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The behavior-analytic origins of constraint-induced movement therapy: An example of behavioral neurorehabilitation

Abstract

Constraint-induced (CI) therapy is a term given to a family of efficacious neurorehabilitation treatments including to date: upper extremity CI movement therapy, lower extremity CI movement therapy, pediatric CI therapy, and CI aphasia therapy. The purpose of this article is to outline the behavior analysis origins of CI therapy and the ways in which its procedures incorporate behavior analysis methods and principles. The intervention is founded on the concept of learned nonuse, a mechanism now empirically demonstrated to exist, which occurs after many different types of damage to the central nervous system (CNS). It results from the dramatic alteration of the contingencies of reinforcement that results from substantial CNS damage and leads to a greater deficit than is warranted by the actual damage sustained. CI therapy produces a countervailing alteration in the contingencies of reinforcement. The intervention has been used successfully to substantially improve motor deficits after stroke, traumatic brain injury, spinal cord injury, multiple sclerosis, with cerebral palsy in a pediatric population, and for language impairment in poststroke aphasia. The protocol of CI therapy consists primarily of standard behavior-analytic methods. It produces a marked plastic brain change that is correlated with its therapeutic effect, and therefore provides an example of the way in which behavior change can contribute to a profound remodeling of the brain. CI therapy may be viewed as an example of behavioral neurorehabilitation.

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References

  1. Azrin, N. H., & Holz, W. C. (1966). Punishment. In W. K. Honig (Ed.), Operant behavior: Areas of research and application (pp. 380–447). New York, NY: Appleton-Century-Crofts.

  2. Bauder, H., Sommer, M., Taub, E., & Miltner, W. H. R. (1999). Effect of CI therapy on movement-related brain potentials [Abstract]. Psychophysiology, 36 (Suppl. 1), S31.

  3. Bhogal, S. K., Teasell, R., & Speechley, M. (2003). Intensity of aphasia therapy, impact on recovery. Stroke, 34, 987–993.

  4. Candia, V., Elbert, T., Altenmüller, E., Rau, H., Schäfer, T., & Taub, E. (1999). Constraint-induced movement therapy for focal hand dystonia in musicians. Lancet, 353, 42.

  5. Candia, V., Schafer, T., Taub, E., Rau, H., Altenmüller, E., Rockstroh, B., et al. (2002). Sensory motor retuning: A behavioral treatment for focal hand dystonia of pianists and guitarists. Archives of Physical Medicine and Rehabilitation, 83, 1342–1348.

  6. Catania, A. C. (1998). Learning (4th ed.). Upper Saddle River, NJ: Prentice Hall.

  7. Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Erlbaum.

  8. DeBow, S. B., Davies, M. L. A., Clarke, H. L., & Colbourne, F. (2003). Constraint-induced movement therapy and rehabilitation exercises lessen motor deficits and volume of brain injury after striatal hemorrhagic stroke in rats. Stroke, 34, 1021–1026.

  9. Dettmers, C., Teske, U., Hamzei, F., Uswatte, G., Taub, E., & Weiller, C. (2005). Distributed form of constraint-induced movement therapy improves functional outcome and quality of life after stroke. Archives of Physical Medicine and Rehabilitation, 86, 204–209.

  10. Draganski, B., Gaser, C., Busch, V., Schuierer, G., Bogdahn, U., & May, A. (2004). Changes in grey matter induced by training. Nature, 427, 311–312.

  11. Draganski, B., Moser, T., Lummel, N., Gänssbauer, S., Bogdahn, U., Haas, F., et al. (2006). Decrease of thalamic gray matter following limb amputation. Neuroimage, 31, 951–957.

  12. Elbert, T., Pantev, C., Wienbruch, C., Rockstroh, B., & Taub, E. (1995). Increased cortical representation of the fingers of the left hand in string players. Science, 270, 305–307.

  13. Estes, W. K. (1944). An experimental study of punishment. Psychological Monographs, 57 (Serial No. 263).

  14. Flor, H., Elbert, T., Knecht, S., Wienbruch, C., Pantev, C., Birbaumer, N., et al. (1995). Phantom limb pain as a perceptual correlate of massive reorganization in upper limb amputees. Nature, 375, 482–484.

  15. Gauthier, L. V., Taub, E., Perkins, C., Ortmann, M., Mark, V. W., & Uswatte, G. (2008). Remodeling the brain: Plastic structural brain changes produced by different motor therapies after stroke. Stroke, 39, 1520–1525.

  16. Jenkins, W. M., Merzenich, M. M., Ochs, M. T., Allard, T., & Guic-Robles, E. (1990). Functional reorganization of primary somatosensory cortex in adult owl monkeys after behaviorally controlled tactile stimulation. Journal of Neurophysiology, 63, 82–104.

  17. Kirmess, M., & Maher, L. (2010). Constraint Induced language therapy in early aphasia rehabilitation. Aphasiology, 24, 725–736.

  18. Knapp, H. D., Taub, E., & Berman, A. J. (1959). Conditioned response following deafferentation in the monkey. Transactions of the American Neurological Association, 84, 185–187.

  19. Knapp, H. D., Taub, E., & Berman, A. J. (1963). Movements in monkeys with deafferented limbs. Experimental Neurology, 7, 305–315.

  20. Kopp, B., Kunkel, A., Mühlnickel, W., Villringer, K., Taub, E., & Flor, H. (1999). Plasticity in the motor ststem related to therapy-induced improvement of movement after stroke. NeuroReport, 10, 807–810.

  21. Kunkel, A., Kopp, B., Muller, G., Villringer, K., Villringer, A., Taub, E., et al. (1999). Constraint-induced movement therapy for motor recovery in stroke patients. Archives of Physical Medicine and Rehabilitation, 80, 624–628.

  22. Lassek, A. M. (1953). Inactivation of voluntary motor function following rhizotomy. Journal of Neuropathology and Experimental Neurology, 3, 83–87.

  23. Liepert, J., Bauder, H., Miltner, W. H. R., Taub, E., & Weiller, C. (2000). Treatment-induced cortical reorganization after stroke in humans. Stroke, 31, 1210–1216.

  24. Maguire, E. A., Gadian, D. G., Johnsrude, I. S., Good, C. D., Ashburner, J., Frackowiak, R. S. J., et al. (2000). Navigation-related structural change in the hippocampi of taxi drivers. Proceedings of the National Academy of Sciences, USA, 97, 4398–4403.

  25. Maher, L. M., Kendall, D., Swearengin, J. A., Rodriguez, A., Leon, S. A., Pingel, K., et al. (2006). A pilot study of use-dependent learning in the context of constraint induced language therapy. Journal of the International Neuropsychological Society, 12, 843–852.

  26. Mark, V., Taub, E., Bashir, K., Uswatte, G., Delgado, A., Bowman, M., et al. (2008). Constraint-induced movement therapy can improve hemiparetic progressive multiple sclerosis. Multiple Sclerosis, 14(7), 992–994.

  27. Mark, V., Taub, E., Bashir, K., Uswatte, G., Delgado, A., Bowman, M., et al. (2008). Constraint-induced movement therapy can improve hemiparetic progressive multiple sclerosis. Multiple Sclerosis, 14(7), 992–994.

  28. Mark, V. W., Taub, E., Uswatte, G., Bashir, K., Bryson, C., Bowman, M., et al. (2008). Impaired gait in progressive multiple sclerosis improves with constraint-induced movement therapy [Abstract]. Archives of Physical Medicine and Rehabilitation, 89(10), E5.

  29. Meinzer, M., Elbert, T., Barthel, G., Djundja, D., Taub, E., & Rockstroh, B. (2007). Extending the constraint-induced movement therapy (CIMT) approach to cognitive functions: Constraint-induced aphasia therapy (CIAT) of chronic aphasia. Neuro-Rehabilitation, 22, 311–318.

  30. Meinzer, M., Elbert, T., Wienburch, C., Djundja, D., Barthel, G., & Rockstroh, B. (2004). Intensive language training enhances brain plasticity in chronic aphasia. BMC Biology, 2, 20–29.

  31. Merzenich, M. M., Kaas, J. H., Wall, J., Nelson, R. J., Sur, M., & Felleman, D. (1983). Topographic reorganization of somatosensory cortical areas 3b and 1 in adult monkeys following restricted deafferentation. Neuroscience, 8, 33–55.

  32. Miltner, W. H. R., Bauder, H., Sommer, M., Dettmers, C., & Taub, E. (1999). Effects of constraint-induced movement therapy on chronic stroke patients: A replication. Stroke, 30, 586–592.

  33. Morgan, W. G. (1974). The shaping game: A teaching technique. Behavior Therapy, 5, 271–272.

  34. Mott, F. W., & Sherrington, C. S. (1895). Experiments upon the influence of sensory nerves upon movement and nutrition of the limbs. Proceedings of the Royal Society of London, 57, 481–488.

  35. Nudo, R. J., Wise, B. M., SiFuentes, F., & Milliken, G. W. (1996). Neural substrates for the effects of rehabilitative training on motor recovery after ischemic infarct. Science, 272, 1791–1794.

  36. Panyan, M. V. (1980). How to use shaping. Lawrence, KS: H & H Enterprises.

  37. Pulvermüller, F. (1990). Aphasische kommunikation. Grundfragen ihrer analyse und therapie [Communication in aphasics. Basic questions and therapeutic approaches]. Tue-bingen, Germany: Gunter Narr Verlag.

  38. Pulvermüller, F., Neininger, B., Elbert, T., Mohr, B., Rockstroh, B., Köbbel, P., et al. (2001). Constraint-Induced therapy of chronic aphasia following stroke. Stroke, 32, 1621–1626.

  39. Pulvermüller, F., & Schonle, P. (1993). Behavioral and neuronal changes during treatment of mixed transcortical aphasia. Cognition, 48, 139–161.

  40. Raymer, A., Beeson, P., Holland, A., Kendall, D., Maher, L., Martin, N., et al. (2008). Translational research in aphasia: From neuroscience to neurorehabilitation. Journal of Speech, Hearing, & Language Research, 5(1), S259–S275.

  41. Shaw, S. E., Morris, D. M., Uswatte, G., McKay, S. B., & Taub, E. (2003). Adherence to constraint induced movement therapy procedures and outcome for persons with traumatic brain injury. Journal of Neurologic Physical Therapy, 27(4), 180.

  42. Sherrington, C. S. (1910). Remarks on the reflex mechanism of the step. Brain, 33, 1–25.

  43. Skinner, B. F. (1938). The behavior of organisms. New York, NY: Appleton-Century-Crofts.

  44. Skinner, B. F. (1968). The technology of teaching. New York, NY: Appleton-Century-Crofts.

  45. Sterr, A., Elbert, T., Berthold, I., Kölbel, S., Rockstroh, B., & Taub, E. (2002). Longer versus shorter daily constraint-induced movement therapy of chronic hemiparesis: An exploratory study. Archives of Physical Medicine and Rehabilitation, 83, 1374–1377.

  46. Taub, E. (1977). Movement in nonhuman primates deprived of somatosensory feedback. Exercise and sports science reviews (Vol. 4, pp. 335–374). Santa Barbara, CA: Journal Publishing Affiliates.

  47. Taub, E. (1980). Somatosensory deafferentation research with monkeys: Implications for rehabilitation medicine. In L. P. Ince (Ed.), Behavioral psychology in rehabilitation medicine: Clinical applications (pp. 371–401). New York, NY: Williams & Wilkins.

  48. Taub, E. (2002). CI therapy: A new rehabilitation technique for aphasia and motor disability after neurological injury. Klinik und Forschung, 8, 48–49.

  49. Taub, E., & Berman, A. J. (1963). Avoidance conditioning in the absence of relevant proprioceptive and exteroceptive feedback. Journal of Comparative and Physiological Psychology, 56, 1012–1016.

  50. Taub, E., & Berman, A. J. (1968). Movement and learning in the absence of sensory feedback. In S. J. Freedman (Ed.), The neuropsychology of spatially oriented behavior (pp. 173–192). Homewood, IL: Dorsey.

  51. Taub, E., Crago, J. E., Burgio, L. D., Groomes, T. E., Cook, E. W., DeLuca, S. C., et al. (1994). An operant approach to rehabilitation medicine: Overcoming learned nonuse by shaping. Journal of the Experimental Analysis of Behavior, 61, 281–293.

  52. Taub, E., Ellman, S. J., & Berman, A. J. (1966). Deafferentation in monkeys: Effect on conditioned grasp response. Science, 151, 593–594.

  53. Taub, E., Goldberg, I. A., & Taub, P. B. (1975). Deafferentation in monkeys: Pointing at a target without visual feedback. Experimental Neurology, 46, 178–186.

  54. Taub, E., Griffin, A., Gammons, K., Nick, J., Uswatte, G., & Law, C. R. (2006). CI therapy for young children with congenital hemiparesis. Atlanta, GA: Society for Neuroscience.

  55. Taub, E., Griffin, A., Nick, J., Gammons, K., Uswatte, G., & Law, C. R. (2007). Pediatric CI therapy for stroke-induced hemiparesis in young children. Developmental Neurorehabilitation, 10, 1–16.

  56. Taub, E., Griffin, A., Uswatte, G., Gammons, K., Nick, J., & Law, C. R. (2011). Treatment of congenital hemiparesis with pediatric constraint-induced movement therapy Journal of Child Neurology, 26, 1163–1173.

  57. Taub, E., Heitman, R., & Barro, G. (1977). Alertness and level of activity and purposive movement following deafferentation in the adult and developing monkey. In H. P. Zeigler & B. M. Wenzel (Eds.), Tonic functions of sensory systems (Vol. 290, pp. 348–365). Ann, NY: Academic Sciences.

  58. Taub, E., Miller, N. E., Novack, T., Cook, E. W., III., Fleming, W. C., Nepomuceno, C. S., et al. (1993). Technique to improve chronic motor deficit after stroke. Archives of Physical Medicine and Rehabilitation, 74, 347–354.

  59. Taub, E., Perrella, P. N., & Barro, G. (1973). Behavioral development following forelimb deafferentation on day of birth in monkeys with and without blinding. Science, 181, 959–960.

  60. Taub, E., Perrella, P. N., Miller, D., & Barro, G. (1975). Diminution of early environmental control through perinatal and prenatal somatosensory deafferentation. Biological Psychiatry, 10, 609–626.

  61. Taub, E., Ramey, S. L., DeLuca, S., & Echols, E. (2004). Efficacy of constraint-induced (CI) movement therapy for children with cerebral palsy with asymmetric motor impairment. Pediatrics, 113, 305–312.

  62. Taub, E., & Uswatte, G. (2009). Constraint-induced movement therapy: A paradigm for translating advances in behavioral neuroscience into rehabilitation treatments. In G. Berntson & J. Cacioppo (Eds.), Handbook of neuroscience for the behavioral sciences (Vol. 2, pp. 1296–1319). Hoboken, NJ: Wiley.

  63. Taub, E., Uswatte, G., King, D. K., Morris, D., Crago, J., & Chatterjee, A. (2006). A placebo controlled trial of constraint-induced movement therapy for upper extremity after stroke. Stroke, 37, 1045–1049.

  64. Taub, E., Uswatte, G., Mark, V., & Morris, D. (2006). The learned nonuse phenomenon: Implications for rehabilitation. Europa Medicophysica, 42(2), 241–255.

  65. Taub, E., Uswatte, G., Mark, V., & Morris, D. (2006). The learned nonuse phenomenon: Implications for rehabilitation. Europa Medicophysica, 42(2), 241–255.

  66. Taub, E., Uswatte, G., & Pidikiti, R. (1999). Constraint-induced movement therapy: A new family of techniques with broad application to physical rehabilitation—a clinical review. Journal of Rehabilitation Research and Development, 36, 237–251.

  67. Taub, E., Williams, E., Barro, G., & Steiner, S. S. (1978). Comparison of the performance of deafferented and intact monkeys on continuous and fixed ratio schedules of reinforcement. Experimental Neurology, 58, 1–13.

  68. Timberlake, W. (1993). Behavior systems and reinforcement: An integrative approach. Journal of the Experimental Analysis of Behavior, 60, 105–128.

  69. Twitchell, T. E. (1954). Sensory factors in purposive movement. Journal of Neurophysiology, 17, 239–254.

  70. Uswatte, G., Miltner, W. H. R., Varma, M., Moran, S., Sharma, V., Foo, B., et al. (1998). Accelerometry: An objective approach to real-world outcome measurement in physical rehabilitation. Paper presented at the inaugural meeting of the Program in Cognitive Rehabilitation of the James S. McDonnell Foundation, St. Louis, MO.

  71. Uswatte, G., Miltner, W., Walker, H., Spraggins, S., Moran, S., Calhoun, J., et al. (1997). Accelerometers in rehabilitation: Objective measurement of extremity use at home [Abstract]. Rehabilitation Psychology, 42, 139.

  72. Uswatte, G., Spraggins, S., Walker, H., Calhoun, J., & Taub, E. (1997). Validity and reliability of accelerometry as an objective measure of upper extremity use at home [Abstract]. Archives of Physical Medicine and Rehabilitation, 78, 896.

  73. Uswatte, G., Taub, E., Morris, D., Barman, J., & Crago, J. (2006). Contribution of the shaping and restraint components of constraint-induced movement therapy to treatment outcome. NeuroRehabilitation, 21(2), 147–156.

  74. Uswatte, G., Taub, E., Morris, D., Barman, J., & Crago, J. (2006). Contribution of the shaping and restraint components of constraint-induced movement therapy to treatment outcome. NeuroRehabilitation, 21(2), 147–156.

  75. Uswatte, G., Taub, E., Morris, D., Light, K., & Thompson, P. (2006). The motor activity Log-28: Assessing daily use of the hemiparetic arm after stroke. Neurology, 67, 1189–1194.

  76. Uswatte, G., Taub, E., Morris, D., Vignolo, M., & McCulloch, K. (2005). Reliability and validity of the upper-extremity motor activity Log-14 for measuring real-world arm use. Stroke, 36, 2493–2496.

  77. van der Lee, J., Beckerman, H., Lankhorst, G., & Bouter, L. (1999). Constraint-induced movement therapy [Letter to the Editor]. Archives of Physical Medicine and Rehabilitation, 80, 1606.

  78. Weiss, T., Miltner, W. H. R., Adler, T., Bruckner, L., & Taub, E. (1999). Decrease in phantom limb pain associated with prosthesis-induced increased use of an amputation stump in humans. Neuroscience Letters, 272, 131–134.

  79. Wittenberg, G. F., Chen, R., Ishii, K., Bushara, K. O., Taub, E., Gerber, L. H., et al. (2003). Constraint- induced therapy in stroke: Magnetic-stimulation motor maps and cerebral activation. Neurorehabilitation and Neural Repair, 17, 48–57.

  80. Wolf, S., Winstein, C., Miller, J., Taub, E., Uswatte, G., Morris, D., et al. (2006). Effect of constraint-induced movement therapy on upper extremity function 3–9 months after stroke: The EXCITE randomized clinical trial. Journal of the American Medical Association, 296, 2095–2104.

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Author information

Correspondence to Edward Taub.

Additional information

This research was supported by Grant HD34273 from the National Institutes of Health, Grants W98 0410 and B2490T from the U.S. Department of Veterans Affairs, Grant RG 4221-A-201 from the Multiple Sclerosis Society, Grants 0365163B, 0815065E, and 0715450B from the American Heart Association Southeast Affiliate, and Grant 97-41 from the James S. McDonnell Foundation. I thank the following collaborators: Gitendra Uswatte, Neal E. Miller, Victor Mark, David Morris, Jean E. Crago, Angi Griffin, Mary M. Bowman, Staci Bishop-McKay, Danna Kay King, Sonya Pearson, Camille Bryson, Michelle Spear, Adriana Delgado, Francilla Allen, Christy Bussey, Margaret Johnson, Leslie Harper, Jamie Wade, Edwin W. Cook, III, and Louis D. Burgio. I also thank Gitendra Uswatte and Edgar E. Coons for critical and insightful readings of this manuscript.

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Taub, E. The behavior-analytic origins of constraint-induced movement therapy: An example of behavioral neurorehabilitation. BEHAV ANALYST 35, 155–178 (2012). https://doi.org/10.1007/BF03392276

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Key words

  • CI therapy
  • CI movement therapy
  • CI aphasia therapy
  • stroke
  • central nervous system injury
  • neurorehabilitation
  • behavior analysis