Archived Policies - Therapy
Constraint Induced Movement Therapy
Constraint-induced movement therapy (CIMT) is 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 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:
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.
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.
The published literature to date does not permit scientific conclusions concerning the effects of CIMT on final health outcomes, particularly in the long-term. Improvements demonstrated in the short-term cannot be isolated to CIMT as concomitant procedures are often performed. Further study is needed to determine long-term functional outcomes.
A search of peer reviewed literature was conducted through October 2013. No additional published studies were identified that would prompt reconsideration of the coverage statement, which remains unchanged. Supplemental studies were added to the references to support the current coverage position.
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Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.
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The following codes may be applicable to this Medical policy and may not be all inclusive.
ICD-9 Diagnosis Codes
Experimental, investigational and/or unproven for all diagnoses codes
ICD-9 Procedure Codes
ICD-10 Diagnosis Codes
Experimental, investigational and/or unproven for all diagnoses codes
ICD-10 Procedure Codes
The information contained in this section is for informational purposes only. HCSC makes no representation as to the accuracy of this information. It is not to be used for claims adjudication for HCSC Plans.
The Centers for Medicare and Medicaid Services (CMS) does not have a national Medicare coverage position. Coverage may be subject to local carrier discretion.
A national coverage position for Medicare may have been developed since this medical policy document was written. See Medicare's National Coverage at <http://www.cms.hhs.gov.
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|