[guest article] real world application of constraint-induced movement therapy after stroke

Many stroke patients are left with residual arm and hand weakness, or hemiparesis, after a stroke -- even months after the incident. There is a big misconception within the general public that strength in the hand and arm will come back naturally on its own. Unfortunately, this is not true. You need to use your muscles as much as you can, even if there is only a slight amount of movement, in order to gain actual strength. Once the neurological connections between your brain and muscles begin to heal and communicate again, it is time to start trying to use your hand and arm again as much as possible.

Research consistently shows that intense active use of a person’s weaker hand and arm after stroke may contribute to improved strength and function. While this technique may not apply to persons without any strength, it should considered a valuable concept for those with even a small amount of active movement. Sometimes this movement is first seen in the fingers or wrist, while others see movement return first in their elbows or shoulders. You do not have to experience movement in all areas in order to start incorporating your weaker side into functional activities.

Constraint-Induced Movement Therapy (CIMT) is an example of a formal therapeutic application used to encourage the use of a person’s weaker hand and arm after stroke by constraining their stronger hand and arm. In CIMT programs, a mitt is worn on the stronger hand to prevent the patient from “cheating” by using their stronger hand or arm when it would be more therapeutic to strengthen their weaker arm by attempting everyday tasks that seem impossible. Very intense CIMT programs require patients to use their weaker extremity 90% of their waking hours while less intense, or modified CIMT (mCIMT), programs require the use of the weaker extremity only six hours every day. Typically, structured therapy is incorporated into these formal programs in addition to the mitt wearing schedule, which continues over a minimum of ten to fourteen days. Limitations of these programs include cost, time, and limited availability.

You do not need to participate in a formal program in order to potentially benefit from this very important therapy technique. Although research is limited on the outcomes of mCIMT outside of a structured therapy program, there is reason to believe gains can still be made using similar principles at home in a real-world context. The basic concept is to force yourself to use your weaker arm in everyday tasks as often as possible. Activities should be modified according to hand and arm strength and activities that could compromise balance or safety should never be attempted. If you have reduced sensation in your weaker hand or arm, avoid handling warm or hot items. Never use your weaker hand to control the use of a straight cane, quad cane, or walker.

For more information on the benefits of CIMT please visit www.stroke.ahajournals.org or contact your personal treatment team for programs in your area.

Example activities

Ways to incorporate your weaker hand and arm into daily activities:

• Stabilizing containers while opening (toothpaste, bottled water, medicine bottles, deodorant)
• Opening/closing cabinets, appliances, or doors
• Turning on the faucet
• Eating finger foods (pretzels, bite-size carrots, grape tomatoes, cubes of cheese)
• Carrying a light bag (either in your hand or on your forearm)
• Buttoning, zippering, tying
• Dialing the phone or answering the phone
• Holding utensils or your toothbrush with built-up foam handles
• Typing on the computer
• Folding clothes or towels

MMS Side Bar:

Persons with mild stroke will be most appropriate for mCIMT or CIMT because they will likely have more movement in their weaker hand and arm.

Persons with moderate to severe stroke should not be excluded from these programs because they may still present with some active hand and arm movement at some point in their recovery. However, activities may be more frustrating or it may take longer to see gains.

Lori Bravi, MS OTR/L is an occupational therapist with the Rehabilitation Institute of Chicago, who specializes in CIMT (and is the one who tests yours truly!).