large sample sizes, long-term follow-up and appropriate control groups (e.g., other motor rehabilitation regimes in similar treatment time and intensity) are needed to determine the effectiveness of CIMT in the treatment of motor disorders caused by neurological injury.
In a small randomized controlled trial (23 subjects) conducted by Boake et al. (2008) the authors concluded “future trials of CIMT during early stroke rehabilitation need greater statistical power, more inclusive eligibility criteria, and improved experimental control over treatment intensity. The relationship between changes in motor function and in evoked motor responses suggests that motor recovery during the first three months after stroke is associated with increased motor excitability of the affected cerebral hemisphere. There is no documented standardized protocol for performing CIMT. Further studies are needed to determine the best protocol for sustained results. Although CIMT is a promising intervention for improving motor function, daily function, and physical aspects in the short term, no long-term effect was found.
Fleet et al. (19) conducted a comprehensive literature search and subsequent analysis identifying studies from a range of designs that investigated constraint-induced movement therapy (CIMT) protocol. This is a treatment for upper extremity (UE) recovery post stroke. Difficulties implementing a traditional CIMT approach have led to development of protocols featuring varying practice schedules, including a 10-week, 3 times per week intervention, termed modified CIMT (mCIMT). To date, systematic reviews of CIMT have grouped the various protocols, precluding the ability to ascertain the level of evidence (LOE) of specific CIMT protocols. Knowing the LOE for various protocols and their relative effectiveness may facilitate decision making regarding which protocol to implement. The aim of this study was to determine the LOE of mCIMT in promoting UE recovery post stroke. Two independent reviewers assigned an LOE to each of the identified studies, which were then examined collectively to determine the overall LOE for mCIMT. Study results were reviewed to assess the effectiveness of mCIMT for improving UE recovery. Of 473 studies identified, 15 utilized mCIMT. The lack of randomized controlled trials (RCT) resulted in assigning an intermediate LOE (C). Study results indicated that participants receiving mCIMT experienced clinically significant improvements in UE impairment and activity-level attributes. The authors concluded that mCIMT protocol is an effective intervention for UE recovery post stroke. Future research including large RCTs could potentially increase the LOE for mCIMT. Additional investigation into the effectiveness of mCIMT in acute and subacute stroke populations is warranted given the limited number of studies performed to date.
A 2015 Cochrane review (21) was conducted and the team of researchers identified 42 relevant studies involving 1453 participants. The participants in these studies had some control of their affected arm and were generally able to open their affected hand by extending the wrist and fingers. CIMT treatments varied between studies in terms of the time for which the participants’ unaffected arm was constrained each day, and the amount of active exercise that the affected arm was required to do. CIMT was compared mainly to active physiotherapy treatments, and sometimes to no treatment. The 42 studies assessed different aspects of recovery from stroke, and not all measured the same things. Eleven studies (with 344 participants) assessed the effect of CIMT on disability (the effective use of the arm in daily living) and found that the use of CIMT did not lead to improvement in ability to manage everyday activities such as bathing, dressing, eating, and toileting. Twenty-eight trials (with 858 participants) tested whether CIMT improved the ability to use the affected arm. CIMT appeared to be more effective at improving arm movement than active physiotherapy treatments or no treatment. The quality of the evidence for each outcome is limited due to small numbers of study participants and poor reporting of study details. Quality of the evidence was considered to be low for disability and very low for the ability to use the affected arm. The authors concluded that CIMT was associated with limited improvements in motor impairment and motor function, but that these benefits did not convincingly reduce disability. This differs from the result of our previous meta-analysis where there was a suggestion that CIMT might be superior to traditional rehabilitation. Information about the long-term effects of CIMT is scarce. Further trials studying the relationship between participant characteristics and improved outcomes are required.
UpToDate 2016 (20)
The author of an UpToDate article on management and prognosis of cerebral palsy, noted that constraint-induced movement therapy (CIMT) for children with hemiplegic CP promotes function of the affected limb by encouraging its use through intermittent restraint of the unaffected limb during therapeutic tasks. The method of restraint varies from holding a child's hand, to casting, and the length of time in the restraint varies from 1 to 24 hours a day. "Forced use" is a variation of CIMT in which the limb's use is encouraged only by placement of the contralateral restraint; no additional therapeutic tasks are assigned to the affected limb. Because the methods and outcomes used varied considerably among these trials, it is unclear which specific CIMT techniques are clinically useful. In addition, the authors of this article noted that although this approach to a physical therapy technique for CP was deemed effective in a systematic review, there is only moderate quality evidence for most, and clinical decisions must be based on individual patient characteristics and available resources.
In a 2017 pilot study, Sparrow and colleagues (22) examined the feasibility of a 3-week CIMT program in children with brain tumors and UE hemiplegia and described resultant change in extremity use. Affected arm use, health-related QOL, and parent-reported feasibility of program participation were measured before and after the intervention and at a 3-month follow-up visit. All 9 participants completed the entire study. The quality and amount of affected arm use improved significantly; gains were maintained at the 3-month follow-up evaluation. Some parents (44 %) reported that program participation was difficult; however, all reported satisfaction with the program. Participants did not experience negative changes in health-related quality of living (QOL) during the intervention, indicating that they tolerated the program well. The authors concluded that the findings from this small (n = 9) pilot study suggested that a child with hemiplegia as a result of a brain tumor can adhere to and benefit from a CIMT program. These preliminary findings need to be validated by well-designed studies.
In 2017 Liu et al. (23) published a meta-analysis to evaluate the clinical efficacy of constraint-induced movement therapy in acute and sub-acute stroke. A total of 379 CIMT patients and 359 healthy controls were included in the meta-analysis. In this meta-analysis, the only comparison was made to the clinical outcomes after rehabilitation therapy to reduce any heterogeneity among the studies. The authors noted that the present meta-analysis demonstrated that CIMT or mCIMT might be more beneficial than traditional rehabilitation therapy in the acute and sub-acute stroke. Furthermore, LO CIMT may be better than HI CIMT. These findings might have clinical significance for the rehabilitation of patients within acute or sub-acute stroke. However, large-scale, well-designed multi-center studies are needed to further confirm the impact that degree of CIMT or mCIMT has on functional outcomes in acute and sub-acute stroke.
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2. Van der Lee, J.H., Wagenaar, R.C., et al. Forced use of the upper extremity in chronic stroke patients: results from a single blind randomized clinical trial. Stroke (November 1999) 30(11):2369-75. PMID: 10548673
3. Van der Lee, J.H., Beckerman, H., et al. Constraint-induced movement therapy. Physical Therapy (2000) 80(7):711-13. PMID: 10869134
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6. Van der Lee, J.H. Constraint-induced movement therapy: Some thoughts about theories and evidence. Journal of Rehabilitation Medicine (2003) (41 Supplement):41-45. PMID: 12817656
7. Page, S.J., Elovic, E., et al. Modified constraint-induced therapy and botulinum toxin A: a promising combination. American Journal of Physical Medicine and Rehabilitation (January 2003) 82(10):76-80. PMID: 12510190
8. Bonifer, N., and K.M. Anderson. Application of constraint-induced movement therapy for an individual with severe chronic upper-extremity hemiplegia. Physical Therapy (April 2003) 83(4):384-98. PMID: 12665409
9. Winstein, C.J., Miller, J.P., et al. Methods for a multisite randomized trial to investigate the effect of constraint-induced movement therapy in improving upper extremity function among adults recovering from a cerebrovascular accident. Neurorehabilitation and Neural Repair (September 2003) 17(3):137-52. PMID: 14503435
10. Pierce, S.R., Gallagher, K.G., et al. Home forced use in an outpatient rehabilitation program for adults with hemiplegia: A pilot study. Neurorehabilitation and Neural Repair (2003) 17(4):214-19. PMID: 14677217
11. Taub, E., Ramey, S., et al. Efficacy of Constraint-Induced Movement Therapy for Children with Cerebral Palsy with Asymmetric Motor Impairment. Pediatrics. (February 2004) 113(2):305-12. PMID: 14754942
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13. Bonifer, N.M., Anderson, K.M., et al. Constraint-induced movement therapy after stroke: efficacy for patients with minimal upper-extremity motor ability. Archives of Physical Medicine and Rehabilitation (2005 September) 86(9):1867-73. PMID: 16181956
14. Wolf, S.L., Winstein, C.J., et al. Effect of constraint-induced movement therapy on upper extremity function three to nine months after stroke: The EXCITE randomized clinical trial. Journal of the American Medical Association (2006 November 1) 296(1):2095-104. PMID: 22561098
15. Wu, C.Y., Chen, C.L., et al. Kinematic and clinical analysis of upper-extremity movements after constraint-induced movement therapy in patients with stroke: a randomized controlled trial. Archives of Physical Medicine and Rehabilitation (2007 August) 88(8):964-70. PMID: 17678656
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17. Dahl, A.E., Askim, T., et al. Short- and long-term outcome of constraint-induced movement therapy after stroke: a randomized controlled feasibility trial. Clinical Rehabilitation (2008 May) 22(5):436-47. PMID: 18441040
18. Shi YX, Tian JH, et al. Modified constraint-induced movement therapy versus traditional rehabilitation in patients with upper-extremity dysfunction after stroke: a systematic review and meta-analysis. Arch Phys Med Rehabil. 2011 June 92(6):972-82. PMID: 21621674
19. Viana R, Teasell R et al. Barriers to the implementation of constraint-induced movement therapy into practice. Top Stroke Rehabil. 2012 Mar-Apr; 19 (2):104-14. PMID: 22436358
20. Fleet, A., Page, S., et al. Modified Constraint-Induced Movement Therapy for Upper Extremity Recovery Post Stroke: What Is the Evidence? Top Stroke Rehabil 2014; 21(4):319–331. PMID: 25150664
21. Miller, G. Management and prognosis of cerebral palsy. UpToDate, Post TW (Ed), Waltham, MA. This topic last updated: Apr 08, 2016. Available at: < http://www.uptodate.com> (accessed on April 20, 2016.)
22. Corbetta D, Sirtori V, et al. Constraint-induced movement therapy for upper extremities in people with stroke. Cochrane Database Syst Rev. 2015 Oct 8;(10):CD004433. PMID: 26446577
23. Sparrow J, Zhu L, Gajjar A, et al. Constraint-induced movement therapy for children with brain tumors. Pediatr Phys Ther. 2017;29(1):55-61. PMID: 27984471
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|10/1/2018||Document updated with literature review. Coverage unchanged. Reference 22-24 added.|
|9/1/2017||Reviewed. No changes.|
|6/1/2016||Document updated with literature review. Coverage unchanged.|
|10/1/2015||Reviewed. No changes.|
|1/1/2014||Document updated with literature review. Coverage unchanged.|
|8/15/2008||Revised/updated entire document.|
|2/1/2006||New medical document|
|Title:||Effective Date:||End Date:|
|Constraint Induced Movement Therapy (CIMT)||09-01-2017||09-30-2018|
|Constraint Induced Movement Therapy (CIMT)||06-01-2016||08-31-2017|
|Constraint Induced Movement Therapy||10-01-2015||05-31-2016|
|Constraint Induced Movement Therapy||01-01-2014||09-30-2015|
|Constraint-Induced Movement Therapy||08-15-2008||12-31-2013|
|Constraint-Induced Movement Therapy||02-01-2006||08-14-2008|