Constraint Induced Movement Therapy (CIMT): Rewiring the Brain by Force

Constraint Induced Movement Therapy (CIMT) is one of the most researched and evidence-based interventions in neurological rehabilitation. It is designed to overcome "Learned Non-Use" in patients with Stroke, Cerebral Palsy, or TBI. By restraining the "good" limb and forcing the "bad" limb to work, CIMT drives massive neuroplastic changes. This guide covers the theory, the protocol, and the inclusion criteria.

1. The Concept: Learned Non-Use

After a stroke, the patient tries to use their weak arm but fails. This failure is punishing. To function, they start using only their good arm. Over time, the brain "learns" not to use the affected arm, even if some motor recovery happens later.

The Theory: CIMT reverses Learned Non-Use by: 1. Physically preventing the use of the unaffected limb (Restraint). 2. Forcing the affected limb to work (Forced Use). 3. Rewiring the cortex through high-intensity practice.

2. The 3 Pillars of CIMT

CIMT is not just "tying up the good hand." It requires three specific components to be effective:

Component	Description
1. Restraint	Wearing a mitt or sling on the unaffected (strong) hand for up to 90% of waking hours.
2. Massed Practice	Repetitive, high-intensity task practice with the affected hand (up to 6 hours/day).
3. Shaping	Selecting tasks that are tailored to the patient's ability and gradually increasing the difficulty (e.g., stacking blocks -> stacking coins).

3. Inclusion Criteria (Who can do it?)

Not every stroke patient is a candidate. To participate, the patient must have minimal active movement:

• Wrist: At least 10° of active extension.
• Fingers: At least 10° of active extension in two fingers and thumb.
• Cognition: Adequate cognitive ability to follow instructions and safety awareness (MMSE > 24).
• Balance: Sufficient balance to function safely while wearing the restraint.

4. Protocols: Standard vs. Modified

The original protocol is intense, often leading to poor adherence. Modified versions (mCIMT) are now common.

Protocol	Restraint Time	Therapy Time	Duration
Original CIMT (Taub)	90% of waking hours	6 hours per day	2 weeks
Modified CIMT (mCIMT)	5 hours per day	30-60 mins per day	10 weeks

5. Examples of Shaping Tasks

Tasks must be functional and progressively harder.

• Gross Motor: Wiping a table, reaching for a cup, rolling dough.
• Fine Motor: Picking up beans, turning pages of a book, stacking checkers, buttoning a shirt.
• Feeding: Eating finger foods (popcorn) with the affected hand.

6. Revision Notes for Students

Originator: Dr. Edward Taub (Monkey deafferentation studies).
Goal: Overcome "Learned Non-Use".
Minimum Movement: 10° wrist ext + 10° finger ext.
Key Element: It is the *intensity* (Massed Practice) combined with *restraint* that drives neuroplasticity.
Contraindications: Severe pain, severe spasticity preventing movement, uncontrolled balance issues.

7. FAQs

Q1. Can CIMT be used for the lower limb?

Technically yes, but it is harder to "restrain" a good leg while walking. Lower limb CIMT often involves "Forced Use" therapy, such as intensive treadmill training or prohibiting the use of handrails.

Q2. Does it work for chronic stroke?

Yes! Evidence shows CIMT is effective even years after a stroke, proving that neuroplasticity is possible in the chronic phase.

Q3. Is spasticity a contraindication?

Not strictly, but if spasticity is so severe that the patient cannot voluntarily open their hand (no active extension), they do not meet the inclusion criteria.

8. 10 Practice MCQs

Q1. CIMT was primarily developed to overcome which phenomenon?

Answer: B) The brain learns to ignore the affected limb because initial attempts to use it failed.

Q2. The minimum active movement criteria for CIMT is approximately:

Answer: C) Some active extension is required to grasp and release objects.

Q3. "Shaping" in CIMT refers to:

Answer: B) Behavioral training technique that rewards small steps toward the goal behavior.

Q4. In the standard (Taub) protocol, the restraint is worn for:

Answer: C) The unaffected limb is restrained almost all day to force use of the affected limb.

Q5. Which of the following is NOT a pillar of CIMT?

Answer: C) Electrical stimulation is an adjunct, not a core pillar of the classic CIMT protocol.

Q6. Modified CIMT (mCIMT) was developed primarily to:

Answer: A) 6 hours of therapy daily is often too expensive or exhausting for many clinics and patients.

Q7. A restraint mitt is placed on:

Answer: B) To prevent the patient from using the good hand for daily tasks.

Q8. CIMT is most effective for:

Answer: B) Active movement is required to participate in the shaping tasks.

Q9. Which principle of Neuroplasticity does CIMT strongly utilize?

Answer: B) Intensive use of the limb expands its representation area in the brain.

Q10. Who is considered the father of CIMT?

Answer: C) Based on his research with deafferented monkeys.

References

• Taub, E., et al. (1993). Technique to improve chronic motor deficit after stroke. Arch Phys Med Rehabil.
• Wolf, S. L., et al. (2006). Effect of constraint-induced movement therapy on upper extremity function 3 to 9 months after stroke: the EXCITE randomized clinical trial. JAMA.
• Corbetta, D., et al. (2015). Constraint-induced movement therapy for upper extremities in people with stroke. Cochrane Database Syst Rev.