Constraint-Induced Movement Therapy in the Treatment Of

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Clinical Rehabilitation

DOI: 10.1177/02692155070807832007; 21; 675Clin Rehabil

Brian Hoare, Christine Imms, Leeanne Carey and Jason Wasiakhemiplegic cerebral palsy: a Cochrane systematic review

Constraint-induced movement therapy in the treatment of the upper limb in children w

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Clinical Rehabilitation 2007; 21: 675685

Constraint-induced movement therapy in the treatment ofthe upper limb in children with hemiplegic cerebral palsy: a

Cochrane systematic reviewBrian Hoare Victorian Paediatric Rehabilitation Service, Monash Medical Centre, Christine Imms Royal Childrens Hospital,

Melbourne, Murdoch Childrens Research Institute and School of Occupational Therapy, La Trobe University, Melbourne,

Leeanne Carey Division of Neurological Rehabilitation and Recovery, National Stroke Research Institute and School of

Occupational Therapy, La Trobe University, Melbourne and Jason Wasiak Burns Unit, The Alfred Hospital, Victoria, Australia

Received 17th April 2007; manuscript accepted 18th April 2007.

Background: Constraint-induced movement therapy (CIMT) is emerging as a treat-

ment approach for children with hemiplegic cerebral palsy. It aims to increase

spontaneous use of the affected upper limb and limit the effects of learned non-use.

This review evaluates the effectiveness of CIMT, modified CIMT or Forced use in the

treatment of children with hemiplegic cerebral palsy.

Design and methods: Systematic Cochrane Review. The Cochrane Central Register

of Controlled Trials (CENTRAL) (The Cochrane Library2006, Issue 3), MEDLINE (1966

to August Week 4 2006), CINAHL (1982 to July Week 3 2006), EMBASE (1980 to

August 2006), PsychInfo (1985 to August Week 4 2006) and reference lists of all

relevant articles were searched. Relevant randomized and controlled clinical trials

were systematically reviewed.

Results: Three studies met the inclusion criteria. One randomized controlled trial

(RCT) showed a trend for positive treatment effect favouring CIMT using the

Dissociated Movement subscale of the Quality of Upper Extremity Skills Test.

A clinically controlled trial demonstrated a significant treatment effect favouring

modified CIMT using the Assisting Hand Assessment at two and six months.

Another inconsistently reported trial showed a significant treatment effect at six

weeks on the self-care component of the WeeFIM using Forced use.

Reviewers conclusions: Given the limited evidence, the use of CIMT, modified

CIMT and Forced use should be considered experimental in children with hemiplegic

cerebral palsy. Further research using adequately powered RCTs, rigorous metho-

dology and valid, reliable outcome measures is essential to provide higher level

support of the effectiveness of CIMT for children with hemiplegic cerebral palsy.

Background

Cerebral palsy and developmental disregardHemiplegic cerebral palsy, characterized by a

clinical pattern of unilateral motor impairment,is a common type of cerebral palsy, accountingfor 35.1% of all cerebral palsy in Victoria,Australia,1 15.3% in Ontario, Canada, 40% in

Address for correspondence: Brian Hoare, Victorian PaediatricRehabilitation Service, Monash Medical Centre, 246 ClaytonRoad, Clayton, Victoria 3168, Australia.e-mail: [email protected]

SAGE Publications 2007Los Angeles, London, New Delhi and Singapore 10.1177/0269215507080783

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Sweden2 and 31.2% in northern England, UK.3

During growth and development, children withhemiplegic cerebral palsy learn strategies and tech-niques to manage daily tasks (e.g. play) with one

hand. Performance of tasks is frequently discov-ered to be more efficient and effective using thenon-affected hand, even if there is only mildimpairment in the affected limb.4 Recently,DeLuca5 introduced the term developmental dis-regard to describe a child with hemiplegia whomay disregard, or learn not to use, the affectedlimb during the development of motor function.This developmental disregard is akin to thelearned non-use reported in the literature onadults who have sustained a stroke.6

Despite the similar behavioural mechanisms of

reinforcement of the unaffected hand and suppres-sion of use of the affected hand, as identified inadults, Eliasson et al. suggested that the learnednon-use may be a different phenomenon in chil-dren who sustain an early brain lesion.7 Unlike anadult who has had a neurological insult later inlife, a child with hemiplegia has not had the experi-ence of normal motor function of the limb. Thereis not the potential to unmask motor function, asfrequently described in adults. Therapy must,therefore, create the opportunity, experience andenvironment in which a child can learn how to use

their affected limb. This experience must reversethe behavioural aspect of suppression of use of theaffected limb and reward use of that limb in eventhe simplest tasks, such as stabilization of anobject. Constraint-induced movement therapy isproposed as a method of achieving this.5

Constraint-induced movement therapy (CIMT)CIMT has its foundation in behavioural

research with non-human primates, conducted byTaub and co-workers.8 Taub suggests that CIMT

for the upper limb involves inducing use of themore-affected limb by using a sling or half gloveto prevent use of the unaffected limb for a targetof 90% of waking hours over a period of 23weeks.6 During this time, concentrated, repetitivetraining of the more affected limb is provided dailyfor 6 hours using a technique to shape motorbehaviour.9 The shaping procedure involves (a)providing explicit verbal feedback and verbal

reward for small improvements in task perfor-mance; (b) selecting tasks that are tailored toaddress the motor deficits of the individualpatient; (c) helping the patient to carry out parts

of a movement sequence, if they are incapable ofcompleting the movement on their own at first;and (d) systematically increasing the difficulty ofthe task performed.10

Two different but linked mechanisms areconsidered to be responsible for increased use ofthe more affected extremity as a result of CIMT:overcoming learned non-use and inducinguse-dependent cortical re-organization.10 CIMTattempts to change the contingencies ofbehavioural reinforcement so that the learnednon-use of the more affected upper limb is

counter-conditioned or lifted.

10

The consequentincrease in the use of the more affected limb isargued to induce expansion of the contralateralcortical area controlling movement of the moreaffected limb and to recruit new ipsilateralareas.10 It is proposed that this may serve as theneural basis for the permanent increase in use ofthe affected limb following treatment.10

Despite the conceptual difference in behaviouraladaptation (learned non-use versus developmentaldisregard) as a result of an acquired condition (e.g.stroke) compared with a congenital condition (e.g.cerebral palsy), the core components of a CIMTprogramme including restraint and massed prac-tice, aim to reverse the behavioural suppression ofmovement in the affected upper limb. As a result,CIMT is emerging as a treatment approach forchildren with cerebral palsy and it raises signifi-cant clinical practice issues for occupational thera-pists. Traditionally, therapists working withchildren with hemiplegia have attempted to encou-rage normal movement of the affected hand byutilizing bimanual tasks or voluntary repetitivepractice of unilateral activities. In order toengage in these activities, often verbal and physical

prompting is required to encourage repeated prac-tice with the affected hand. Such persistentprompting can become frustrating for a childwhen movements are clumsy and effortful andoften do not result in a successfully completedtask, as perceived by the child. Negative beha-viours can occur in response to this persistentprompting. Forced use of the affected limbthrough a CIMT programme however, removes

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the need for persistent prompting and may be amore effective way of improving outcomes. Itmay, on the other hand, lead to the oppositeeffect if a child demonstrates adverse behavioural

responses to the restraint.

ObjectivesTo evaluate the effectiveness of CIMT, modified

CIMT (mCIMT) or Forced use in the treatment ofthe affected upper limb in children with hemiplegiccerebral palsy as measured by objective outcomesof upper limb function.

Materials and methods

The systematic method used for this review wasderived from the Cochrane Handbook forSystematic Reviews of Interventions.11 This reviewis a summarized version of a more extensivelyreported Cochrane Systematic Review.12

Literature searchThe literature was searched to identify both

published and unpublished research using the fol-lowing databases: Cochrane Central Register of

Controlled Trials (CENTRAL) (The CochraneLibrary 2006, Issue 3), MEDLINE (1966 toAugust Week 3 2006), EMBASE (1980 toAugust 2006), CINAHL (1982 to August Week 32006) and PsychInfo (1985 to August Week 42006). In addition, reference lists of articles andconference abstracts were examined. No languagerestrictions were applied. Individual searchstrategies were developed and these wereadapted for each database (see Table 1 forsample search).

Selection criteriaAll randomized controlled trials (RCTs) and

controlled clinical trials (CCTs) that comparedthe effect of any form of CIMT with traditionaltreatments (that is occupational therapy or phy-siotherapy) or no treatment were considered forinclusion in this review. Trials were included ifparticipants were diagnosed with hemiplegic cere-bral palsy, aged between 0 and 19 years and they

received treatment of the affected upper limb.Outcomes included any objective measure of theupper limb. This could include domains of bodyfunction/structure, activity or participation, asdefined by the International Classification ofFunctioning, Disability and Health (ICF).13

Studies that used any treatment approach thatprovided massed practice of movement to theaffected upper limb (that is behavioural shapingor motor learning principles) when a restraintdevice was worn were included and categorizedaccording to the following definitions as described

by Taub (personal communication, 14 November2002).

Constraint-induced movement therapy:Restraintof the unaffected upper limb is applied andmore than 3 hours of therapy per day (massedpractice) is provided for at least two consecu-tive weeks.

Modified constraint-induced movement therapy(mCIMT): Restraint of the unaffected upperlimb is applied and less than 3 hours per dayof therapy is provided to the affected limb.

Forced use: Restraint of the unaffected upperlimb is applied but no additional treatment ofthe affected upper limb is provided.

Due to the vastly different intensity of treatmentprovided within each type of therapy these termsare not interchangeable and studies investigatingeach treatment type were therefore reviewedseparately.

Table 1 Sample search on MEDLINE

MEDLINE (Ovid)1. Constraint adj3 therapy.tw2. CIMT.tw

3. CI therapy.tw4. Forced.tw5. Massed practice.tw6. or/157. Cerebral palsy8. Cerebral pals$.tw9. Hemiplegia/

10. Hemiplegi$.tw11. or/71012. 6 and 11

Constraint-induced movement therapy for the upper limb 677



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Evaluation of methodological qualityTwo authors independently reviewed titles and

abstracts of articles retrieved following the search.Methodological quality was assessed using

an adaptation of the method outlined inSchultz et al.14 This involved independent judge-ments of adequacy of randomization and alloca-tion concealment processes, equivalence ofparticipant characteristics at baseline, blinding ofassessors and description of withdrawals anddrop-outs. In addition, validity and reliability ofoutcome measures were evaluated for each study.

Data analysisData from eligible studies were extracted using a

data extraction tool and summarized indepen-dently by two reviewers. The authors of primarystudies were contacted to provide informationwhen missing or incomplete data were encoun-tered. A combined analysis using pooled datawas not appropriate due to the small number ofstudies located, inconsistency in outcome mea-sures used and the variations in intensity oftreatment.

The reviewers followed the Cochrane preferredmethod for handling continuous variables.15

This approach assessed mean change scores (and

standard deviation of the change) from baseline totime points following intervention, thus allowingfor differences in baseline performance. In order toobtain the standard deviation of the mean differ-ence authors were contacted where necessary.This method of analysis was used only for primaryoutcomes within studies. For all other outcomes,calculations and comparisons were based on meandifferences between groups at postinterventionand follow-up. All data were analysed by thereview authors using RevMan16 and thestandard mean difference (SMD) and 95% confi-

dence intervals (95% CIs) of each outcome werecalculated.

Results

Literature searchA total of 214 references were identified.

Independent scrutiny of the titles and abstracts

identified 26 potentially relevant articles. Of the26 assessed in full text form, 23 were excludedbecause they were abstracts, case reports, caseseries, narrative reviews or included children with

diagnoses other than cerebral palsy. The remain-ing three trials met the inclusion criteria andformed the basis of this review.5,17,18

Study characteristicsCharacteristics of included studies are described

in Table 2. The RCT by DeLuca5 (n 18)compared CIMT with traditional services. Therestraint was a bivalved fibreglass cast on theless involved extremity from the upper arm tothe fingertips. The protocol included the provisionof occupational therapy and physiotherapy for 6hours per day for 21 consecutive days using oper-ant training (shaping). The trial was reported in anunpublished dissertation5 from the University ofAlabama and later published in 2004.19

Although the trial was reported as an RCT witha crossover design,5 data from only one group(CIMT) were reported in the crossover periodand the publication19 omitted both the crossovercomponent of the trial and the Quality of UpperExtremity Skills Test (QUEST) data. As a result,the trial was reviewed as an RCT without thecrossover component and results from both theunpublished dissertation and the publication arediscussed in this review.

In the largest trial (n 45), Eliassonet al.17 useda CCT design to compare a mCIMT protocol withtraditional services. The restraint was a fabricglove with a built-in stiff volar plastic splintworn on the unaffected hand for 2 hours a day,7 days a week for two months. The mCIMT wasprovided in the childs usual environment (home/preschool). Parents and/or preschool teacherswere responsible for accomplishing the interven-

tion on a daily basis with occupational therapistsupervision once weekly. Although recruitmentwas undertaken by open invitation to parents,and children were not randomly allocated togroups, matching of children for age and degreeof hand impairment ensured baseline characteris-tics of children were similar on these variables.

In 2005, Sung et al.18 (n 31) compared Forceduse with conventional therapy services.

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Table

2

Sampleandoutcomecharacteristicsofincludedstudie

s

Variable

DeLuca(2002)5

Eliassonetal.(2005)1

7

Sungetal.(2005)18

Intervention

CIMT

ModifiedCIMT

Forceduse

Sample

N

18

N

45

N

31

9treatment,9control

21treatment,20cont

rol

18treatment,13

control

13male,5female

20male,21female

15male,16female

Aged7monthsto8years

Aged18to51months

Agedlessthan8

years

Diagnosedwithasymmetric

involvementoftheupperextrem

ities

Hemiplegiccerebralpalsy

Hemiplegiccereb

ralpalsy

Alllevelsofimpairedhandfunction

Alllevelsofimpairedhandfunction

Childrenwithsev

erelyimpaired

handfunctionwereexcluded

Assessmentfrequency

Baseline,3and6weeks,3and6months

(CIMTgrouponly)

Baseline,2and6months

Baselineand6w

eeks

Outcomemeasures

QUESTDissociatedMovements

ubscale,

CAUT,PMAL,EBS

AHA

BoxandBlocksT

est,

EDPA,WeeFIM

CIMT,constraint-inducedm

ovementtherapy;QUEST,QualityofU

pperExtremitySkillsTest;CAUT,ChildArmUseTest;PMAL,PediatricMotorActivityLog;

EBS,EmergingBehaviours

Scale;AHA,AssistingHandAssessme

nt;EDPA,ErhardtDevelopmentalPrehensionAssessment;WeeFIM,PaediatricFunctional

IndependenceMeasure.




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The restraint involved the application of a short-arm cast from below the elbow to the fingertips onthe unaffected upper limb. Occupational therapywas provided twice weekly in 30-minute sessions

for six weeks for both groups. Although thetrial was reported as a prospective case seriesdesign in the abstract, the text reported randomassignment of children to treatment or controlgroup. This provided ambiguity regarding thetrue methodology of the trial. Due to therandom assignment of children and a two-groupdesign, the study was viewed as an RCT for thepurposes of this review.

Methodological quality

Comparative data on design characteristicsimpacting on methodological quality of eachstudy is provided in Table 3. Of note was thelack of evidence related to psychometric propertiesfor a number of outcomes within the DeLuca5 trialincluding the Pediatric Motor Activity Log,Emerging Behaviours Scale and the Toddler ArmUse Test. Each of these tools was developed spe-cifically for this trial and their psychometric prop-erties have not been reported. Sunget al.18 did notreport on randomization or allocation conceal-ment processes or on the level of masking, suggest-

ing poor methodological quality.14

Findings from review analysisAnalysis of DeLucas5 change scores from base-

line level of performance to immediately posttreatment at three weeks did not demonstrate asignificant treatment effect on the QUEST Dissociated Movement subscale (SMD 0.91, 95%CI 0.08 to 1.89) (Figure 1). However, a trendfavouring the CIMT group was evident. QUESTdata were not reported at the six-week, three-

month or six-month follow-up. Results from thePediatric Motor Activity Log Frequency of Usesubscale (SMD 1.53, 95% CI 0.45 to 2.62) andEmerging Behaviors Scale (SMD 1.22, 95% CI0.19 to 2.24), both parent-rated questionnaire-based measures, indicated a significant treatmenteffect immediately after treatment (at threeweeks). The treatment effect for the PediatricMotor Activity Log Frequency of Use subscale

remained significant at six weeks (SMD 1.30, 95%CI 0.26 to 2.34), however the Quality of Use sub-scale did not show a significant treatment effect atpost treatment (SMD 0.72, 95% CI 0.24 to 1.69)

or at the six-week follow-up (SMD 0.67, 95% CI0.29 to 1.63). The blindly rated measure, theToddler Arm Use Test, did not show significantdifference between groups as demonstrated in theANCOVA analysis (F 1.42, P 0.25) reportedin the dissertation. Further analyses reported inthe publication19 found significant between-group differences after treatment in percentageof items for which children use their more affectedarm and overall quality of use.

Analysis of Eliasson et al.17 data demonstrateda significant treatment effect at two months (SMD

1.12, 95% CI 0.46 to 1.78) and at six months(SMD 0.74, 95% CI 0.10 to 1.37) based onchange scores of the Assisting Hand Assessment(Figure 2). These outcomes supported the conclu-sion that over a six-month period mCIMT induceda rate of improvement in bimanual performanceusing the hemiplegic hand that was greater thanwith traditional services.

The Sung et al.18 trial demonstrated a signifi-cant treatment effect at six weeks on one outcomemeasure, the self-care component of theFunctional Independence Measure for Children

(WeeFIM) (SMD 1.25, 95% CI 0.46 to 2.03)(Figure 3). At six weeks, all other measures includ-ing the Erhardt Developmental PrehensionAssessment (SMD 0.57 95% CI 0.16 to 1.30),Box and Blocks Test (SMD 0.67 95% CI 0.07to 1.40), motor component WeeFIM (SMD0.40 95% CI 0.32 to 1.12), WeeFIM cognitivecomponent (SMD 0.54 95% CI 0.19 to 1.27) andWeeFIM total score (SMD 0.54 95% CI 0.19 to

1.27) demonstrated a trend favouring Forced usebut no significant treatment effects.

Discussion

Constraint-induced movement therapy (CIMT),mCIMT and Forced use are emerging as treatmentapproaches for children with hemiplegic cerebralpalsy. The purpose of this review was to evaluatethe effectiveness of these interventions using thehighest-level evidence available. Three trials, with

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Table

3

Designcharacteristicsimpactingthequalityofincludedstudies

De

Luca(2002)5

Eliassonetal.(2005)17

Sungetal.(2005)18

Design

Sin

gleblindRCT

CCT

RCT

Randomization

Foldingapieceofpaper,tapedclosed

anddrawnfromajarsetupbeforethe

beginningoftheparticipantenrolment

NA

Notdescribed

Allocation

concealment

Un

clear

Notused

Unclear

Drop-outs

No

ne

Fourchildrenfromtreatmentgroup

Notreported

Baseline

characteristics

No

statisticallysignificantdifferences

betweengroupsforage,gender,severity

of

hemiparesis,priortreatmenthistoryo

r

baselinescoresonoutcomemeasures

Nostatisticallysignificantdiffe

rence

betweengroupsforageandd

egree

ofhandfunction(usingAHA)

Nostatisticallysignificant

differences

betweengroupsforage,

genderandbaseline

scoresonoutcomemeasures

Outcomes

Validity

Reliability

Validity

Reliability

Validity

Reliability

QU

EST:yes

23,

24

QUEST:yes

23

AHA:yes2

0,

25

AHA:yes

25,

26

Box&Blocks:

Box

&Blocks:

CA

UT:no

CAUT:no

yes

27

yes

3

0

PM

AL:no

PMAL:no

EDPA:no

EDP

A:no

EB

S:no

EBS:no

WeeFIM:yes

28,

19

Wee

FIM:yes3

1,

32

Blindingofassessors

CA

UTonly

Yes

Notreported

RCT,randomizedcontrolledtrial;CCT,controlledclinicaltrial;QU

EST,QualityofUpperExtremitySkillsTest;CAUT,ChildArmUseTest;PMAL,Pediatric

MotorActivityLog;EBS,EmergingBehavioursScale;AHA,Assis

tingHandAssessment;EDPA,Erhard

tDevelopmentalPrehensionAssessm

ent;WeeFIM,

FunctionalIndependenceM

easureforChildren.




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Review: Constraint induced movement therapy in the treatment of the upper limb in children with hemiplegic cerebral palsyComparison: 01 CIMT versus traditional servicesOutcome: 01 QUEST "change" score from baseline to immediately post treatment (3 weeks)

Studyor sub-category

Weight%

SMD (random)95%CI

SMD (random)95%CI

Controlmean (SD)

Treatmentmean (SD)

NN

01 Post-treatment (0 to 3 weeks "change" score)DeLuca 2002 9 14.23(17.48) 9 1.74(16.02) 100.00 0.91 [0.08, 1.89]

Subtotal (95%CI) 9 9 100.00 0.91 [0.08, 1.89]

Test for heterogeneity: not applicable

Test for overall effect: Z=1.81 (P=0.07)

10 5 0 5 10

Favours control Favours CIMT

Figure 1 QUEST (dissociated movement) change scores from baseline to three weeks.

Review: Constraint induced movement therapy in the treatment of the upper limb in children with hemiplegic cerebral palsyComparison: 02 mCIMT versus traditional services

Outcome: 01 Assisting hand assessment "change" score from baseline to 2 & 6 months

03 Post-Treatment (0 to 2 months "change" score)Eliasson 2005 21 1.23(1.03) 20 0.24(0.65) 100.00 1.12 [0.46, 1.78]

Subtotal (95% CI) 21 20 100.00 1.12 [0.10, 1.37]


Test for overall effect: Z=3.31(P=0.0009)

046 month follow up (0 to 6 months "change" score)

Eliasson 2005 21 1.79(1.03) 20 0.93(1.19) 100.00 0.74 [0.10, 1.37]

Subtotal (95% CI) 21 20 100.00 0.74 [0.10, 1.37]

Test for heterogeneity: not applicableTest for over all effect: Z = 2.27 (P = 0.02)

10

5 0 5 10


Study

or sub-category

CIMT

mean (SD)N NTraditional

mean (SD)

SMD (random)

95%CI

Weight

%

SMD (random)

95%CI

Figure 2 Assisting Hand Assessment change score from baseline to two and six months.

Review: Constraint induced movement therapy in the treatment of the upper limb in children with hemiplegic cerebral palsyComparison: 03 Forced Use versus traditional servicesOutcome: 06 WeeFIM - Total "change" scores

N N

01 Post-treatment (0 to 6 weeks "change" score)

Sung 2005 18 1.94(1.70) 13 1.15(2.20) 100.00 0.40 [0.32, 1.12]

Subtotal (95% CI) 18 13 100.00 0.40 [0.32, 1.12]


Test for overall effect: Z=1.09 (P=0.28)

10 5 0 5 10


Studyor sub-category

CIMTmean (SD)

Traditionalmean (SD)

SMD (random)95%CI

Weight%

SMD (random)95%CI

Figure 3 WeeFIM total change score from baseline to six weeks.

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varying methodological quality and sample sizeswere identified.5,17,18 The three intervention proto-cols varied significantly, particularly in relation tothe intensity of treatment, from no increase in con-ventional treatment18 to 6 hours a day for 21 con-secutive days.5 As each trial examined differentCIMT intervention protocols, CIMT, mCIMTand Forced use respectively, it was not possibleto undertake a meta-analysis.

Results from DeLuca5 on the DissociatedMovement subscale of the QUEST, which wasscored by blinded raters and the only outcomemeasure with known validity and reliability, didnot show statistically significant treatment effectfor CIMT. This was despite a 14.23 (SD 17.48)

point change in the CIMT group compared with1.74 (16.02) in the control group, indicating thatthe result may have been clinically important forat least some individuals. The small sample sizeof the study (n 18) and high variability acrossindividuals is likely to have resulted in inadequatepower to detect a statistically significant differencebetween groups. Significant treatment effectsfavouring CIMT, however, were found byDeLuca5 on parent response questionnaires thatwere without reported psychometric properties(Pediatric Motor Activity Log Frequency of

Use subscale, Emerging Behaviors Scale). Resultsfrom the Toddler Arm Use Test, administered byraters blind to group allocation, were not signifi-cant. The clinical importance of these results isdifficult to determine in the absence of evidencerelated to validity and reliability of the measures.

The significant treatment effect demonstratedby Eliasson et al .17 at two and six monthspost intervention using the Assisting Hand

Assessment,2022 has important implications forthe use of CIMT protocols in clinical practice. Amodified protocol using a removable mitt, asopposed to a long arm cast, and significantly

reduced intensity of practice (2 hours per day)when compared with a CIMT protocol (6 hoursper day) may be more clinically feasible and devel-opmentally appropriate for young children.Additionally, the identification by Eliassonet al.17 that older children and those with verypoor hand function improved more than youngerand less impaired children highlights the need forfurther investigation into the individual character-istics of children who will benefit from CIMT andits modified versions.

The Forced use trial by Sung et al.18 reported

statistically significant results on all outcomesusing what was described as non-parametricpaired and unpaired t tests.18 The findings fromthese unclear analytical processes were not sup-ported by further analysis using RevMan,16 whichfound a significant treatment effect for only oneoutcome: the self-care component of theWeeFIM. The clinical significance of this treatmenteffect is questionable with a mean differencebetween groups of one point on a 56-point scale.The authors of the review strongly recommend thefindings from this trial be viewed with caution giventhe ambiguity of its specific methodology, lack ofmethodological rigour and inadequate reporting.

Reviewers conclusions

This systematic review found a significant treat-ment effect using mCIMT in a single non-rando-mized trial. A positive trend favouring CIMT andForced use was also demonstrated. While theseearly results are encouraging, they are inconclu-sive. It is recommended that the use of CIMT,mCIMT and Forced use should remain within

clinical trials until the evidence is clearer.Suggestions for future research include conductingappropriately powered studies and utilizing uni-form and objective outcome measures which willallow pooling of data in future meta-analyses.Valid and reliable outcomes which measure theusefulness of the affected upper limb in bimanualtasks (e.g. the Assisting Hand Assessment) and inrelation to individual client and family goals

Clinical messages

This systematic review found a significant

treatment effect using modified constraint-induced movement therapy in a single non-randomized trial.

A positive trend favouring CIMT andForced use was demonstrated.

The use of CIMT, mCIMT and Forced useshould remain within clinical trials until theevidence is clearer.




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(for example the Canadian OccupationalPerformance Measure and Goal AttainmentScaling) should be included. Investigationsshould pursue longer term outcomes and examine

the individual characteristics of children whoexperience positive CIMT outcomes. The impactof varying intensities of treatment and the envir-onment or social context in which the treatment isprovided should also be examined with a view tooptimizing treatment protocols and enhancingtreatment outcomes.

Competing interestsNone declared.

ContributorsBH initiated the review, designed the review,

wrote the paper, rated methodological quality,extracted and analysed data and was guarantor.CI monitored progress revising the review criti-cally for intellectual content, extracted and ana-lysed data and contributed to the discussion ofthe results. LC analysed data, monitored progressrevising the review critically for intellectualcontent and contributed to the discussion ofthe results. JW contributed to the design of thereview, conducted the search strategy and

monitored progress.

AcknowledgementsThe authors appreciate the help and support of

the Movement Disorders Cochrane Review Group.This paper is based on a Cochrane Reviewpublished in The Cochrane Library 2007, Issue 2(see www.thecochranelibrary.com for informa-tion). Cochrane Reviews are regularly updated asnew evidence emerges and in response to feedback,and The Cochrane Library should be consulted

for the most recent version of the review.

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