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“I got knowledge of myself and my prospects for leading an easier life”:
Stroke patients' experience of training with lower-limb CIMT
Ingela Marklund abc ; Maria Klässbo d ; Birgitta Hedelin ef
a Department of Physiotherapy, Torsby Hospital, Sweden b Research Centre for Primary Care,
Värmland County Council, Karlstad, Sweden c Department of Community Medicine and
Rehabilitation, Umeå University, Sweden d Centre for Clinical Research, Värmland County Council,
Karlstad, Sweden e Department of Nursing, Gjövik University College, Gjövik, Norway f Department
of Nursing Science, Karlstad University, Karlstad, Sweden
First published on: 04 August 2009
To cite this Article Marklund, Ingela, Klässbo, Maria and Hedelin, Birgitta(2009) '“I got knowledge of myself and my
prospects for leading an easier life”: Stroke patients' experience of training with lower-limb CIMT', Advances in
Physiotherapy,, First published on: 04 August 2009 (iFirst)
To link to this Article: DOI: 10.1080/14038190903141048
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Downloaded By: [Marklund, Ingela] At: 07:14 27 November 2009
Advances in Physiotherapy
2009, 1 8, iFirst article
ORIGINAL ARTICLE
‘‘I got knowledge of myself and my prospects for leading an easier
life’’: Stroke patients’ experience of training with lower-limb CIMT
INGELA MARKLUND 1 , MARIA KLÄSSBO 2 & BIRGITTA HEDELIN 3
1 Department of Physiotherapy, Torsby Hospital, Sweden, Research Centre for Primary Care, Värmland County Council,
Karlstad, Sweden and Department of Community Medicine and Rehabilitation, Umea˚ University, Sweden, 2 Centre for
Clinical Research, Värmland County Council, Karlstad, Sweden, 3 Department of Nursing, Gjövik University College, Gjövik,
Norway and Department of Nursing Science, Karlstad University, Karlstad, Sweden
Abstract
Rehabilitation after stroke has changed and more studies with intensive therapy have been conducted. When a new
method here lower-limb constraint-induced movement therapy (CIMT) is introduced, it is important to investigate
participants’ own experience of the therapy. The present purpose was accordingly to describe stroke patients’ experience of
training with lower-limb CIMT. Qualitative interviews with seven stroke patients who had participated in lower-limb CIMT
were conducted. The interviews were transcribed verbatim and analysed with qualitative content analysis. One theme,
knowledge of myself and my prospects for leading an easier life, emerged. Two main categories were found: the therapy and me and
my body, with four and three categories respectively. The therapy comprised the informants’ experience of preparation for
CIMT, the actual intensive training and its effects, and their views on the physiotherapists involved. Me and my body
comprised the informants’ reflections on their own significance for the therapy, how the reflections had affected them and
what insight into their condition CIMT had given. The informants reported that CIMT for the lower extremity gave them
knowledge of their body and their prospects for leading an easier life. The intensive training instilled hope, since the
functional improvements showed the possibilities of improvements, increasing the respondents’ independence and selfesteem.
Even though the intensive training is tough, it was experienced as entirely necessary.
Key words: Stroke, physiotherapy, Constraint-induced movement therapy, qualitative content analysis
Introduction
Stroke is among the most common causes of invalidity
in Sweden. With lengthening life expectancy and
survival after earlier stroke, the prevalence is increasing
(1). The situation is of great importance in the
community and similar in many western countries.
Constraint-induced movement therapy (CIMT) is
an approach in stroke rehabilitation, developed by
Taub & Wolf (2). It targets motor recovery by
limiting the use of the unaffected limb and promoting
normal co-ordinated movement of the affected
limb through massed practice. The therapy involves
placing the unaffected upper extremity in a sling and
targeting training of the affected upper extremity 6 h/
day for 2 weeks (2 4). Studies show that CIMT can
improve activities of daily living (ADL), and that
these improvements persist at follow-up 2 years after
completed CIMT. The brain’s plastic ability has
been investigated in connection with intensive training
and is considered to play a part in explaining the
effect of CIMT (2,5 7).
Formerly, when a person with stroke has arrived at
a plateau of functional recovery, it was hard to
achieve further improvements. However, Page et al.
(8) considered that this should be reassessed.
Instead, rehabilitation interventions should be reviewed
regarding their intensity, and training should
be more varied to overcome learned movement
patterns. Kwakkel et al. (9) showed in their review
article that intensity, defined in time, is significant.
Higher therapy intensity gave better results in ADL
and in neuromuscular function.
How people with stroke experience CIMT is still
unknown. In one article, post-stroke patients and
Correspondence: Ingela Marklund, Department of Physiotherapy, Torsby Hospital, Box 502, 685 29 Torsby, Sweden. E-mail: ingela.marklund@liv.se
(Received 18 February 2009; accepted 23 June 2009)
ISSN 1403-8196 print/ISSN 1651-1948 online # 2009 Informa UK Ltd.
DOI: 10.1080/14038190903141048

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2 I. Marklund et al.
personnel were both asked their views on the
method employed, but none of them have had
personal experience of CIMT (10). On the other
hand, some articles describe how it is to live with
stroke and their experiences when physiotherapy/
rehabilitation interventions are concluded (11 13).
People with stroke often have high goals and
expectations regarding rehabilitation. Some consider
that there cannot be too much training and express
their disappointment at not getting enough (13).
One interview study also shows that younger persons
with stroke become frustrated that the rehabilitation
is not adapted to their needs (14).
Few published articles discuss CIMT for the
lower extremity. The effect of CIMT for the lower
extremity appears to resemble that for the upper
extremity (15 17). Regarding CIMT for the lower
extremity, the leg cannot be fixed in a sling. The use
of the unaffected limb can be restricted with a
whole-leg orthosis that prevents knee flexion
(16,17). The lower-limb CIMT (16,18) consists of
training 6 h/day for 2 weeks. Each training session
last for an hour and the patients are active at least
40 min of every hour. The patients are instructed to
perform as near their maximum as they could in
every session. To increase the use of the affected leg,
daily training included in varying order cycling,
pool training, functional strength training in different
start position (sitting down, stand up and lay
down), load exercises with weight transfer, standing,
weight-bearing in different directions, stair training
without use of banister, indoor walking, outdoor
walking on uneven surfaces and passive (joint)
mobility training.
When a new method is introduced, it is important
to investigate participants’ own experience of the
therapy. The present purpose was to describe what
experience people with stroke have of CIMT for the
lower extremity.
Methods
The study has an inductive qualitative approach
based on the assumption that people’s experience
constitutes significant knowledge. The aim of such
approaches is to obtain rich descriptions of the
phenomenon under study. For this reason, openness
to the informants’ experience is important (19,20).
Informants and data collection
The informants were recruited from a rehabilitation
department in Sweden where CIMT for the lower
extremities is conducted. CIMT for the lower
extremity at this department consist of intensive
training 6 h/day for 2 weeks, with the unaffected leg
restricted with a whole-leg orthosis. Strength training,
weight-bearing in different directions, indoor/
outdoor walking, stair training and stretching of stiff
muscles are included in the programme. The inclusion
criteria for participating in lower-limb CIMT
at this clinic were: the patients have to be able to
walk outdoors with or without walking aid, motivated
and prepared for the hard training; score over
23/30 points in the Mini-Mental State Examination
(MMSE) and not more than 4 s difference between
results from Timed Up and Go (TUG) with and
without a glass of water were also required. At this
rehabilitation department, 16 people had participated
in CIMT for the lower extremity when this
study started.
Inclusion criteria in this study referred to people
with stroke who: 1) had completed CIMT for the
lower extremity, 2) were resident in Sweden, 3) were
able to express themselves in Swedish and 4) were not
suffering from other serious diseases. Exclusion
criteria were patients known or treated by the authors.
Twelve people met the inclusion criteria and
received oral and written information from the
treating physiotherapist and a reply-paid letter to
notify their interest to participate. Seven informants,
four men and three women, expressed interest and
gave their informed consent (Table I). All had
participated in traditional care for patients with
stroke, in Sweden, before CIMT for the lower
extremity.
Data was collected during October and November
2006 using qualitative interviews in the informant’s
homes, except for one informant where the interview
was held at the rehabilitation department. An interview
guide was used, containing the overall prompt,
‘‘Describe how you experienced the intensive training’’.
Follow-up questions were then asked for more
depth and clarification. The interviews took 35
60 min, were recorded and then transcribed verbatim
by the author (IM) (one interview) and by a
medical secretary (six interviews).
Table I. Characteristics of the informants included in the study.
Informant Sex
Age
(years)
Affected
side
(right/left)
Time since
stroke
event
(years)
1 Man 48 Left 4
2 Woman 57 Right 11
3 Man 65 Right 1
4 Man 49 Left 6
5 Woman 74 Left 4
6 Woman 35 Right 16
7 Man 58 Left 3

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The author (IM) has experience of working, for
several years, as a physiotherapist with people with
neurological diseases and has conducted CIMT both
for upper and lower extremity in persons with stroke
before the study started. The other authors have
minor or none experience of working with persons
with stroke or CIMT but have used qualitative
interviews for research purposes.
Data analysis
The data material was processed using qualitative
content analysis (21,22). The authors met and
analysed three interviews jointly, after which one of
them (IM) analysed the remaining four in the same
way with continuous feedback from the other
authors throughout the whole process. First, all
data was read by all the authors to obtain a sense
of the whole. Then meaningful units were extracted
and condensed to capture key thoughts or concepts.
These meaningful units were labelled and sorted by
similarities and differences. The latent content, i.e.
the implicit meaning of the text, and the manifest
content, what was explicit expressed, were analysed.
Main categories and categories were created from
the manifest content of the material and were
exhaustive and mutually exclusive (21). Finally,
one theme was formulated that corresponded to
the latent content of the texts (22).
Ethical considerations
The regional Board of Research Ethics at Uppsala
University, Sweden, (Dnr2006/039) approved the
study.
Results
When analysing the data one theme emerged knowledge
of myself and my prospects for leading an easier life.
This theme constituted the latent content of
the material. Two main categories the manifest
content were found: the therapy and me and my
body, with four and three categories respectively
(Table II).
Stroke patients’ experience of training with lower-limb CIMT 3
Knowledge of myself and my prospects for leading an
easier life
The informants stated that lower-limb CIMT,
through intensive repetition both in the training
and in the information/education, gave them knowledge
about themselves and the function of their
bodies. This knowledge helped them to live their
lives more easily. They felt that there was still hope
and possibilities for functional improvements, which
gave them increased independence and self-esteem.
But when I look back on CIMT, I see that ...it
was this that in fact changed everything, it made
things really great. [I:5]
The therapy
The main category the therapy comprised the informant’s
experiences of the preparations for CIMT,
the actual intensive training, its effects and their
views of the physiotherapists who conducted CIMT.
Preparation. The preparation for CIMT was considered
important for all informants. Since the lowerlimb
CIMT involve hard and intensive training, it
was important to accept this and be prepared for it to
be tough. Three of the informants had previous
experience of CIMT for the upper extremity and
they felt that their earlier experiences were crucial for
how they could benefit from the lower-limb therapy.
The others felt they could have benefited even more
from the therapy a second time, when they knew
what was required of them. During the preparations,
goals and goal images were identified by the participants
themselves, as part of the motivation process
to give them strength for the intensive training. The
preparation was also important for others, as well as
for the informants.
...Then you had to go to an information meeting
and take a relative with you because these relatives
must also accept that it’s going to be so tough.
[I:5]
Table II. Stroke patients’ experience of training with lower limb CIMT: Theme, main categories and categories derived from analysing
interviews.
Theme Knowledge of myself and my prospects for leading an easier life
Main category The therapy Me and my body
Categories Preparation The training Effects Physiotherapists Motive force Changes Frustration

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4 I. Marklund et al.
The training. The training was experienced as concentrated,
intensive and challenging, since each
exercise was always at the limit of each individual’s
ability and capacity. The training was strenuous, but
by focusing on the basis of what each individual
could manage, and with a clear objective, the
informants were able to carry out lower-limb
CIMT. Restriction, with the whole leg orthosis, of
the ‘‘healthy’’ extremity during the training, compelled
the informants to use the weak leg more than
formerly. This was an important part of the training,
since it showed them what compensatory patterns
they had become accustomed to use. The restriction
also clarified for the informants, what function they
still had in the afflicted leg.
A splint like this on this one (the healthy leg)
suddenly makes you see what a big difference
there is in how your legs function. [I:7]
The training consisted largely of learning new ways
of doing things, e.g. learning to walk in a new way,
and do things the informants did not believe they
would manage. This compelled both body and
brain. They experienced a feeling of being ‘‘entirely
empty-headed’’ during training, and that the brain
‘‘protested’’.
And then the feeling, that you pressurise all your
senses and all your muscles so much and yes these
are really things you’ve never done before. [I:6]
To carry out CIMT, backup and support at home
were needed. This intensive training involved such
physical exertion that it was hard to keep up social
activities during the CIMT period. To complete the
therapy, it was required that CIMT had the top
priority and everything else had to be cut out.
Yes but I got help both from the home-help and
from my friends ...but I got so enormously tired
it frightened me. [I:2]
During the training, high demands were required in
each exercise at high pace, which was experienced as
extremely tough. The training was always at the limit
of the patients’ capacity. The strong group feeling
gave the informants the strength to manage one
more day. That the training was conducted in an
adapted environment, even though in cramped
premises, was felt to be stimulating.
Effects. The physical effects of the lower-limb CIMT
were described in various ways: stronger legs, better
balance, ‘‘I manage more and I use the leg more than
before’’. Training effects were experienced partly
during the CIMT period, but also later on. The
therapy gave a positive experience of being able to
trust the leg more and feel like a fully capable person
who could walk faster, almost normally, with a new
gait technique.
It’s starting to come bit by bit, afterwards, now;
and above all I feel my right leg is as strong as my
left so that I can rely on it more. [I:3]
Feelings and expressions such as ‘‘quite fantastic,
overwhelming, a feeling of freedom’’ that outweighed
all the hard work and an experience that
the body was recovering faster than the brain,
emerged at the same time as the informants became
aware of how fragile and exposed their situation
were.
This is what my body needed. [I:6]
Physiotherapists. The informants reported that the
physiotherapists and their work were very professional.
They had great competence, were sensitive to
changes, were at the same time ‘‘sharing their lives’’,
and were participating in all activities during the day.
The physiotherapists were seen as responsible for
control and discipline, by continually modify the
training. They made demands, spurred on, gave
positive feedback, encouraged and confirmed; and
this made the informants feel that their work was
strenuous. The physiotherapists clearly focused on
making every participant better on the basis of his or
her own potential.
They join in and we eat together and they join in
all the time and they’re on to you, you can hardly
cheat on anything without them turning up. [I:7]
Me and my body
The main category me and my body comprised the
informants’ reflections on their own significance in
the therapy, how this affected them and what insight
on their situation it gave them.
Motive force
The informant’s motivation, persistence, desire to
train and the fact that they themselves made the
decision to take part, were important aspects for
completing CIMT. They felt that they were specially
chosen and made the effort since few had the
opportunity to undergo this therapy. By making
priorities and giving themselves time to work in a
goal-oriented way, they managed to complete
CIMT.

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I think you have to be selfish enough to focus on
yourself. [I:4]
Changes. The physical effects changed the informants’
view of their own capacity and gave a feeling
of human worth, of not being finished as a human
being. By succeeding in various exercises and reaching
their anticipated goals, they strengthened their
self-esteem, and their belief in the future was
aroused. The knowledge the informants gained
about their bodies during CIMT, gave them security
in their daily living. Changes also concerned spreading
the knowledge and experience they gained. It
was important for the informants to be able to report
their experience and in this way influence the
situation for others with stroke. They also felt that
other people experienced them differently after the
therapy.
There’s lot of, I think, positive things about
working hard, too, partly because you get attention
yourself and the help you need, but in this
way you also get past these natural obstacles, you
believe you’re going to manage things yourself.
You grow in yourself you recover a certain position
in your home. [I:4]
Frustration. The informants felt frustrated by the fact
that few know about lower-limb CIMT in the
healthcare system in Sweden. They considered
CIMT should come early in the rehabilitation for
everybody afflicted by stroke. Through reflection
over their earlier rehabilitation, the informants felt
that the level was too low in traditional rehabilitation
and they needed to ‘‘raise the bar’’. They said that
‘‘overtraining’’ was needed. They also want an
overall programme from the start, since stroke in
the acute stage to lifelong rehabilitation, so they can
plan their future. In their frustration, there were also
disappointments about the focus on managing as
well as possible with the help of the ‘‘healthy’’ side in
the acute stage of rehabilitation, instead of rehabilitating
the ‘‘weak’’ side.
I can’t understand how they think, first they must
rescue a person ...I mean we might well have
died ...but then they sit there in the care system
and save them, and then they tell you you must
live; but you don’t get any help for living. [I:7]
Despite knowledge and experience of lower-limb
CIMT, the informants felt that they could not
manage to train intensively themselves: recurrent
periods of lower-limb CIMT were needed. There
emerged clearly a frustration that it is not even
Stroke patients’ experience of training with lower-limb CIMT 5
possible to pay for it privately and a feeling that the
council for the healthcare system in Sweden was
dragging its heels regarding introduction of new
therapy methods.
But can’t you pay, I asked, to get this therapy; but
that was not possible either. [I:1]
Discussion
People who had had a stroke experienced that
CIMT for the lower extremity gave them knowledge
about their body and their chances to be able to live
their life more easily. The intensive training gave
them hope, since the functional improvements
showed opportunities of change that increased their
independence and self-esteem. Even though the
intensive training, which continued 6 h/day every
day for 2 weeks is tough, it was experienced as
entirely necessary.
One weakness in the study is that the author (IM)
who conducted the interviews lacked earlier experience
of qualitative studies. This was overcome partly
by running a trial interview before the study, not
included in the results. The other authors (MK, BH)
have experience of qualitative methods: their supervision
and continual co-operation during the whole
process strengthened the study’s trustworthiness.
A further weakness was that the material was small.
Since there is very little CIMT for the lower
extremity in Sweden and the authors should not
know them before the study started, there were not
many informants to ask. However, the informants
were both men and women, in different ages, and
with variation in affected side and time since stroke.
Strength was that all authors were involved in the
analysis, open for the informants’ experiences, and
reached consensus about the results. This increased
the credibility of the study. The audibility was
enhanced by following the steps in the analysing
process described by Graneheim & Lundman (22)
and by giving quotations in the result section.
Another strength was that the first author (IM)
had many years experience of rehabilitating people
with stroke, how various symptoms can be expressed
emotionally and linguistically. This simplified the
interview situation and the informants were given
scope to express themselves freely. On the other
hand, the personal experience of the first author
(IM) from the field reduces the possibilities of being
open and unbiased vis-à-vis the informants’ descriptions.
Through close co-operation and discussion
among the authors, the risk of subjective interpretations
was taken into account (23).

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6 I. Marklund et al.
Röding et al. (14) showed in their study the
importance of understanding and taking into account
the situation of the stroke-afflicted person
when rehabilitation is being planned and conducted,
so that it corresponds to the patient’s own priorities
and needs. Stroke gives a multifaceted symptom
depending on the localization of the damage. Therefore
rehabilitation should be influenced by many
perspectives and more based on the individual’s
needs and potentials. The informants in the present
study expressed a need for more and repeated
training, even late after stroke onset, which also
have been shown earlier (11,13). Frustration was
expressed how the rehabilitation is planned and
conducted in Sweden. Even if the patients have the
knowledge about how to train, the time and the
necessary equipment, they still needed further
supervision. This need of supervision and advice
how to continue training was described already in
1995 by Lewinter & Mikkelsen (24), but not much
have changed according to the stroke patients’
experiences of getting the rehabilitation they need.
To train 6 h/day, every day, in 2 weeks requires
motivation, for both the patient and the relatives.
Maclean et al. (25) showed in their study that highly
motivated patients were more likely to view rehabilitation
as the most important means to recovery and
to accord themselves an active role in rehabilitation.
They also showed that information from professionals
about rehabilitation had a positive effect on
motivation. In this study, the informants and their
relatives met the physiotherapists before CIMT
started and received information about the therapy
and what was expected from them. This procedure
increased the informants’ motivation and emerges as
a part of the result. The preparation was important
for all the informants and their relatives in the
success of completing the intensive training.
Evidence exists that more intensive exercise therapy
is beneficial, but it is still unknown how
intensively and which subgroup benefits most. Van
Peppen et al. (26) and Young & Forster (27) showed
in their review articles the evidence for different
types of rehabilitation after stroke. Strong evidence
was found for strengthening the lower paretic limb
and for task-oriented exercise training to restore
balance and gait. In addition, strong evidence
emerged for improved symmetry in the training of
rising from sitting to standing, an exercise that is
trained frequently in CIMT for the lower extremity.
If one adds what Kwakkel et al. (9) showed back in
1997, that intensity is significant for the effect of
rehabilitation, then one has obtained most of the
different exercises included in CIMT for the lower
extremity, as the present informants confirmed when
they reported that their paretic leg became stronger
and that they could walk further and being able to
trust the weak leg more.
Despite a number of studies showing that CIMT
for the upper extremity gives positive results, no firm
conclusions can be drawn, since there are, so far, too
few randomized controlled trials (28). One problem
is that the studies now available use different
evaluation instruments. Another problem is that
the therapy is not comparable, since different
intensities, different number of training hours/day
and number of days/weeks are used. Attempts are
also being made to arrive at what item of CIMT for
the upper extremity is most important for the
positive effects. Effort has been made to find out
whether it is the actual restriction of the ‘‘healthy’’
limb (29), the intensity in time (30,31), the significance
of treating individually or in group (32), or
whether it is the shaping exercises (33), that are most
important for the improvements. In the present
study, the informants reported their experiences
that it was their brains that were being trained,
that the intensive training was at the limit of their
capability, that they experienced an ‘‘emptiness’’ in
their head and that it was this that brought about the
change.
In rehabilitation, there is a meeting between the
therapist and the patient, and the interaction between
them is surely of great importance for the
result. We need not only to understand the disease,
but also the patient, and here qualitative studies are
at to a strength. Every rehabilitation situation is
about more than medically, physically measurable
effects: it also concerns communication experience,
expectations, attitudes and desires (34). Regarding
lower-limb CIMT, there is an interaction between
the therapist and the patient during 6 h/day, for
2 weeks. Hence contact is both developed and
deepened. An increased exchange of knowledge, a
process of learning, is a natural element as there are
opportunities for feedback directly in all situations.
A Cochrane review has shown (35) that stroke
survivors and their carers often feel they have not
been given enough information about stroke and
they feel unprepared for life after discharge from
hospital. There was also some evidence that when
information is provided in a way that more actively
involved patients and cares by offering repeated
opportunities to ask questions patients’ mood
was positively affected (35). In the present study,
knowledge emerged as a constant theme that was
important for all the informants, that they had
opportunities of asking the same physiotherapist
the same questions again and again. The informants
needed to deepen their knowledge of their own
bodies and how they functioned after stroke. Yet
knowledge alone was not sufficient: feeling at the

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same time what was happening in their bodies when
they were training, they learned new techniques and
tried things they had not done earlier, thus obtaining
a tool (knowledge and security) for use in daily
living. They learned, for example, both how gait
is produced purely technically and how their
bodies should sense when they were walking correctly.
Different cognitive impairments following
stroke can affect learning ability, and this places
high demands on the treating physiotherapist’s
competence and ability to vary the methods of
learning employed.
Even though training after stroke is an area with
relatively much research, the present results suggest
that there may be reasons for further refinement of
the methods used.
However, one issue that needs further elucidation
is to identify in what sense knowledge and interaction,
between the patient who participate in CIMT
and the physiotherapists, are significant for lowerlimb
CIMT. More studies of CIMT for the lower
extremity should be conducted. Quantitative studies
to clarify the long-term effects of lower-limb CIMT
and cost-effectiveness compared to qualities of life in
persons with stroke must be done. With qualitative
studies, the phenomena frustration and motivation
can be explain and understood.
Acknowledgements
We thank the informants who so generously shared
their experiences with us. We also want to thank
Annika Sefastsson and Sara Vive at Katarinakliniken,
Stockholm, Sweden, for their support. The
study was supported with grants from Research and
Public Health and the Research Centre for Primary
Care, Värmland County Council, Karlstad, Sweden
and the Enoch Danielsson Foundation, Torsby,
Sweden.
Conflict of interest:
None declared.
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