ConstraintInduced Therapy

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Constraint-Induced Therapy

• Darcy Fehlings, MD, MSc, FRCPC
• Sophie Lam-Damji, BSc, OT

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Outline

• Constraint-Induced Therapy Definition
• Evidence from the literature
• Report of a Case Study
• ? Integration into Clinical Practise

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Constraint-Induced Therapy (CIT)

• Constraint of the less affected arm
• Intensive behavioral training for the affected
  arm in individuals with hemiplegia

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CIT Lessons from the Adult Literature

• Case series and RCTs in adult stroke literature
  support CIT (Taub 1993 Taub 1998 Kunkle 1999)
• Dose effect demonstrated for the number of hours
  of intensive behavioural training provided (Taub
  2002)

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CIT Evidence in Pediatrics Willis et al.
Pediatrics 200211094

• RCT
• Constraint alone with arm cast x 1 month vs no
  constraint
• No intensive behavioral training
• Significant improvement in motor function
  following constraint therapy (PDMS)

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Efficacy of Constraint-Induced Movement
TherapyTaub et al Pediatrics 2004 113 305-312

• RCT of 18 children with hemiplegic CP (age 7-96
  months)
• Tx group received CI therapy (bivalved cast and
  intensive behavioral training 6hrs/day for 21
  days
• Results CIT improved motor skills of involved
  arm on EBS, PMAL, TAUT measured at 3 weeks and
  maintained at 6 months
• Group will be reporting on cross-over trial in
  near future

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Effects of Constraint-induced movementEliason
et al DMCN 2005, 47 266-275

• Controlled clinical trial (25 children in Tx, 20
  in control) Dx hemiplegia age 18 mo to 4 yrs
• Tx group- wore a constraint glove for 2 hours/day
  over 2 months, paired with OT weekly and
  parent/caregiver carry-over
• Results significant impvt in the Tx group in
  the AHA

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Modified Constraint...A pilot studyNaylor et al
DMCN 2005, 47 365-369

• Single-case experimental design using children as
  their own controls
• Assessments at baseline, 4,8 and 12 weeks
• Intervention between 4 and 8 weeks consisted of
  2X weekly therapy (verbal instruction and gentle
  restraint)
• Significant impvt seen on QUEST

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Issues with Constraint

• Intensive Behavioral Therapy or tx to go with
  constraint
• Different types of Constraint (cast vs glove)
• Who will respond
• When to repeat
• Side Effects concerns re constraining good
  arm, child tolerance of the constraint, risk of
  falls