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A Systematic Review of the Effectiveness of Constraint-Induced

Movement Therapy in Adults Post Stroke

Kelsey Didericksen and Taylor Bryant

University of Utah Department of Occupational Therapy

Research Methods of Occupational Therapy

Dr. Lorie Richards

April 6, 2020
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Introduction

Across the globe, stroke is a leading cause of death and disability making it’s prevention

and treatment a public health concern (Doussoulin et al., 2017). After stroke, 55-75% of patients

have upper limb hemiparesis that affect their upper extremity (UE) motor function and

performance of activities of daily living (ADLs) (Abo, et al. 2014; Page, et al., 2004). Many

rehabilitation strategies have been developed to address these deficits. Conventional post-stroke

rehabilitation emphasizes compensatory behaviors in the less affected limb, while newer

approaches have found some success by focusing on the restoration of UE function in the

affected limb (El-Helow et al., 2015).

One such restoration-centric intervention for improving performance of ADLs and motor

function in UE hemiparesis is constraint-induced movement therapy (CIMT). Evidence suggests

that some level of disability in the more affected limb may be due to a learned phenomenon

involving a conditioned suppression of movement, sometimes referred to as “learned nonuse”

(Taub, Crago, & Uswatte, 1998). CIMT seeks to promote the restoration of the paretic arm by

limiting compensatory use of the less affected side for long periods of the day (Ju & Yoon,

2018). This helps engage the natural plasticity of the brain to reverse learned nonuse in the

affected limb (Taub, Crago, & Uswatte, 1998).

As described by Taub, Crago, & Uswatte (1998), the original CIMT protocol can be

understood as three components. One, intensive training for the more affected arm. Two,

restriction of the less affected arm by placement in a sling or mitt (hereafter referred to as the

constraint). Three, the application of a “transfer package,” a set of behavioral techniques which
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help transfer therapeutic gains made in the treatment setting to daily life. Examples would be

contracts designed to promote adherence, home diaries, and home practice schedules.

Exercises are led by a therapist for 6 hours a day, for 10 of the 14 days of the therapy

period. The selection of exercises is influenced by patient preference (to maximize

meaningfulness) and therapist opinion (to maximize potential for improvement). All training is

applied using “shaping,” the incremental grading of tasks to match patient ability combined with

immediate positive feedback in response to any gain in function. The constraint is worn for 90%

of waking hours over a 14 day intervention period.

Like many therapeutic approaches to the recovery of upper limb function, CIMT is time

and resource intensive (Da-Silva, et al., 2018). Various modifications on the original protocol

have been introduced, most commonly adjusting the amount of time the constraint is worn on the

less affected hand or the duration of daily exercises in an effort to increase patient compliance

and decrease difficulty of implementation (Page, et al., 2004).

The most common variation of CIMT is modified constraint induced movement therapy

(mCIMT). mCIMT differs in the length of individual therapy sessions, amount of daily

constraint use, and the length of intervention period. There is no strict agreement in the literature

as to what exactly constitutes mCIMT. Interventions referred to as mCIMT feature reduced

length of task-specific practice (ranging from 30 minutes to 3 hours), reduced time spent wearing

the constraint (from 5 hours to only during practice), and variable intervention periods that can

last up to five times as long as traditional CIMT (from 2 to 10 weeks) (Shi, Tian, Yang, & Zhao,

2011).
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There are a wide range of possible therapies for recovery of UE function, and insurance

coverage and therapist time is a limited resource. Although most motor recovery occurs in a

limited window of time of six to twelve months after stroke, CIMT researchers have reported use

and function improvements in patients >1 year poststroke (Page, et al., 2004). Given the idea that

CIMT has therapeutic potential in both the acute and chronic phase of stroke, and the importance

of wisely allocating resources to maximize patient recovery, this review seeks to answer whether

CIMT and its variations are an effective intervention to improve UE use post-stroke, as measured

by disability and arm motor function.

Methods

Literature Search Strategy

A systematic review of relevant literature was conducted using two databases, CINAHL

and PUBMED. Literature that was considered in the review used the following filters: published

in English, limited to human participants, and published between January 2010 and March 2020.

Key words and their corresponding Medical Subject Headings (MeSH) terms were used in the

initial search of relevant articles. Details of key words and MeSH terms are found in the search

strategy specifics in the Appendix.

Study Selection

Figure 1 outlines the selection process of the articles included in this review. After the

initial search using the key words and MeSH terms enumerated in the appendix, duplicates were

removed and the titles and abstracts remaining were screened by the two reviewers for inclusion

criteria. Any controversies were discussed until a resolution was reached. Only those studies
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examining human adults were included. “Adult” was defined as eighteen years of age or older.

To be included, the study participants had to have been receiving treatment post stroke.

Included studies were those that used CIMT or mCIMT alone as an intervention and not

CIMT as a combined treatment. Additionally, inclusion criteria included either ADL relevant or

measures of motor function as the measure of outcome. Articles were excluded if one of the

interventions was not either CIMT or mCIMT, the outcomes did not measure ADLs or UE motor

function, study participants were not recovering from stroke, or other comorbidities besides

stroke were included. Additionally, articles were excluded if they were not in the English

language. After title and abstract screening, the full text of the articles were screened by the two

reviewers using the same inclusion and exclusion criteria as outlined above. Any controversies

about full text screening were discussed until resolution was reached. After full text screening,

six articles were chosen for this systematic review via random selection.

Study Appraisal Methods

Studies were examined to determine the strength of evidence using the Oxford Centre for

Evidence-Based Medicine (OCEBM) 2011 Levels of Evidence. Each of the articles was

evaluated for bias using either the Physiotherapy Evidence Database (PEDro) scale (1999) for all

randomized controlled trials (RCT) or the table provided by the National Heart Lung and Blood

Institute (2014) for any non RCTs.

Results

Study Size and Quality

After the initial search, 123 articles were found, 13 duplicates were removed, and 110

titles and abstracts remained. After title and abstract screening, 37 articles of the 110 were
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included for full text text screening. After full text screening, 25 of the 37 articles remained and

six were randomly selected for this systematic review. Group size for these studies ranged from

14 to 156 participants, with ages ranging between 41 and 71 years. All six studies show multiple

variations of CIMT to be effective at facilitating ADLs and UE motor function in participants

post-stroke. Levels of evidence of the included articles ranged from levels 1B to 3B. Of the

studies, three had a level of evidence of 1B (RCT with ≥60 participants), two had a

level of evidence of 2B (RCT with <60 participants), and one had a level of evidence of

3B (one group trial with 14 participants). Given the inclusion of three well-designed level 1

studies, a strong level of certainty was established for the assessed body of research supporting

the effectiveness of CIMT.

The mean PEDro score for the five RCTs in this literature review was 6.8 (see Table 1).

Higher PEDro scores reflect superior methodological quality, with a score between six to eight

out of ten considered to be “good” quality (Cashin & Mcauley, 2020). The one group pre-test,

post-test, follow-up design had a moderate risk of bias (see Table 2).

Study Design

Heterogeneous dosing schedules were observed across the six studies, with five out of six

(83%) designs having restraint intensities less than the original CIMT protocol of 90% of waking

hours. CIMT or mCIMT therapy intensities ranged from 1-6 hours, 5-7 days a week or daily for

10 days to 4 weeks (see Table 3 for per study specifics on samples, measures, and findings).

The time since stroke varied slightly across the reviewed studies. Time elapsed since the

stroke incident can be divided into acute (<2 weeks since stroke), subacute (2 weeks to 6

months), and chronic phases (six months or greater) (Kiran, 2012). CIMT was applied to chronic
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stroke populations in four of the six studies. One study applied the intervention to a subacute

population, and another studied CIMT in an acute population.

Two of the six studies (33%) proposed novel changes that could significantly decrease

therapist burden: the adaptation of CIMT therapy to small groups by Doussoulin et al. (2017) and

the home-based intervention from Barzel et al. (2015). Other variations explored in the literature

involved the combination of CIMT with other therapeutic protocols (Bang et al., 2018).

Of the six articles, five were RCTs of various quality and one was a pre-test, post-test,

follow-up one group design. One RCT studied CIMT and a comparison intervention. Abo et al.

(2014) allocated participants into two groups, one received CIMT and the other received an

intervention which included low-frequency repetitive transcranial magnetic stimulation (LF-

rTMS) combined with occupational therapy (TMS + OT). Four of the RCTs assessed either

mCIMT or an alternative version of CIMT and a comparison intervention. Bang et al. (2018)

compared outcomes between a group receiving mCIMT alone and a group receiving mCIMT

with trunk restraint (mCIMT + TR), a non-elastic strap in order to minimize trunk compensation

during training. El-Helow et al. (2015) examined the differences between mCIMT and a

conventional rehabilitation therapy which, according to the study, included traditional

positioning, management of spasticity, standard occupational therapy, compensatory techniques

in ADL’s, strengthening exercises, and range of motion exercises. Doussoulin et al. (2017)

assessed outcome differences of mCIMT, as it is traditionally done through individual treatment,

and compared it to mCIMT in a “collective” modality, which was defined as treatment groups

consisting of four individuals. Barzel et al. (2015) compared a less intensive home-based CIMT

and standard therapy treatment, which was defined as conventional physical or occupational

therapy including mobilization, isometric training, muscle strengthening, ADL skills and
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training, sensory training, fine motor skills, and trunk mobilization and stabilization. The one

group study by Takashi et al. (2015) followed a group of participants who received mCIMT

alone for one year after the intervention.

Common measures used in CIMT research

Various measurements were used to assess the intended outcomes which were changes in

UE motor function and performance of ADLs. The Functional Independence Measure (FIM) and

the Modified Barthel Index were used to assess performance of ADLs. The FIM assesses levels

of functioning and impairment related to motor and cognition in 13 items including eating,

grooming, bathing, dressing, toileting, bowel and bladder control, transfers, and locomotion

(Linacre et al., 1994). The Barthel Index was originally created to evaluate ADLs in individuals

after stroke. The Modified Barthel Index was developed to achieve the same outcome measure as

the Barthel Index, but with greater reliability and validity (Ohura et al., 2017). There were a

variety of methods of evaluation for UE motor function including the Fugl-Meyer Assessment

(FMA), Action Research Arm Test (ARAT), Wolf Motor Function Test (WMFT), Motor

Activity Log (MAL), maximal elbow extension angle during reaching, and Motor Evoked

Potentials. The upper limb portion of the FMA is a performance based measure used to assess

motor performance and function in individuals after a stroke (Abo et al., 2013; El-Helow et al.,

2015). The ARAT is an UE test of motor function including grasp, grip, pinch, and gross

movement (Bang et al., 2018; El-Helow et al., 2015). The WMFT measures performance time

and functional ability through performance of 15 simulated motor activities (Abo et al., 2013;

Barzel et al., 2015). The MAL is a semi-structured interview which measures the quantity and

quality of upper limb use in 14 ADLs in the participant’s own home (McDermott, 2019).

Effectiveness of CIMT or mCIMT

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Both Doussouline et al. (2017) and Bang et al. (2018) observed significant improvements

in performance of ADLs after the mCIMT intervention according to the FIM and the Modified

Barthel Index. Doussoulin et al. (2017) found that both the individual and “collective” modalities

improved significantly for both the motor and cognitive components of the FIM. However, the

individual group saw more gain on the motor component and total FIM score compared to the

“collective” modality. Bang et al. (2018) found significant improvements according to the

Modified Barthel Index for mCIMT alone, as well as for mCIMT + TR, but differences were

significantly greater in favor of mCIMT + TR.

CIMT and mCIMT showed improvements for UE motor function according to the

assessments. Four of the six studies used scores on the FMA to measure treatment outcomes and

found that CIMT and mCIMT produced significant improvements (e.e.Takashi et al., 2015; Abo

et al., 2014; Bang et al., 2018; El-Helow et al., 2015). In addition to CIMT, Bang et al. (2018)

and Abo et al. (2014) found significant FMA improvements in comparison groups, with

significant differences between interventions in favor of TMS + OT and mCIMT + TR.

Significant improvements were seen in participants after mCIMT according to the ARAT (Bang

et al., 2018; El-Helow et al., 2015). Bang et al. (2018) found that although both mCIMT alone

and mCIMT + TR showed significant improvement on the ARAT, results were significantly

greater in the mCIMT + TR group. Two studies examined differences on the WMFT and found

significant improvements in the mCIMT and comparison interventions (Abo et al., 2013; Barzel

et al., 2015). Abo et al. (2014) and Barzel et al. (2015) did not find significant differences

between groups for WMFT performance time, however differences were significant for WMFT

functional ability in favor of TMS + OT. Takashi et al. (2015), Barzel et al. (2015), and Bang et

al. (2018) observed significant improvements in MAL performance time and functional ability
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after the mCIMT intervention. Significant differences were also seen in comparison groups in

studies done by Barzel et al. (2015) and Bang et al. (2018). Differences were significant in favor

of mCIMT + TR in all areas of the MAL and significant in favor of the home-based CIMT for

quality of movement, but were not for functional ability and performance time (Bang et al.,

2018; Barzel et al., 2015). Findings by Bang et al. (2018) showed significant improvement in

maximal elbow extension angle during reaching in mCIMT alone, as well as for mCIMT + TR,

with significant differences between groups in favor of mCIMT +TR. El Halow et al. (2015)

measured Motor Evoked Potentials on the affected hand and found significant improvement in

the mCIMT group compared to the standard therapy control group.

The available evidence includes consistent results from three well-designed, well-

conducted Level 1 studies. Results from the two Level 2 and one Level 3 study were in

agreement with the results of the Level 1 studies. Based on guidelines provided by the U.S.

Preventive Services Task Force (2018), the level of certainty for this systematic review was

determined to be high in favor of the effectiveness of CIMT and mCIMT for post-stroke

intervention.

Discussion

Differences in CIMT delivery

CIMT appears to be effective in less intense formats than the original protocol, as

demonstrated by the effectiveness of mCIMT in the studies included here. It appears to

complement some variations, for example the addition of trunk restraint by Bang et al. (2018).

This was not uniformly the case - the group-based adaptation by Doussoulin et al. (2017) saw

reduced motor improvements compared to individual CIMT, and the home-based protocol tested
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by Barzel et al. (2015) was superior to conventional therapy in perceived motor use but did not

prove superior to standard therapy in motor function.

None of the studies reviewed compared two or more groups with different dosing

schedules (e.g. therapy time, restraint time, or overall duration). The heterogeneity of dosing

schedules in the research suggests further investigation may be warranted to refine the

understanding of dose-dependent relationships in these variables. Establishing a “minimum

effective dose” could potentially increase the accessibility and affordability of CIMT.

The data were insufficient to elucidate what differences may exist in the efficacy of

CIMT based on when the interventions were applied in the recovery process (i.e. populations

with subacute vs. chronic stroke). However, based on the literature reviewed here, CIMT was

observed to be effective in participants at all post-stroke intervals, from weeks to years.

Alternatives to CIMT

While the efficacy of CIMT was supported in this review, it’s worth noting that the study

comparing CIMT to TMS + OT (Abo et al., 2014) demonstrated significantly higher scores on

the FMA and the Functional Ability Score of the WMFT with TMS + OT than did CIMT. While

this does not undermine the conclusion about the overall efficacy of CIMT, it highlights the need

for clinicians and therapists to be aware of potential alternative therapies that may displace

CIMT in the future.

Limitations in the reviewed literature

While the reviewed literature uniformly detailed the length of individual therapy sessions,

amount of daily constraint use, and the length of intervention period, most did not address any

specifics regarding the “transfer package.” Based on the variability in dosing, it seems likely that

similar variability exists in the behavioral techniques applied to maximize therapeutic gain
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outside of the clinical setting. More research is needed to understand the role the transfer

package plays in long term increase in motor function and decreases in disability from CIMT.

Limitations in this review

Limiting the search to articles published in English may risk missing important nuance

regarding variations in CIMT. For example, Abo et al. (2014) mentions that although CIMT is

practiced in Japan, adoption rates are hampered by incomplete coverage by the Japanese

government public health insurance program, and Takashi et al. (2015) mentions that the

protocol was modified in order to fit that same insurance system. A search not limited to English

might have revealed useful data on other CIMT variations driven by similar cultural

considerations.

Due to mCIMT being the more recent innovation, the date range for articles might have

influenced the mCIMT to CIMT ratio and may not accurately reflect adoption in the field, giving

an inaccurate impression of the prevalence of CIMT versus mCIMT.

Conclusion

The number of adults with decreased ADL and UE motor function performance

secondary to stroke will continue to rise as the global population ages. Occupational therapy

practitioners trained in CIMT and its variations are well suited to intervene to help restore UE

motor function and reduce disability in the post-stroke population. The literature included in this

systematic review provides strong evidence supporting the use of CIMT as an effective

intervention to improve ADLs and motor function when providing for clients post-stroke. The

evidence supports mCIMT protocols may be employed without reservation, where patient

adherence, therapist availability, and cost considerations apply. Occupational therapists should

be trained to offer these interventions to their clients. Although a significant body of literature is
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available in this area of practice, future research exploring dose-dependent relationships between

constraint utilization, exercise intensity, and intervention duration would provide useful insights

to maximize the effectiveness and efficiency of occupational therapy services to this population.

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