What is the role of constraint-induced movement therapy (CIT) for the treatment of hemiplegic shoulder pain?

Updated: Feb 08, 2019
  • Author: Robert Gould, DO; Chief Editor: Stephen Kishner, MD, MHA  more...
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Answer

Constraint-induced movement therapy (CIT) is a family of therapies that induce patients who have had a stroke to greatly increase the amount and quality of movement of their paretic limb, in turn improving function. CIT is based on the theory of "learned nonuse," first described by Wolf and colleagues [73] and later by Taub and coauthors. [74]

Substantial neurological injury leads to a shocklike phenomenon, called diaschisis, with dramatically depressed motor neuron function. During this shock period, the patient is unable to move the affected limb and subsequently learns to compensate with the functional limb. As the shock resolves and function starts to improve, attempts to use the affected limb result in clumsy and ineffective movements; according to the learned nonuse theory, this difficulty positively reinforces continued compensation.

Treatment begins by restraining the functional limb during all waking hours, except for specified activities, and then forcing the patient to perform tasks almost exclusively with their paretic limb for up to 2 weeks. This usually produces measurable improvement of function in the paretic limb, as well as increases in speed and strength of contraction, provided the patient has some selective hand movement (slight wrist and finger extension), good balance, and good cognitive and communication skills.

As reported by Morris, a behavioral training technique called shaping often is used in conjunction with CIT. [75] Shaping has resulted in substantial improvement of motor function.

Shaping approaches a desired motor outcome in small successive steps through explicit positively reinforced feedback by the therapist. This allows subjects to experience successful gains in performance with relatively small amounts of motor improvement.

A battery of approximately 60 tasks has been developed with a preliminary shaping plan for each task. Each task can be broken down into subtasks. Performance regressions are never punished and usually are ignored. If performance continues to exhibit no improvement after approximately 3 trials, the subject is encouraged to improve further at a later time, a simpler subtask is attempted, or an entirely different task is substituted. Eventually, an individualized task-oriented home program that emphasizes the use of the most impaired movements and joints is established.

Researchers report that patients tend to reach a plateau in motor recovery within 6-12 months following stroke. Taub and coauthors refuted this by studying the effectiveness of CIT in overcoming learned nonuse in chronic hemiplegic stroke patients. [74]

Compared with an attention-comparison group, the restrained subjects improved on each measure of motor function (ie, performance time, quality of movement, range of activities); in most cases, patients improved markedly. Two-year follow-up revealed that ADL functions had been maintained or increased. Researchers subsequently concluded that the use of CIT proved to be an effective means of restoring substantial motor function in chronic stroke patients.


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