Constraint-induced movement therapy (CI, CIT, or CIMT)

Constraint-induced movement therapy (CIMT) is a series of rehabilitation techniques to help patients improve their ability to use their limbs. CIMT has been used in patients with a variety of medical issues, including those who have experienced strokes or traumatic brain injury, individuals with multiple sclerosis, and children with hemiplegia or unilateral cerebral palsy, which means paralysis or motor disorder affecting movement and muscle tone on one side of the body.

CIMT involves limiting the patient’s use of the limb that is less affected—for example, by putting the less affected arm in a sling or mitt for most of the day—and having the patient use the other limb almost exclusively for two to three weeks. The patient also receives several hours of training using the more affected limb daily. Another treatment, modified CIMT (mCIMT), is similar but includes less daily training while the more affected limb is restricted.

Studies have found that CIMT can have an effect on brain activity. Imaging studies show that areas of the brain related to moving the more affected limb undergo structural changes in patients engaged in CIMT. This has been described as a rewiring of the brain.

Background

CIMT is based on the research of behavioral neuroscientist Edward Taub and others at the University of Alabama at Birmingham. Taub began the work earlier, however. He was a graduate student at Columbia University when he conducted laboratory work in a research institute at the Jewish Chronic Disease Hospital in New York. Researchers operated on monkeys to sever the spinal nerve connection, allowing them to feel sensation in one or both front limbs. The monkeys used these limbs as supports to move around and to grasp and manipulate items. Although the limbs were not affected in any other way—they still operated as before—the monkeys stopped using the limbs that lacked sensation.

Researchers persuaded the monkeys to use the affected limbs through several conditioning techniques. For example, the monkey could learn to move the limb when it hears a sound, such as a buzzer, because if it failed to move the limb, it received a small electric shock. Taub and the other researchers also tried a restraint method—the unaffected limb was restrained using a straitjacket, so the monkey could not use it, but the affected limb was left free. If the monkey did not use the affected limb, it was more or less helpless. Food was placed outside of the monkeys’ cages. Researchers found that within a few hours, the monkeys began to use the unbound limbs. They reached out to pick up the food and managed to feed themselves. Some of the monkeys began using the unbound limbs to support their bodies as they moved around their cages. Their movements were clumsy because they did not have sensation in the limbs, but they were able to function well. After one week with the unaffected limbs bound, the monkeys continued to use the limbs that did not have sensation. This behavior continued and was found to be permanent. Taub and his colleagues began to publish papers on their monkey studies during the 1960s, although the work continued for decades.

The researchers worked to build on knowledge from earlier studies. Previous studies had concluded that without sensory input, a living creature could not move or use its limbs. Taub’s research clearly proved this to be untrue. The work also disproved ideas about the adult brain. Previously, researchers believed only immature brains could adapt—they had what is called plasticity—but the monkey experiments showed that adult primate brains were not rigid and set.

Researcher Larry Anderson, who had observed Taub’s work, attempted to translate Taub’s findings to human patients in 1967. Anderson immobilized the unaffected arms of three stroke patients. He sounded a tone. Patients who did not move their affected but unbound arms received mild electric shocks. After some success with his small study, Anderson applied his work to a larger group of twenty-four stroke patients. All of the patients in this group saw improvement in their affected limbs. Taub began a series of his own experiments using human stroke patients in 1986.

Overview

CIMT is based on learned non-use. This is the idea that when a person does not use a limb, the person’s brain forgets how to use it.

Learned non-use often arises when an individual does not try to use a weakened limb because it is just easier to use the other one. The less the affected limb is used, the greater the loss of mobility as the brain forgets how to use it; this leads the person to rely even more on the other limb, creating a cycle of non-use. This prevents the individual from regaining strength in and using an affected limb.

CIMT helps to counteract learned non-use by forcing the individual to use the affected limb. This use helps the brain relearn how to operate the limb. Physical therapists have found that the adage “use it or lose it” is true in recovery, and patients must use the affected limbs regularly to rewire the brain and regain control of the limbs.

Many stroke patients need to relearn how to use an affected arm and hand. A physical therapist often begins working with a stroke patient by restraining the functional arm with a mitt for 90 percent of the patient’s waking time. The patient undergoes supervised practice of repetitive tasks using the affected free hand. This helps the brain repair and reorganize the pathways required to use the limb. These repetitive tasks involve shaping, or adaptive task practice (ATP). This means the therapist breaks tasks down into manageable pieces and then changes one part of it at a time. For example, making a telephone call involves picking up the phone and dialing a number. Shaping might involve learning to grasp the phone first. After the patient repeatedly practices this action, the therapist might have the patient grasp the phone and bring it to their ear. After repeatedly practicing these steps, the patient would add another step, and so on.

When used soon after the event that caused paralysis, such as a stroke, CIMT may prevent patients from developing learned non-use. CIMT has been found to be effective even long after patients have experienced loss of limb control, however. Physical therapists advise patients to begin therapy no matter how much time has passed.

The 2023 National Institute for Health and Care Excellence (NICE) update reiterated its recommendation that CIMT could be considered for some patients with stroke who already have a minimum amount of wrist and finger movement. A 2025 clinical study showed that CIMT could reduce shoulder pain and improve arm movement in patients with stroke, with effects lasting for at least three months after treatment.

Bibliography

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Schwartz, Jeffrey M., and Sharon Begley. The Mind and the Brain: Neuroplasticity and the Power of Mental Force. HarperCollins, 2002, pp. 138–62.

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Wolf, Steven L., et al. “The EXCITE Stroke Trial: Comparing Early and Delayed Constraint-Induced Movement Therapy.” Stroke, vol. 41, no. 10, Oct. 2010, pp. 2309–15.