Constraint induced movement therapy

Yes, i have done constraint therapy with incredible results in my recovery. If youre going to invest in anything in your recovery, invest in constraint cause its the best treatment right now. 

Dear K Silvia,

I hope that you hear from more stroke survivors in the coming weeks. Thanks William Lo for the first reply.

A constraint therapy program is intensive, tiring (for stroke survivors and therapists!) but can be very beneficial. Constraint therapy is suitable for people who have some arm and hand movement, but is not unfortunately suitable for people with little or no upper limb recovery.

Stroke survivors need to free up their schedule to attend for 3-4 hours per day x 10 days. Some programs run for 6 hours per day, but 3-4 hours produces similar outcomes to the 6 hour per day program.

Most programs run from Mon-Fri in Week 1, with a rest on the weekend, then run again from Mon-Fri in Week 2. If you attend any other sessions (eg therapy or leisure) my advice is to cease these activities for the 2 weeks, as you will be VERY tired at the end of each day. There are different timetables /schedules but most are intensive for two weeks, each aiming to help stroke survivors achieve 250-300 repetitions of arm practice per hour, for several hours per day.

Therapists usually need to attend a workshop to learn how to set up a constraint therapy program so that the content reflects what has been provided in published research studies.  They will want to find out what you CAN do with your affected hand/arm, what you cannot do but want to do (ie what your upper limb goals are), then establish a tailored program of practice tasks for each day.

Therapists supervise and coach you during a range of challenging upper limb tasks, for example, squeezing out cloths in the sink, turning over cards or dominoes. They help you work towards individual goals such as using an electric drill or bouncing a basketball. Practice tasks progress over the 2 weeks.

Homework is negotiated each night, including tasks that the person has not previously used their hand for (eg opening curtains or kitchen drawers). This part of the program is called the 'transfer package' to help you transfer skills and change your behaviour at home before the program ends. The transfer package seems to be an essential part of the program, and you will need family and friends to be involved to encourage you when you get tired.

Some programs are run 1:1, while others are offered in a small group, offering encouragement and peer support.

The mitt or 'constraint' is less important in my view than the shaped, progressed task practice that you do during each day, and at home each evening. However, most people wear a 'mitt' for most of their waking hours, including out and about in the community to stop use of their 'good' hand during everyday activities.

There are a few (public) health services in Sydney that provide 2-week CIMT programs once or twice a year. For example, occupational therapists from the Stroke Outreach Service in Central Sydney LHD based at RPAH have run a group program at Concord Hospital and Balmain Hospital for community clients. Occupational therapists at St Joseph's Hospital in Auburn/ Western Sydney LHD ran a group program in mid 2016, with help from students. All programs are free (to my knowledge).

From March 2017, Bankstown, Liverpool, and Camden/Campbelltown Health Services in SWS Local Health Districts will also be offering this type of therapy to inpatients and outpatients as a result of some funding for continuing education for therapists.

In Brisbane, Deirdre Cooke, an occupational therapist from the Australian Catholic University offers a 2-week constraint therapy program in March, June and November on their campus at Banyo, with student input. There is a small fee to cover costs. Anyone that is keen to attend a program from anywhere in Australia could travel and stay in Brisbane, and attend one of these programs, if eligible. Contact deirdre.cooke@acu.edu.au.

Other constraint therapy programs may also be available free of charge in other cities.

Remember that just wearing a mitt or oven glove while you do your upper limb practice/therapy for 1-2 hours here and there is NOT constraint therapy. To be effective and improve function, it is the intensive practice for 3-4 hours daily over 10 days that is needed.

A recent study in the Netherlands used a 1-hour/day program with acute inpatients (Kwakkel et al, 2016) and stroke participants got similar positive results to the 3-4 hour published constraint therapy programs (compared to usual OT/PT therapy); however at the 6 month follow up, both groups were comparable; no differences in upper limb function remained after the 1-hour constraint therapy program. This suggests that a 3-4 hour daily program is probably needed, as well as the home/transfer package, which was not part of the Kwakkel program.

Until recently, Australian stroke survivors have had to either travel overseas for CIMT, at considerable expense, or pay for a private program. These private services are important, and represent excellent/best practice (and are still available for stroke survivors who can afford them). It is good to see our public health services offering this therapy to stroke survivors who want and are eligible for this therapy.

William lo that is very encouraging to hear I'm definitely looking forward to it, and thank you Annie for such a detailed response. The one I'm participating in is 3 to 4 hrs a day for 3 weeks at the University of Alabama 

Yes, I have done it, here in Melbourne, Australia, but, probably, since it was a voluntary thing done at home, I did not get any spectacular results from it.  I think a lot of my lack of success came from the fact that it is my non dominant hand that is affected, so, constraint therapy is asking my non dominant hand to become my dominant hand, which, even were it not injured would be a big ask.  So the result was when something in daily living was too hard with my injured hand, I would just get impatient, and use my good, dominant hand.

Also, if it is your dominant hand that is injured, you know subconsciously that it is the best hand to use for any task, after a stroke, it is your conscious mind that tells you that it is of no use, so I think that being forced to use an injured dominant hand would be easier than forcing an injured non dominant hand to work as the primary hand. 

If you are very disciplined, you would not have to go into a rehab setting to use CIMT, just find something to stop your good hand from working and you are on your way.

I actually found that when I broke my good left arm, and had to use my affected arm, I did far better than I thought I would

I operate a clinic in Sydney doing Constraint Induced Movement Therapy I trained at the University of Alabama in 2009.We have now treated more than 50 clients using Constraint Induced Therapy .It is a very effective intervention for about 50 percent of stroke survivors.

It is best done in the first 2 yrs after the stroke and has lots of research to support its effectiveness.

Phillip Occupational Therapist CItherapyaustralia