Effectiveness of constraint-induced movement therapy on upper-extremity function in children with cerebral palsy: a systematic review and meta-analysis of randomized controlled trials

Abstract

Objective:

To systematically examine the research literature on the effectiveness of constraint-induced movement therapy on improving arm function in children with cerebral palsy, and to assess the association between the study effect size and the characteristics of the patients and intervention protocol.

Data sources:

A systematic literature search was conducted in PubMed, PsycINFO, Cochrane, CINAHL, Web of Science, and TRIP Database up to May 2014.

Review methods:

Studies employing randomized controlled trial design, children with cerebral palsy, comparing constraint-induced movement therapy with another intervention with a focus on arm function, and upper-extremity measures were included in this review. Methodological quality was evaluated using the Physiotherapy Evidence-based Database (PEDro) scale.

Results:

The literature search resulted in 27 randomized controlled trial studies with good methodological quality that compared constraint-induced movement therapy with other intervention therapy. Overall, constraint-induced movement therapy provided a medium beneficial effect (d = 0.546; p < 0.001) when compared with conventional therapy. For the subgroup analyses, presence of a dose-equivalent comparison group, intervention location, and time of follow-up were significant factors. Studies examining constraint-induced movement therapy effect without a dose-equivalent comparison group showed a large effect in children with cerebral palsy, but studies with a dose-equivalent group only showed a small effect. Children who received home-based constraint-induced movement therapy had a better improvement in arm function than those who received constraint-induced movement therapy elsewhere.

Conclusion:

The research literature supports constraint-induced movement therapy as an effective intervention to improve arm function in children with cerebral palsy.

Keywords

Cerebral palsy constraint-induced movement therapy upper extremity (arm)meta-analysis systematic review

Introduction

Constraint-induced movement therapy has recently become a popular intervention for arm function training in children with hemiplegic cerebral palsy.^1–3 There have been some attempts at reviewing the efficacy of constraint-induced movement therapy in improving arm function in children with hemiplegic cerebral palsy,^4–6 but included very few randomized controlled trials (RCTs) (3–7 RCTs only). To the best of our knowledge, no systematic reviews using a meta-analytic method to examine the effectiveness of constraint-induced movement therapy in children with cerebral palsy have been published. In addition, 35 studies using RCT design have been published since the databases were accessed for the two most recently published systematic reviews.^5,6 Thus, this review was designed to clarify the effects of constraint-induced movement therapy on arm function in children with cerebral palsy using a rigorous systematic review and meta-analytic approach. We expanded upon previous systematic reviews by: (1) adding more studies; (2) quantifying effect sizes (Cohen’s d) of constraint-induced movement therapy; and (3) using the International Classification of Functioning, Disability, and Health levels (ICF) model to classify outcome variables and then combine the outcome measures.⁷ We also attempted to explain the between-study variance in effect size by examining the effects of various factors, including key characteristics of the children (e.g. age) and aspects of the intervention protocol (e.g. constraint-induced movement therapy setting, restraint type, restraint duration, constraint-induced movement therapy dosage).

Methods

Two of the authors independently conducted systematic literature searches in January 2012, January 2013, October 2013, and again in May 2014, using the electronic databases: PubMed, PsycINFO, Cochrane Central Register of Controlled Trials, CINAHL, Web of Science and Trip Database, as well as a manual search of the reference lists of each article. The keywords or mesh terms (if applicable) used for the search were: constraint-induced movement therapy, constraint induced therapy, forced use therapy, and cerebral palsy. References found in publications such as review articles were also considered for inclusion.

Studies meeting the following criteria were considered for review: (1) the study was conducted in children with cerebral palsy (aged between birth and 21 years old); (2) the study compared constraint-induced movement therapy with another therapy, such as bimanual intensive therapy, or conventional rehabilitation, which emphasized upper-extremity training; (3) the outcome measures used in the study were related to arm function; (4) the study was an RCT; and (5) the study was written in English. Studies were excluded if the study did not compare constraint-induced movement therapy with another therapy (e.g. only compared three-week constraint-induced movement therapy against six-week constraint-induced movement therapy) or the study did not provide sufficient data to compute the effect size (e.g. no standard deviations).

A data extraction form was used to code the demographic, methodological, medical, and miscellaneous variables extracted from each RCT included in the review. Demographic and medical variables included children’s age, gender, diagnosis, severity, cognitive status, and lesion side. Sample size, instruments used as outcome measures, restraint type, restraint duration, constraint-induced movement therapy dosing (session intensity, duration, frequency, and total accumulated constraint-induced movement therapy duration), comparison therapy type, dosing in comparison therapy, and time of follow-up were coded as methodological characteristics. Year and type of publication, names of authors, and country and affiliation of the authors were included in the miscellaneous section.

The quality of RCTs was evaluated using the Physiotherapy Evidence-Based Database Scale (PEDro: www.pedro.fhs.usyd.edu.au). The PEDro scale includes 11 items, in which the first item assesses the external validity and the remaining 10 items assess the internal validity, examining random allocation, concealment of allocation, baseline equivalence, blinding procedure, ‘intention to treat’ analysis, adequacy of follow-up, between-group statistical analysis, and measurement of data variability. This scale yields a total possible score of 10 points for the evaluation of internal validity, with a score of 9–10 considered ‘methodologically excellent’, 6–8 ‘good’, 4–5 ‘fair’, and less than 4 ‘poor’.⁸

Data analysis

The outcome measures of each RCT were converted to a standard format by calculating the standardized mean difference (Cohen’s d), which is referred to as effect size throughout this review.^9,10 If the RCT reported Cohen’s d in the results, we used that value and calculated the study variance based on effect sizes and sample sizes. Because correlations of pre- and postintervention measurements were not reported in any study, we used the postintervention mean and standard deviation data to compute effect size using the equation: (mean of constraint-induced movement therapy – comparison mean) divided by the pooled standard deviation. If more than one outcome measure was used in an RCT, the effect size for each outcome measure was computed separately and then the multiple effect sizes were averaged together to represent the overall effect size of each RCT. In addition, the outcome measures of each RCT were also classified based on the ICF model,⁷ and then the multiple effect sizes of the same ICF level within a study were averaged to represent the effect size of the specific ICF level in each RCT.

Meta-analyses were run with a random-effects model that accounted for true inter-study variation in effects, as well as for random error within studies. A random-effect model was chosen over a fixed-effect model, because of the wide variation in experimental factor levels (e.g. constraint-induced movement therapy dosage, restraint duration, children’s age) used in the included studies. We also sought to determine the role of experimental factors in explaining the considerable inter-study variation observed in effect size. These experimental factors can be treated as moderator variables in a meta-analysis. Meta-regressions (using a method-of-moments model) for continuous variables or subgroup meta-analyses for categorical variables were used to examine the following potential moderator variables: (1) presence or not of a dose-equivalent comparison group; (2) children’s age; (3) restraint type; (4) restraint duration; (5) constraint-induced movement therapy daily session intensity; (6) constraint-induced movement therapy frequency per week; (7) constraint-induced movement therapy length in weeks; (8) total accumulated constraint-induced movement therapy duration; (9) location of training (e.g. laboratory or home); and (10) time of follow-up.

Meta-analyses and meta-regressions were conducted using the Comprehensive Meta-analysis software (Version 2.2; Biostat Inc., Englewood, NJ). An α value of 0.05 was used for significance in all analyses. Effect sizes were interpreted using Cohen’s convention as small (0.2), medium (0.5), or large (0.8). The effect of publication bias on the primary meta-analyses was addressed by combining a funnel plot assessment with the Duval and Tweedie’s trim and fill correction.¹¹ This is a preferred method for assessing the extent of publication bias, as well as for making a correction to the overall effect size.

Results

A total of 141 published studies were found from the database searches. After reviewing abstracts and titles, 40 RCTs,^2,3,12–49 16 reviews,^{4–6,50–62} and two clinical guidelines^63,64 related to constraint-induced movement therapy use in cerebral palsy were selected for full-text review. One additional RCT study was added after reading previously published reviews.⁶⁵ Thus, a total of 41 RCT studies were retrieved for full evaluation (see Figure 1).

Among the 41 studies, 12 studies were excluded: four studies^3,43,47,48 reported the same participants and outcome measures as in other articles;^26,31,32 four studies^40,41,45,46 did not include a comparison group that received traditional therapy; and four studies^2,39,42,65 did not provide sufficient data to compute an effect size, which did not meet our inclusion criteria. Therefore, a total of 29 articles were included for data extraction.^{12–38,44,49} During data extraction, two studies were found to report their outcome measures in multiple articles;^12,13,31,32 therefore, their outcome measures were merged and treated as the same studies. The final number of RCTs included in this review was 27, published between 2004 and 2014.

Description of the studies

The characteristics of these studies are summarized in Tables 1 and 2 and Supplementary Table 1, available online. There were 894 participants in the 27 studies. The average age of participants ranged from 2.4 to 10.7 years. The restraint types used in the studies included slings, glove, mitten, and cast. The restraint duration over the entire study ranged from 16 to 1008 hours, whereas the daily dose ranged from 0.5 to 6 hours. Intervention length ranged from 2 to 10 weeks, with the majority of the studies having an intervention length around two to three weeks. Intervention frequency ranged from two to seven days a week, with the majority of the studies having a frequency of about five days a week. The PEDro quality scores for the studies ranged from 5 to 9 (with only one article with a score of 5), indicating that the quality of the RCTs included in this meta-analysis was good to excellent. There were 15 studies that had a matched-dose comparison group, while 12 studies did not. Several measures of arm function were used in the studies, including the Canadian Occupational Performance Measure (COPM), the Quality of Upper Extremity Skills Test (QUEST), the Jebsen-Taylor Hand Function Test (JTHF), the Melbourne Assessment of Unilateral Upper Limb Function (Melbourne), the Bruininks-Oseretsky Test of Motor Proficiency (BOTMP), the Assisting Hand Assessment (AHA), range of motion, and reaching kinematics (e.g. movement time, trajectory smoothness).

Table 1.

Characteristics of the constraint-induced movement therapy and cerebral palsy studies that met the inclusion criteria of this meta-analysis.

Study	Mean age (years)	Number of subjects	Comparison group therapy content	Equivalent dose between CIMT and comparison group	Country of authors
Aarts et al., 2010, 2011^12,13	4.93	28 CIMT 22 comparison	Usual care + home programme	Yes	Netherlands
Al-Oraibi et al., 2011¹⁴	4.72	7 CIMT 7 comparison	NDT	No	Jordan
Charles et al., 2006¹⁵	6.67	11 CIMT 11 comparison	Ordinary therapy	No	USA
Chen et al., 2012¹⁶	8.75	24 CIMT 23 comparison	Traditional rehabilitation	Yes	Taiwan
Choudhary et al., 2012¹⁷	5.04	16 CIMT 15 comparison	Conventional therapy	No	India
de Brito Brandao et al., 2010¹⁹	5.82	8 CIMT 7 comparison	Regular OT	No	Brazil
de Brito Brandao et al., 2012¹⁸	6.24	8 CIMT 8 comparison	Bimanual HABIT	Yes	USA
Deppe et al., 2013²⁰	6.33	16 CIMT 13 comparison	Intensive bimanual therapy	Yes	Germany
El-Kafy et al., 2014⁴⁹	6.10	14 CIMT 13 comparison	Non-structured movement therapy	Yes	Egypt
Eliasson et al., 2011²¹	2.39	12 CIMT 13 comparison	Ordinary therapy	No	Sweden
Eugster-Buesch et al., 2012²²	10.68	12 CIMT 11 comparison	Regular therapy	No	Switzerland
Facchin et al., 2011²³	7.92	39 CIMT 33 comparison	Traditional therapy	No	Italy
Fedrizzi et al., 2012²⁴	7.92	39 CIMT 33 comparison	Traditional therapy	No	Italy
Geerdink et al., 2013²⁵	4.93	28 CIMT 22 comparison	Usual care + home programme	Yes	Netherlands
Gordon et al., 2011	6.35	21 CIMT 21 comparison	Bimanual HABIT	Yes	USA
Hoare et al., 2013⁴⁴	2.98	17 CIMT 17 comparison	Bimanual occupational therapy	Yes	Australia
Hsin et al., 2012²⁷	6.9	11 CIMT 11 comparison	Traditional rehabilitation	Yes	Taiwan
Hung et al., 2011²⁸	6.9	10 CIMT 10 comparison	Bimanual HABIT	Yes	USA
Lin et al., 2011²⁹	6.63	10 CIMT 11 comparison	Control	Yes	Taiwan
Rostami et al., 2012³⁰	8.17	8 CIMT 8 comparison	Regular therapy	No	Iran
Sakzewski et al. 2011, 2012^31,32	10.12	32 CIMT 30 comparison	Bimanual	Yes	Australia
Smania et al., 2009³³	3.33	10 CIMT 10 comparison	Conventional therapy	Yes	Italy
Sung et al., 2005³⁴	3.12	18 CIMT 13 comparison	Control	No	Korea
Taub et al., 2004³⁶	3.44	9 CIMT 9 comparison	Conventional therapy	No	USA
Taub et al., 2011³⁵	3.65	10 CIMT 10 comparison	Usual care	No	USA
Wallen et al., 2011³⁷	4.05	25 CIMT 25 comparison	Intensive occupational therapy	Yes	Australia
Xu et al., 2012³⁸	4.55	22 CIMT 23 comparison	Occupational therapy	Yes	China

CIMT: constraint-induced movement therapy; NDT: neurodevelopmental therapy; HABIT: Hand-Arm Bimanual Intensive Therapy; OT: Occupational Therapy.

Table 2.

Restraint type, restraint duration, constraint-induced movement therapy intervention protocol (i.e. duration, intensity), and intervention location for individual studies.

Study	Restraint type	Restraint duration	CIMT protocol	Total CIMT duration in hours	Location
Aarts et al., 2010, 2011^12,13	Slings	3 hours/day × 3 days/week × 8 weeks	3 hours/day × 3 days/week × 8 weeks	72	Clinic
Al-Oraibi et al., 2011¹⁴	Glove	2 hours/day × 6 days × 8 weeks (actual 92.2 hours)	2 hours/day × 8 weeks	96	Home
Charles et al., 2006¹⁵	Slings	6 hours/day × 5 days × 2 weeks	6 hours/day × 5 days × 2 weeks	60	Camp
Chen et al., 2012¹⁶	Mitten	3.5–4 hours/day × 7 days/week × 4weeks	3.5–4 hours/day × 2 days/week × 4 weeks	105	Home
Choudhary et al., 2012¹⁷	Slings	2 hours/day × 10 days	2 hours/day × 10 days	20	Clinic
de Brito Brandao et al., 2010¹⁹	Splint	10 hours/day × 10 days	3 hours/day × 5 days/week × 2 weeks	30	Clinic
de Brito Brandao et al., 2012¹⁸	Slings	6 hours/day × 5 days × 3 weeks	6 hours/day × 5 days × 3 weeks	90	Camp
Deppe et al., 2013²⁰	Elastic bandage	4 hours/day × 5 days × 3 weeks	4 hours/day × 5 days × 4 weeks	80	Clinic
El-Kafy et al., 2014⁴⁹	Slings	6 hours/day × 5 days × 4 weeks	6 hours/day × 5 days × 4 weeks	120	Clinic & home
Eliasson et al., 2011²¹	Glove+splint	2 hours/day × 2 months	2 hours/day × 2 months	120	Home
Eugster-Buesch et al., 2012²²	Removable velcro cast	6 hours/day × 14 days	6 hours/day × 14 days	84	Home
Facchin et al., 2011²³	Glove+splint	3 hours/day × 7 days/week × 10 weeks	3 hours/day × 7 days/week × 10 weeks	210	Clinic
Fedrizzi et al., 2012²⁴	Glove+splint	3 hours/day × 7 days/week × 10 weeks	3 hours/day × 7 days/week × 10 weeks	210	Clinic
Geerdink et al., 2013²⁵	Slings	3 hours/day × 3 days/week × 8 weeks	3 hours/day × 3 days/week × 8 weeks	72	Clinic
Gordon et al., 2011²⁶	Slings	6 hours/day × 5 days × 3 weeks	6 hours/day × 5 days × 3 weeks	90	Camp
Hoare et al., 2013⁴⁴	Glove	3 hours/day × 7 days × 8 weeks	1 hour/day × 2 days × 8 weeks	16	Clinic
Hsin et al., 2012²⁷	Glove	3.5 hours/day × 4 weeks	3.5–4 hours/day × 2 days/week × 4 weeks	105	Home
Hung et al., 2011²⁸	Slings	6 hours/day × 5 days × 3 weeks	6 hours/day × 5 days × 3 weeks	90	Camp
Lin et al., 2011²⁹	Elastic bandage	3.5–4 hours/day × 7 days/week × 4 weeks for both groups + CIMT training time	3.5–4 hours/day × 2 days/week × 4 weeks	105	Home
Rostami et al., 2012³⁰	Splint	5 hours/day × 4 weeks	1.5 hours/day × 3 days/week × 4 weeks	18	Clinic
Sakzewski et al., 2011, 2012	Glove+splint	6 hours/day × 10 days	6 hours/day × 5 days/week × 2 weeks	60	Camp
Smania et al., 2009³³	Mitten	8 hours/day × 5 weeks	1 hour/day × 2 days/week × 5 weeks	10	Clinic
Sung et al., 2005³⁴	Cast	24 hours/day × 7 days × 6 weeks	0.5 hour/day × 2 days/week × 6 weeks	6	Clinic
Taub et al., 2004³⁶	Cast	24 hours/day × 21 days	6 hours/day × 21 days	126	Clinic
Taub et al., 2011³⁵	Cast	24 hours/day × 13 days	6 hours/day × 5 days/week × 3 weeks	90	Home
Wallen et al., 2011³⁷	Mitten	2 hours/day × 7 days/week × 8 weeks	2 hours/day × 7 days × 8 weeks	112	Clinic
Xu et al., 2012³⁸	Splint	4 hours/day × 5 days/week × 2 weeks	3 hours/day × 5 days/week × 2 weeks	30	Clinic

CIMT: constraint-induced movement therapy.

We used the ICF model to group outcome variables (see Supplementary Table 1, available online). For example, COPM was categorized at ICF’s participation level; QUEST, Melbourne, AHA were at activity level; and reaching kinematics were at body structure and function level. Among the studies used in this meta-analysis, the majority (12 studies) included outcome variables in activity level, five studies contained activity and participation levels, five contained body structure and activity levels, one contained participation level only, one contained body structure level, and three included all three levels.

Overall effect of constraint-induced movement therapy

Across all studies, there was a medium effect (d = 0.546; p < 0.001) of constraint-induced movement therapy on arm function in children with cerebral palsy. The individual study and overall effect sizes are illustrated in the forest plot in Figure 2. We found moderate heterogeneity among the studies as the value of I² was 53% (Q = 55.74, p = 0.0006).

When effect sizes were broken down based on the classification of outcomes using the ICF model, a medium effect (d = 0.641) was found at posttest for activity level, and small effects were found for participation, and body structure and function levels (d = 0.306 for participation and d = 0.486 for body structure and function). During follow-up, a medium effect (d = 0.600) was found for participation level, and small effects were found for activity, and body structure and function levels (d = 0.394 for activity and d = 0.279 for body structure and function) (see Table 3 for details).

Table 3.

Average effect size when breaking down outcomes based on the classification by the ICF model. The numbers in parentheses are the lower and upper limit of 95% confidence interval for the effect size.

Variables	N	Post	N	Follow-up
Body structure and function	8	0.486 (0.122, 0.849)	5	0.279 (0.009, 0.550)
Activity	23	0.641 (0.396, 0.885)	18	0.394 (0.172, 0.617)
Participation	9	0.306 (−0.069, 0.680)	8	0.600 (0.148, 1.051)

Publication bias was assessed by examining a funnel plot of standard error vs. effect size. Minor asymmetry was noted in the plot, and thus a Duval and Tweedie’s trim and fill correction to the overall effect size was calculated. This correction shifted from 0.546 to 0.365.

Subgroup meta-analyses and meta-regression analyses

Presence or absence of a dose-equivalent comparison group, constraint-induced movement therapy location, and time of follow-up were significant factors (p < 0.05) (see Supplementary Table 2, available online). Studies with a dose-equivalent comparison group had a smaller effect size than studies without a dose-equivalent comparison group (See Figure 3). Home-based constraint-induced movement therapy and clinic-based constraint-induced movement therapy had a larger effect size than camp-based constraint-induced movement therapy. Meta-regression analysis also showed a statistically significant negative linear relationship between time of follow-up and study effect size (p < 0.05): the longer the follow-up time, the smaller the effect size.

Discussion

In general, when combining all outcome measures and evaluation time points of all studies, constraint-induced movement therapy had a medium effect in improving arm function in children with cerebral palsy (d = 0.546). The effect was similar to the effect of constraint-induced movement therapy when used in adults with stroke (d = 0.44).^66,67 When outcome measures were examined based on the ICF model, a medium effect size was found for activity level and a small effect size for the other two levels (body structure and function, and participation) immediately after the intervention; a medium effect size for participation level and a small effect size for the other two levels (body structure and function, and activity) were found during follow-up. This suggests that improvements in activity level may be prominent in a short period of time but may disappear without continuous practice, while improvement in participation level may require extended time, and therefore showed up only during the follow-up period. This finding is similar to findings on the use of constraint-induced movement therapy in adults with stroke.^66,67

Previous systematic reviews of the effectiveness of constraint-induced movement therapy on children with cerebral palsy were unable to identify associations among study effect size, children’s characteristics, and intervention protocol (e.g. Huang et al.,;⁵ Sakzewski et al.,;⁵⁵ Hoare et al.,⁴). Because a greater number of RCTs was included in this meta-analysis, we found that intervention location, time of follow-up, and presence of a dose-equivalent comparison group had significant associations with study effect size.

In terms of intervention setting, home-based constraint-induced movement therapy had a larger effect size than other settings (clinic-based and camp-based). This finding was consistent with the proposed benefits of using a natural environment (home) as the intervention location.^68,69 The natural environment (home) offered less distress during constraint-induced movement therapy practice for both children with cerebral palsy and their parents. Further, the training schedule can be tailored to fit into the family’s daily routine. A home-based intervention can also save the family time and money for commuting and parents can be more involved throughout the process, increasing opportunities for parent–child interaction.

The time of follow-up was negatively associated with study effect size: the longer the follow-up time, the smaller the study effect size. This finding is also consistent with the logical assumption that the constraint-induced movement therapy effect could not be maintained over time. After constraint-induced movement therapy ended, children with cerebral palsy might not practice with their affected arm as much as they did previously during constraint-induced movement therapy. From the motor learning perspective, repetitive practice advances motor skills. Research on patients with stroke suggested the patients with proper ‘transfer’ training from constraint-induced movement therapy to real-life functional tasks had a better follow-up performance than patients without ‘transfer’ training.⁷⁰ The majority of the studies reviewed here either did not include a ‘transfer’ training in their intervention or included a relatively short ‘transfer’ training to help these children apply to their daily living the new functional skill they learned using their affected hand. Consequently, the effect of this newly learned function could fade away without proper practice and reminding over time.

As expected, once we compared studies with and without a dose-equivalent comparison group, the overall effect size changed from large (d = 0.844 without a dose-equivalent comparison group) to small-to-moderate (d = 0.370 with a dose-equivalent group). The finding that constraint-induced movement therapy showed a large effect size when compared with a non-equivalent dose comparison group suggests the importance of intensive intervention regardless of the intervention type. Children in this meta-analysis received constraint-induced movement therapy intensively (a few hours per day, two to seven days per week), whereas children in the non-equivalent comparison group received conventional therapy only once per week or once every other week. Thus, the large effect was expected. In a meta-analysis done by Arpino et al.,⁷¹ intensive interventions, regardless of the treatment content, were compared with non-intensive rehabilitation treatment for children with cerebral palsy using the Gross Motor Function Measure score as the outcome measure. The authors found a large effect size with intensive intervention (d = 1.32) compared with the non-intensive therapy. Our finding is consistent with theirs.

When constraint-induced movement therapy was compared with a dose-equivalent comparison group, constraint-induced movement therapy was slightly better than the comparison group with a small-to-moderate effect size. That is, although small, constraint-induced movement therapy still showed an advantage in improving arm function in children with cerebral palsy.

We did not find any association between constraint-induced movement therapy dosage with study effect size. We believe this finding might come from a complex interaction from the study heterogeneity included in this review, especially if the intervention-related dosage in the comparison group was not equivalent with that of the constraint-induced movement therapy group. The effect of different constraint-induced movement therapy dosage remains inconclusive. Further investigations with vigorous research design are needed before a conclusion can be made.

Potential limitations of our study include: (1) inclusion of only published RCT studies; (2) publication bias; (3) exclusion of few studies because the information needed to compute effect size was unavailable; and (4) the varied outcome measures, intervention protocols, and children’s characteristics made the analysis and conclusions complicated, even though we used the ICF model as our theoretical framework.

In conclusion, our systematic review and meta-analysis found that constraint-induced movement therapy overall is an effective intervention to improve arm function in children with cerebral palsy. In contrast, when constraint-induced movement therapy is compared with a non-dose-equivalent comparison group, the overall effect of constraint-induced movement therapy appears smaller when compared with a dose-equivalent comparison group.

Clinical messages

Constraint-induced movement therapy provides a medium effect (d = 0.546) in improving arm function in children with cerebral palsy.

Studies examining constraint-induced movement therapy effect without a dose-equivalent comparison group showed a large effect in children with cerebral palsy; however, studies with a dose-equivalent comparison group only showed a small effect.

Constraint-induced movement therapy intervention settings were significantly associated with study effect size.

Footnotes

Conflict of interest

The authors declare that there is no conflict of interest.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

References

Gordon

Charles

Wolf

. Efficacy of constraint-induced movement therapy on involved upper-extremity use in children with hemiplegic cerebral palsy is not age-dependent. Pediatrics 2006; 117(3): e363–373.

Sakzewski

. Bimanual therapy and constraint-induced movement therapy are equally effective in improving hand function in children with congenital hemiplegia. J Physiother 2012; 58(1): 59.

Sakzewski

Ziviani

Abbott

Macdonell

Jackson

Boyd

. Randomized trial of constraint-induced movement therapy and bimanual training on activity outcomes for children with congenital hemiplegia. Dev Med Child Neurol 2011; 53(4): 313–320.

Hoare

Wasiak

Imms

Carey

. Constraint-induced movement therapy in the treatment of the upper limb in children with hemiplegic cerebral palsy. Cochrane Database Syst Rev 2007(2): CD004149.

Huang

Fetters

Hale

McBride

. Bound for success: a systematic review of constraint-induced movement therapy in children with cerebral palsy supports improved arm and hand use. Phys Ther 2009; 89(11): 1126–1141.

Nascimento

Gloria

Habib

. Effects of constraint-induced movement therapy as a rehabilitation strategy for the affected upper limb of children with hemiparesis: Systematic review of the literature. Rev Bras Fisioter 2009; 13(2): 97–102.

WHO. ICF: International Classification of Functioning, Disability and Health. Geneva: World Health Organization, 2001.

Foley

Teasell

Bhogal

Speechley

. Stroke rehabilitation evidence-based review: Methodology. Top Stroke Rehabil 2003; 10(1): 1–7.

Cohen

. Statistical power analysis for the behavioral sciences. Hillsdale, NJ: Erlbaum, 1988.

10.

Cooper

Hedges

(eds). The handbook of research synthesis. New York City: Russell Sage Foundation, 1994.

11.

Borenstein

Hedges

Higgins

JPT

Rothstein

. Introduction to meta-analysis. Wiley, 2009.

12.

Aarts

Jongerius

Geerdink

van Limbeek

Geurts

. Effectiveness of modified constraint-induced movement therapy in children with unilateral spastic cerebral palsy: a randomized controlled trial. Neurorehabil Neural Repair 2010; 24(6): 509–518.

13.

Aarts

Jongerius

Geerdink

van Limbeek

Geurts

. Modified constraint-induced movement therapy combined with bimanual training (mCIMT-BiT) in children with unilateral spastic cerebral palsy: how are improvements in arm-hand use established? Res Dev Disabil 2011; 32(1): 271–279.

14.

Al-Oraibi

Eliasson

. Implementation of constraint-induced movement therapy for young children with unilateral cerebral palsy in Jordan: a home-based model. Disabil Rehabil 2011; 33(21–22): 2006–2012.

15.

Charles

Wolf

Schneider

Gordon

. Efficacy of a child-friendly form of constraint-induced movement therapy in hemiplegic cerebral palsy: a randomized control trial. Dev Med Child Neurol 2006; 48(8): 635–642.

16.

Chen

Kang

Hong

Chen

. Effect of therapist-based constraint-induced therapy at home on motor control, motor performance and daily function in children with cerebral palsy: a randomized controlled study. Clin Rehabil 2012; 27(3): 236–245.

17.

Choudhary

Gulati

Kabra

. Efficacy of modified constraint induced movement therapy in improving upper limb function in children with hemiplegic cerebral palsy: A randomized controlled trial. Brain Dev 2012; 35(9): 870–876.

18.

de Brito Brandao

Gordon

Mancini

. Functional impact of constraint therapy and bimanual training in children with cerebral palsy: a randomized controlled trial. Am J Occup Ther 2012; 66(6): 672–681.

19.

de Brito Brandao

Mancini

Vaz

Pereira de Melo

Fonseca

. Adapted version of constraint-induced movement therapy promotes functioning in children with cerebral palsy: a randomized controlled trial. Clin Rehabil 2010; 24(7): 639–647.

20.

Deppe

Thuemmler

Fleischer

Berger

Meyer

Wiedemann

. Modified constraint-induced movement therapy versus intensive bimanual training for children with hemiplegia - a randomized controlled trial. Clin Rehabil 2013; 27(10): 909–920.

21.

Eliasson

Shaw

Berg

Krumlinde-Sundholm

. An ecological approach of constraint induced movement therapy for 2–3-year-old children: a randomized control trial. Res Dev Disabil 2011; 32(6): 2820–2828.

22.

Eugster-Buesch

de Bruin

Boltshauser

. Forced-use therapy for children with cerebral palsy in the community setting: a single-blinded randomized controlled pilot trial. J Pediatr Rehabil Med 2012; 5(2): 65–74.

23.

Facchin

Rosa-Rizzotto

Visona Dalla Pozza

. Multisite trial comparing the efficacy of constraint-induced movement therapy with that of bimanual intensive training in children with hemiplegic cerebral palsy: postintervention results. Am J Phys Med Rehabil 2011; 90(7): 539–553.

24.

Fedrizzi

Rosa-Rizzotto

Turconi

. Unimanual and bimanual intensive training in children with hemiplegic cerebral palsy and persistence in time of hand function improvement: 6-month follow-up results of a multisite clinical trial. J Child Neurol 2012; 28(2): 161–175.

25.

Geerdink

Aarts

Geurts

. Motor learning curve and long-term effectiveness of modified constraint-induced movement therapy in children with unilateral cerebral palsy: A randomized controlled trial. Res Dev Disabil 2013; 34(3): 923–931.

26.

Gordon

Hung

Brandao

. Bimanual training and constraint-induced movement therapy in children with hemiplegic cerebral palsy: A randomized trial. Neurorehabil Neural Repair 2011; 25(8): 692–702.

27.

Hsin

Y-j

Chen

F-C

Lin

K-c

Kang

Chen

C-y

. Efficacy of constraint-induced therapy on functional performance and health-related quality of life for children with cerebral palsy: A randomized controlled tial. J Child Neurol 2012; 27: 992–999.

28.

Hung

Casertano

Hillman

Gordon

. The effect of intensive bimanual training on coordination of the hands in children with congenital hemiplegia. Res Dev Disabil 2011; 32(6): 2724–2731.

29.

Lin

Wang

. Effects of home-based constraint-induced therapy versus dose-matched control intervention on functional outcomes and caregiver well-being in children with cerebral palsy. Res Dev Disabil 2011; 32(5): 1483–1491.

30.

Rostami

Arastoo

Nejad

Mahany

Malamiri

Goharpey

. Effects of modified constraint-induced movement therapy in virtual environment on upper-limb function in children with spastic hemiparetic cerebral palsy: A randomised controlled trial. NeuroRehabil 2012; 31(4): 357–365.

31.

Sakzewski

Carlon

Shields

Ziviani

Ware

Boyd

. Impact of intensive upper limb rehabilitation on quality of life: a randomized trial in children with unilateral cerebral palsy. Dev Med Child Neurol 2012; 54(5): 415–423.

32.

Sakzewski

Ziviani

Abbott

Macdonell

Jackson

Boyd

. Equivalent retention of gains at 1 year after training with constraint-induced or bimanual therapy in children with unilateral cerebral palsy. Neurorehabil Neural Repair 2011; 25(7): 664–671.

33.

Smania

Aglioti

Cosentino

. A modified constraint-induced movement therapy (CIT) program improves paretic arm use and function in children with cerebral palsy. Eur J Phys Rehabil Med 2009; 45(4): 493–500.

34.

Sung

Ryu

Pyun

Yoo

Song

Park

. Efficacy of forced-use therapy in hemiplegic cerebral palsy. Arch Phys Med Rehabil 2005; 86(11): 2195–2198.

35.

Taub

Griffin

Uswatte

Gammons

Nick

Law

. Treatment of congenital hemiparesis with pediatric constraint-induced movement therapy. J Child Neurol 2011; 26(9): 1163–1173.

36.

Taub

Ramey

DeLuca

Echols

. Efficacy of constraint-induced movement therapy for children with cerebral palsy with asymmetric motor impairment. Pediatrics 2004; 113(2): 305–312.

37.

Wallen

Ziviani

Naylor

Evans

Novak

Herbert

. Modified constraint-induced therapy for children with hemiplegic cerebral palsy: a randomized trial. Dev Med Child Neurol 2011; 53(12): 1091–1099.

38.

Wang

Mai

. Efficacy of constraint-induced movement therapy and electrical stimulation on hand function of children with hemiplegic cerebral palsy: a controlled clinical trial. Disabil Rehabil 2012; 34(4): 337–346.

39.

Boyd

Sakzewski

Ziviani

. INCITE: A randomised trial comparing constraint induced movement therapy and bimanual training in children with congenital hemiplegia. BMC Neurol 2010; 10: 4.

40.

Case-Smith

DeLuca

Stevenson

Ramey

. Multicenter randomized controlled trial of pediatric constraint-induced movement therapy: 6-month follow-up. Am J Occup Ther 2012; 66(1): 15–23.

41.

DeLuca

Case-Smith

Stevenson

Ramey

. Constraint-induced movement therapy (CIMT) for young children with cerebral palsy: effects of therapeutic dosage. J Pediatr Rehabil Med 2012; 5(2): 133–142.

42.

Deluca

Echols

Law

Amey

. Intensive pediatric constraint-induced therapy for children with cerebral palsy: randomized, controlled, crossover trial. J Child Neurol 2006; 21(11): 931–938.

43.

Gordon

Chinnan

Gill

Petra

Hung

Charles

. Both constraint-induced movement therapy and bimanual training lead to improved performance of upper extremity function in children with hemiplegia. Dev Med Child Neurol 2008; 50(12): 957–958.

44.

Hoare

Imms

Villanueva

Rawicki

Matyas

Carey

. Intensive therapy following upper limb botulinum toxin A injection in young children with unilateral cerebral palsy: a randomized trial. Dev Med Child Neurol 2013; 55(3): 238–247.

45.

Klingels

Feys

Molenaers

. Randomized trial of modified constraint-induced movement therapy with and without an intensive therapy program in children with unilateral cerebral palsy. Neurorehabil Neural Repair 2013; 27(9): 799–807.

46.

Rostami

Malamiri

. Effect of treatment environment on modified constraint-induced movement therapy results in children with spastic hemiplegic cerebral palsy: a randomized controlled trial. Disabil Rehabil 2012; 34(1): 40–44.

47.

Sakzewski

Ziviani

Abbott

Macdonell

Jackson

Boyd

. Participation outcomes in a randomized trial of 2 models of upper-limb rehabilitation for children with congenital hemiplegia. Arch Phys Med Rehabil 2011; 92(4): 531–539.

48.

Sakzewski

Ziviani

Boyd

. Best responders after intensive upper-limb training for children with unilateral cerebral palsy. Arch Phys Med Rehabil 2011; 92(4): 578–584.

49.

El-Kafy

EMA

Elshemy

Alghamdi

. Effect of constraint-induced therapy on upper limb functions: a randomized control trial. Scand J Occup Ther 2014; 21(1): 11–23.

50.

Charles

Gordon

. Development of hand-arm bimanual intensive training (HABIT) for improving bimanual coordination in children with hemiplegic cerebral palsy. Dev Med Child Neurol 2006; 48(11): 931–936.

51.

Dong

Tung

Siu

Fong

. Studies comparing the efficacy of constraint-induced movement therapy and bimanual training in children with unilateral cerebral palsy: A systematic review. Dev Neurorehabil 2013; 16(2): 133–143.

52.

Gordon

. To constrain or not to constrain, and other stories of intensive upper extremity training for children with unilateral cerebral palsy. Dev Med Child Neurol 2011; 53(Suppl 4): 56–61.

53.

Hoare

Imms

Carey

Wasiak

. Constraint-induced movement therapy in the treatment of the upper limb in children with hemiplegic cerebral palsy: a Cochrane systematic review. Clin Rehabil 2007; 21(8): 675–685.

54.

Novak

McIntyre

Morgan

. A systematic review of interventions for children with cerebral palsy: state of the evidence. Dev Med Child Neurol 2013; 55(10): 885–910.

55.

Sakzewski

Ziviani

Boyd

. Systematic review and meta-analysis of therapeutic management of upper-limb dysfunction in children with congenital hemiplegia. Pediatrics 2009; 123(6): e1111–1122.

56.

Taub

. The behavior-analytic origins of constraint-induced movement therapy: An example of behavioral neurorehabilitation. Behav Analyst 2012; 35(2): 155–178.

57.

Taub

Griffin

Nick

Gammons

Uswatte

Law

. Pediatric CI therapy for stroke-induced hemiparesis in young children. Dev Neurorehabil 2007; 10(1): 3–18.

58.

Taub

Uswatte

Mark

Morris

. The learned nonuse phenomenon: implications for rehabilitation. Eura Medicophys 2006; 42(3): 241–256.

59.

Little-Hayes

Allgier

Klein

Reder

Burch

. Embracing the spirit of inquiry: Creating an evidence-based guideline for using CIMT. Occup Ther Practice 2007; 8: 9–15.

60.

Andersen

Majnemer

O’Grady

Gordon

. Intensive upper extremity training for children with hemiplegia: From science to practice. Semin Pediatr Neurol 2013; 20: 100–105.

61.

Pidcock

Garcia

Trovato

Schultz

Brady

. Pediatric constraint-induced movement therapy: A promising intervention for childhood hemiparesis. Top Stroke Rehabil 2009; 16(5): 339–345.

62.

Sakzewski

Ziviani

Boyd

. Efficacy of upper limb therapies for unilateral cerebral palsy: a meta-analysis. Pediatrics 2014; 133(1): e175–204.

63.

Center CCsHM. Evidence-based care guideline for pediatric constraint induced movement therapy (CIMT). National Guideline Clearinghouse 2009; 16: 1–17.

64.

Eliasson

Krumlinde-Sundholm

Gordon

. Guidelines for future research in constraint-induced movement therapy for children with unilateral cerebral palsy: an expert consensus. Dev Med Child Neurol 2014; 56(2): 125–137.

65.

Willis

Morello

Davie

Rice

Bennett

. Forced use treatment of childhood hemiparesis. Pediatrics 2002; 110(1 Pt 1): 94–96.

66.

Corbetta

Sirtori

Moja

Gatti

. Constraint-induced movement therapy in stroke patients: systematic review and meta-analysis. Eur J Phys Rehabil Med 2010; 46(4): 537–544.

67.

Peurala

Kantanen

Sjogren

Paltamaa

Karhula

Heinonen

. Effectiveness of constraint-induced movement therapy on activity and participation after stroke: a systematic review and meta-analysis of randomized controlled trials. Clin Rehabil 2012; 26(3): 209–223.

68.

Brusco

Taylor

Watts

Shields

. Economic evaluation of adult rehabilitation: A systematic review and meta-analysis of randomized controlled trials in a variety of settings. Arch Phys Med Rehabil 2014; 95(1): 94–116.

69.

Chen

Lee

S-Y

Howard

. Effect of virtual reality on imporving upper-extremity function in children with cerebral palsy: A meta-analysis. Pediatric Phys Ther 2014; 26(3): 289–300.

70.

Takebayashi

Koyama

Amano

. A 6-month follow-up after constraint-induced movement therapy with and without transfer package for patients with hemiparesis after stroke: a pilot quasi-randomized controlled trial. Clin Rehabil 2013; 27(5): 418–426.

71.

Arpino

Vescio

De Luca

Curatolo

. Efficacy of intensive versus nonintensive physiotherapy in children with cerebral palsy: a meta-analysis. Int J Rehabil Res 2010; 33(2): 165–171.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.17 MB