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Constraint-induced movement therapy for the leg (CIMT-Leg)

Last update: 6 May 2016

► CIMT-Leg is used with children with hemiplegic cerebral palsy to help develop gross motor skills
► A splint or orthosis is worn on the well-functioning leg to limit its use and give the child extra opportunities to use his or her hemiplegic leg.
► While the splint is worn, the child practices gross motor skills .

Who is it for?

Although research has not yet been completed on CIMT-Leg, it may be suitable to trial with children and adults with hemiplegic cerebral palsy and the following characteristics:
Age: Infants and Toddlers, Preschoolers, School-aged, Adolescents, Adults, Older adults
Type of cerebral palsy : Hemiplegia, Unilateral cerebral palsy

More information about cerebral palsy is contained in the What is CP? section.

Mobility : GMFCS I, GMFCS II, GMFCS III

Gross Motor Function Classification System (GMFCS) – classifies severity of mobility difficulties of children and adolescents with CP.

GMFCS Level I
Walks without limitations in the home and community, climbs stairs and can run and jump, difficulties with speed and coordination.

GMFCS Level II
Walks with limitations, difficulties with long distances and uneven surfaces, uses a railing for climbing stairs, limited running and jumping.

GMFCS Level III
Walks using a hand-held mobility device such as crutches or walking frame, may use wheeled mobility for long distances.

GMFCS Level IV
Usually relies on wheeled mobility with assistance, may use powered mobility, usually needs special seating and assistance with transfers.

GMFCS Level V
Usually transported in a manual wheelchair, requires specialised seating and full assistance for transfers.

Arm ability : MACS I, MACS II, MACS III, MACS IV, MACS V

Manual Ability Classification System (MACS) – classifies severity of upper limb impairment: how children with cerebral palsy use their hands to handle objects in daily activities in the home, school, and community settings.

MACS Level I
Handles objects easily and successfully.

MACS Level II
Handles most objects but with somewhat reduced quality and/or speed of achievement.

MACS Level III
Handles objects with difficulty; needs help to prepare and/or modify activities.

MACS Level IV
Handles a limited selection of easily managed objects in adapted situations.

MACS Level V
Does not handle objects and has severely limited ability to perform even simple actions.

Communication ability : CFCS I, CFCS II, CFCS III, CFCS IV, CFCS V

Communication Function Classification System (CFCS) – classifies severity of everyday communication of people with cerebral palsy.

CFCS Level I
Effective Sender and Receiver with unfamiliar and familiar partners.

CFCS Level II
Effective but slower paced Sender and/or Receiver with unfamiliar and/or familiar partners.

CFCS Level III
Effective Sender and Receiver with familiar partners.

CFCS Level IV
Inconsistent Sender and/or Receiver with familiar partners.

CFCS Level V
Seldom effective Sender and Receiver even with familiar partners.

Movement disorder : Ataxia, Athetosis, Dystonia, Hypotonia, Spasticity

More information about movement disorders can be found on our websites.

Intellectual ability : No intellectual disability, Mild intellectual disability, Moderate intellectual disability

A person’s thinking skills – ability to understand ideas, learn and solve problems. People with intellectual disability have difficulty with intellectual functioning which may influence learning, communication, social and daily living skills. Intellectual disability may be mild to very severe.

Who can assist?

CIMT-Leg is usually provided by physiotherapists and other similarly qualified rehabilitation specialists or allied health professionals. The therapist and family will work together on ways to make therapy part of everyday life; during play time, at the park and at preschool. It’s important to use fun activities, so the child is motivated to practice.

Cerebral Palsy Alliance offers a service where our physiotherapists can help your family decide if CIMT-Leg is a good choice for you and your child.

Find a Cerebral Palsy Alliance service

Fees

Fees will apply for physiotherapy assessment and intervention, and will depend on the provider and the number of sessions needed. Check with the physiotherapist whether fees will also apply for development of a home program, report writing or therapist travel.

A splint will also be required to restrain the well-functioning leg. Ask the physiotherapist if you are eligible for funding to assist with fees and the leg splint. People with a disability living in Australia may be eligible for a health care rebate through Medicare or funding from the National Disability Insurance Scheme.

Time

As yet, no research into CIMT-Leg for children with cerebral palsy has been carried out – so there is limited evidence to guide how frequently and intensively therapy should take place.

The current suggestion is to provide at least 60 hours of intensive intervention, over two to eight weeks. To achieve this intensity, children will need to follow a home program of exercises and also have regular face-to-face therapy with a physiotherapist.

This recommendation is based on what has been learnt through using constraint-induced movement therapy for the arms of children with cerebral palsy and the legs of adults with hemiplegia caused by stroke.

More about constraint-induced movement therapy for the leg

Constraint-induced movement therapy is an established intervention to increase the movement of the affected arm of children with hemiplegic cerebral palsy1 (affecting one side of the body).

In recent years, it has also been found to improve the leg movement - including balance and walking ability - of adults with hemiplegia caused by stroke2-4.

In a new development, therapists are trialling constraint-induced movement therapy for the leg (CIMT-Leg for short) to improve the gross motor skills of children with one leg affected – to improve their crawling, standing, walking, and balance.

Assessments

There are two types of assessment which are necessary when using CIMT-Leg.

To guide intervention

A thorough assessment with a physiotherapist before starting CIMT-Leg is required to identify the goals for therapy and ensure the program is suitable for the child’s ability level. Assessments throughout the therapy process are also required to check if the intervention is suitable for the child and family.

To measure the outcome of the intervention

The second type of assessment is to measure the outcome of the intervention to ensure that CIMT-Leg is meeting the child’s needs and helping them achieve their goals. A physiotherapist, together with the child and family, will decide on the most suitable measures. Outcome measures typically used for this intervention are:

  • Goal Attainment Scaling (GAS goals) – measures the extent to which individuals’ goals are achieved and can be used to measure change in gross motor ability
  • Gross Motor Function Measure (GMFM) – measures change over time in children’s gross motor abilities
  • Timed Up and Go Test – tests mobility and balance by measuring time taken to stand up, walk three metres, turn around and sit down again
  • 6 Minute Walk Test – measures mobility by the distance a child can walk in six minutes.

The physiotherapist may also measure the range of motion and strength of both legs.

Best available research evidence

Where did we search?

We searched the allied health and medical literature to find research evaluating the outcomes of using CIMT-Leg for children with hemiplegic cerebral palsy.

What were we looking for?

The search aimed to find the best available research into whether this intervention improved balance, leg strength and gross motor skills.

What did we find?

No studies were found for children with cerebral palsy. The search was then expanded to find high level studies (systematic reviews and randomised controlled trials) of adults with hemiplegia following stroke.

No high level studies were found. However, a small number of low level studies suggests that CIMT-Leg used by people following stroke improves balance, leg function and mobility3,4.

Why research is limited

The lack of research on the effectiveness and potential risks of CIMT-Leg for children with cerebral palsy is because this approach is still in its infancy.

CIMT-Leg is a means of achieving an intensive intervention. This, in combination with the low level evidence that does exist on its use with adults following stroke, suggests it may be worthwhile trialling with children with cerebral palsy. Physiotherapists and families considering CIMT-Leg should work together to identify goals for this therapy and carefully monitor the way it is implemented and the results achieved.

Date of literature searches: November 2015

  1. Eliasson, A. C., Krumlinde-Sundholm, L., Gordon, A. M., Feys, H., Klingels, K., Aarts, P. B., . . . Hoare, B. (2014). Guidelines for future research in constraint-induced movement therapy for children with unilateral cerebral palsy: An expert consensus. Developmental Medicine and Child Neurology, 56(2), 125-137. doi: 10.1111/dmcn.12273
  2. Corbetta, D., Sirtori, V., Castellini, G., Moja, L., & Gatti, R. (2015). Constraint-induced movement therapy for upper extremities in people with stroke. Cochrane Database Syst Rev, 10, CD004433. doi: 10.1002/14651858.CD004433.pub3
  3. Kallio, K., Nilsson-Wikmar, L., & Thorsén, A.-M. (2014). Modified constraint-induced therapy for the lower extremity in elderly persons with chronic stroke: Single-subject experimental design study. Topics in Stroke Rehabilitation, 21(2), 111-119. doi: 10.1310/tsr2102-111 See abstract
  4. Marklund, I., & Klässbo, M. (2006). Effects of lower limb intensive mass practice in poststroke patients: Single-subject experimental design with long-term follow-up. Clinical Rehabilitation, 20(7), 568-576. See abstract
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