Modified Constraint Induced Therapy (mCIT)

It is with publication of research on Modified Constraint Induced Therapy that the hope offered by CIT becomes more realistic for the many stroke patients around the world.

Whilst CIT offered hope for stroke patients, the reality was that it was expensive, was not covered by private insurance or public funding, and a significant onerous effort on the part of the patient. The majority of stroke patients were resistant to what it involved, and, of those who participated in the treatment, around 30% opted out before the treatment had completed and a significant number didn't comply with the constraint requirements.

Modified Constraint Induced Therapy is a less onerous therapy that appears to offer similar potential for improvement. It has become the "hot topic" in physical rehabilitation post-stroke. Most importantly (as is the case for CIT), it is not restricted to those patients who have recently had a stroke - it has proven to be effective for chronic stroke patients, who have been out of rehabilitation programs for years. Indeed, most of the research is conducted on these patients. 

What It Is

Modified Constraint Induced Therapy involves a combination of face-to-face therapy at the clinic with the therapist and then at home activities that the patient conducts by themself, or with the support of their caregiver.

The basis of this variation is that the massed practice principle may not be as important as was assumed when CIT was originally developed. Supplementary to this is the finding that repetitive, task-specific training can trigger the brain to reorganise (brain plasticity).

Modified Constraint Induced Therapy typically lasts over a ten week period and consists of the following components:

• Three half hour sessions per week with the therapist. In these sessions, the focus is on three functional tasks (e.g. writing, using a fork, combing hair, brushing teeth). Each task is broken down into sub-tasks and the patient is assessed on their capability for each sub-task. Shaping techniques are used to refine the patient's capability. These techniques involve coaching and encouraging.
• At home, patients constrain the unaffected limb for five hours per day. The time for constraint is selected to be the time when the arm is used most frequently during the day. The constraint mechanism is a sling and a mitt, as in CIT. Patients specifically practice the homework items identified by the therapist as well as performing other daily activities during this time.

The activities undertaken are the same type of activity as for the original CIT. Example tasks are:

• Reaching for and grasping a cup
• Turning a page in a book
• Using a pen to write
• Using a fork to eat
• Using a hairbrush or a comb.

Effectiveness

Research has shown that mCIT and CIT provide similar effectiveness in improvement of function of the affected limb. However, the improvement from mCIT comes from a longer period than CIT - due to the length of the treatment (10 weeks vs 2 weeks).

Steven Page has been a key researcher in this area. His studies have shown that improvements in Modified Constraint Induced Therapy patients are clinically significant over those of patients who used conventional or no therapy. Examples of the sort of function that mCIT patients achieved (having not been able to do these prior to the therapy) include:

• Ability to dress and groom themselves
• Ability to feed themselves
• Ability to write and use a computer
• Ability to turn a doorknob.

In addition to the equivalent physical outcome, it would appear that Modified Constraint Induced Therapy has advantages over CIT in that it is often covered by private health insurance and possibly by public funding and the opt out rate is significantly reduced due to the less onerous requirements.

Variations

Further research has been undertaken by Steven Page (and colleagues Peter Levine and Jane Khoury) which has combined Modified Constraint Induced Therapy  with mental practice. The combination of these two therapies has shown even greater improvement for the patient over Modified Constraint Induced Therapy  alone.

Mental practice is the process of imagining performing a particular activity. This process has been on the agenda for some time, as I recall an anecdote of a study where a group of people were tested for their basketball shooting skills. One third of the people did no practice, one third practiced each day and one third mentally practiced each day. At the end of the study period, the improvement of the mental practice people was almost equivalent to that of the "real" practicers!

In the study that Steven Page offers (and this is very new, having only been published in the January 2009 edition of the Stroke Journal), patients received mCIT three days a week for a 10 week period (as described above). At the end of each therapy session, half the patients were given a relaxation tape to listen to and the other half were given a guided mental practice tape to listen to. At the end of this period, the improvement in those who did the mental practice was scored at almost twice that of those who did not.

How You Can Leverage This

Dr Taub, who created CIT, has suggested that "any technique that induces a patient to use an affected limb ... should be considered therapeutically efficacious." This means that whilst the disciplines of CIT and mCIT have proven effective, you can potentially get improvement with less onerous engagement.

Our personal experience is that this is the case. Peter has selected a limited number of daily activities that are important to him and that he focuses on performing with this affected hand. Initially, he supplemented this with the use of his biofeedback / muscle stimulation machine. What we have now noticed is a significant improvement in his left arm and hand. He has gone from the limb being virtually useless to being able to use it to set the indicator when driving, holding a vegetable to cut from it and for some carrying function.

You can also initiate mCIT therapy with an occupational therapist or physiotherapist. Involve them in the therapy sessions (whether as frequently as specified in mCIT or not) and follow up with practice at home (again, you don't need to do the full constrained period - or you can just consciously limit use of the non-affected limb). The simple act of trying to use the affected limb to do things each day seems to make a difference.

The mental practice study adds a new dimension. It is possible for anyone to go through the process of imagining a specific activity. Doing this after a therapy session is how the researchers have done it. But there's no reason why you can't do it before and after you work at a particular activity.p