Running Head: CIMT IN ADULTS AFTER STROKE 1

Evaluating the Effects of Constraint-Induced Movement Therapy on Upper Limbs in Adults

After Stroke

Allie A. Ritchie

Andie B. Campbell

University of Utah
CIMT IN ADULTS AFTER STROKE 2

Introduction

According to the National Institute of Neurological Disorders and Stroke (2016), a stroke

occurs when there is an interruption in blood flow to the brain, either by a blocked blood vessel

(ischemic stroke) or a ruptured vessel causing abnormal bleeding (hemorrhagic stroke). The

Centers for Disease Control and Prevention (2015) estimates that stroke is the fifth leading cause

of death in the United States, with 800,000 strokes occurring each year and it is the leading cause

of serious long-term disability (CDC, 2015). In the United States, strokes cost $34 billion per

year in medications, health care costs, and loss of productivity poststroke (CDC, 2015).

Up to 85% of people after a stroke experience an upper limb deficit, and only 50% will

regain functional use of this limb (Pedlow, Lennon, & Wilson, 2014, p. 276). This creates a

challenge for individuals who have had a stroke to adapt to living with the debilitating effects of

a stroke in many aspects of their lives. Activities of daily living (ADLs) pose a unique

substantial challenge for stroke individuals, creating a level of dependence on caregivers

(Pedlow et al., 2014, p. 276). A stroke can affect many different facets of life including:

recreational activities, employment, mood, financial status and quality of life in both stroke

victims and caregivers.

Treating patients that have experienced a stroke is common in the practice of

occupational therapy, as well as many other healthcare disciplines. It is important for

occupational therapy practitioners to understand the multifaceted effects stroke can have on a

client, and to educate themselves to provide the best multifaceted client-centered treatment to

clients. With stroke being the leading cause of long-term disability, there are many treatment

options that are available to clients through occupational therapy and other healthcare services.

A treatment option that has been widely researched recently is constraint-induced movement
CIMT IN ADULTS AFTER STROKE 3

therapy (CIMT). Constraint-induced movement therapy is a complex, multicomponent, and

patient-center rehabilitation intervention (Blanton, Wilsey, & Wolf, 2008).

Constraint-induced movement therapy forces the use of the affected limb by restraining

the unaffected limb with a sling after a stroke. By using the affected limb intensively, it is widely

believed to help stroke survivors overcome the initial feelings of failure when trying

unsuccessfully to use the affected limb (American Stroke Association, 2014). Constraint-induced

movement therapy has become a viable option for therapeutic intervention, and current research

suggests there are increased patient benefits when using CIMT. However, compared to

conventional stroke therapy, the implementation of CIMT into clinical practice has yet to

increase. Therefore, the researchers main objective in this paper was to analyze literature to

find evidence regarding the effectiveness of using CIMT as a therapeutic intervention on affected

upper extremities for adult individuals who have sustained a stroke.

Methods

Three scientific research databases were used to collect relevant data: PubMed, CINAHL

and OTSeeker. To find scientific data relevant to OT, a research question was developed based

on the PICO (Person, Intervention, Comparison, Outcome) format. The initial PICO question

used to refine search outcomes was: Does Constraint Induced Movement Therapy (CIMT)

increase functional use of affected upper extremity in adults after stroke? The initial PICO

question resulted in too few search results. Researchers modified the original PICO question to

increase search results. The modified PICO question applied to the research databases was:

Constraint-induced movement therapy and stroke. This PICO question resulted in an

increased number of search results. In conjunction with the PICO question, keywords were also

used to find pertinent articles. The keywords that were employed were: stroke, adult, constraint-
CIMT IN ADULTS AFTER STROKE 4

induced movement therapy. Twelve articles were found, and researchers developed inclusion

and exclusion criteria in order to narrow down the amount of articles that were relevant based on

our established criteria.

Inclusion Criteria

Articles were read and evaluated by researchers and determined usable based on the

following inclusion criteria: articles were published after 2006; participants were adults who had

sustained a stroke; participants received either modified-CIMT (mCIMT) or CIMT as a treatment

for stroke, outcome measures relevant to occupational therapy were used to determine efficacy of

CIMT treatment and articles were published in a peer-reviewed journal. Studies that were

randomized-control trials (RCTs) were assessed for quality using the PEDro scale, with a score

of six being the minimum level for inclusion in this review. It is important to note that blinding

the participants and therapists in these studies was difficult, due to the fact that both parties

would recognize if they were receiving or administering CIMT. See Table 2 for the PEDro

scores of each RCT. Articles that were not randomized-control studies were evaluated by

researchers to determine the validity and reliability of the studies using the following criteria:

article findings were accurate; findings are applicable in multiple contexts; and others can

replicate results. Articles that met the criteria and minimized threats to internal and external

validity were included in this review.

Exclusion Criteria

Articles were excluded based on the following criteria: articles were published before

2006; participants were not adults; m-CIMT treatment or CIMT treatment was used for

diagnoses other than stroke, or CIMT treatment was not used. Randomized-control studies that

scored below six on the PEDro scale were not used in this review.
CIMT IN ADULTS AFTER STROKE 5

Results

Types of Studies and Levels of Evidence

Seven studies were selected that met the inclusion criteria for this review, including six

randomized-control trials (Level 1 evidence), and one 2-group non-randomized study (Level 2

evidence). See Table 1 for a summary of details of each article.

Key Findings

Wu, Chuang, Lin, Chen, and Tsay (2011) conducted a RCT to examine the effects of

bilateral arm training (BAT), distributed constraint-induced therapy (dCIT), and control

treatment (CT) on performance of daily functions and motor control of the hemiparetic upper

extremity in people who have sustained a stroke. The results showed that dCIT significantly

improved performance in the WMFT-Time and WMFT-FAS compared to the CT group. The

dCIT group also showed better scores in the MAL-AOU and MAL-QOM tests than the BAT or

CT groups. Kinematic analysis showed smoother movements in the dCIT and BAT groups, but

the BAT group showed a significant increase in force produced during movement compared to

the dCIT and CT groups. Overall, the study concluded that BAT is a better choice if force

generation is a goal, whereas dCIT is better at increasing functional ability and use of the

affected upper extremity. The study recognized limitations such as the limited amount of tasks

used to perform the kinematic analysis, as well as the movement requirements of the patients as

part of the inclusion criteria.

Smania et al. (2012) performed a randomized control trial comparing reduced-intensity

modified constraint-induced movement therapy (mCIMT) and conventional rehabilitation

techniques on the affected upper extremity in adults after a stroke. The results showed that both

groups significantly improved in all outcome measures, however, there were significant
CIMT IN ADULTS AFTER STROKE 6

differences between the two groups in WMFT-FA and MAL-QOM after the intervention and at

the follow-up, with the mCIMT group showing greater improvements. Both groups appeared to

show a decrease in spasticity of the affected arm after treatment. The study concluded that

mCIMT may improve function and use of the affected arm better than conventional

rehabilitation techniques. The authors addressed limitations such as the lack of a long-term

follow-up (such as 6 months to 1 year), the high attrition rate at the 3-month follow-up which

affected the interpretation of the outcome measures of disability, and the lack of a patient diary

to monitor intensity of household activities. They also noted that it was difficult to actually test

the specific effects that the modified-intensity of the restraining mitt had on the outcomes versus

traditional-intensity CIMT.

Wolf et al. (2006) performed a very large clinical trial that examined the effect of CIMT

on upper extremity function compared to usual and customary care in adults who had sustained

a stroke within 3-9 months. The results presented significant improvements in the CIMT group

on the affected limb movement time (WMFT) and the quality of movement and amount of use of

the limb (MAL-AOU/MAL-QOM) which were still present at the 12-month follow-up. The

CIMT group also reported a decreased perceived difficulty with the affected limb (SIS) at the 12-

month follow-up. The control group also showed improvements in these areas, but not as

significant as the CIMT group. Overall, the study concluded that with patients who have had a

stroke within 3-9 months, CIMT produced better improvements in UE function that lasted for 12

months. Limitations that were identified were the high amount of low-functioning individuals in

their study, which made it difficult to interpret the outcomes as a result of the intervention or the

inherent characteristics of the population itself. They discussed how it was difficult to compare

the intensity of treatments between the groups, and that there is a possibility that customary care
CIMT IN ADULTS AFTER STROKE 7

was just as intense as CIMT. In addition, they had limited knowledge of the types of strokes,

medications, and outside treatments that the patients were receiving, thus they could not assess

the influence of those variables on the outcomes.

Dromerick et al. (2009) conducted a study comparing standard CIMT, high-intensity

CIMT, and typical stroke rehabilitation techniques on UE motor function in adults in an acute

inpatient stroke rehabilitation setting. The authors rationale for studying this is the idea that

high-intensity CIMT can reduce costs during inpatient rehabilitation while trying to improve

patient outcomes. In addition, early CIMT may prevent the learned non-use phenomenon and

result in better function.The results showed an inverse dose effect, where high-intensity CIMT

showed less improvements than the standard CIMT group. There were also no significant

differences between the standard CIMT group and the control group, which suggests it is equally

beneficial as traditional poststroke therapy. This study identified limitations such as the inability

to control for outside treatments such as medication and treatment, as well as the differing levels

of ability among the participants.

Lin, Wu, Wei, Lee, and Liu (2007) examined how modified constraint-induced

movement therapy affected motor control during reach-to-grasp tasks as well as functional

performance of ADLs compared to traditional therapy in adults after chronic stroke. The results

showed significant improvements on functional performance (MAL and FIM tests) for the

mCIMT group compared to the control group. The mCIMT also showed significant

improvement in reaction time during the kinematic analysis of reaching and grasping, however it

did not decrease overall movement time. The authors suggest that the mCIMT group were taking

less time to preplan the movement and shifted towards a feedforward movement strategy rather

than feedback. The study concluded that mCIMT improved functional use during reaching and
CIMT IN ADULTS AFTER STROKE 8

grasping tasks more than traditional rehabilitation therapy. Lin et al. (2007) discussed a large

measurement limitation in which a marker used to measure grasp was moved during assessment,

thus confounding the grasp data. In addition, they did not use a variety of objects during the

grasp measurements, so the outcomes may not be generalized to the overall grasping abilities.

Finally, authors also discussed the inconsistency in functioning among the participants and how

it can affect their responses to the intervention.

Barzel et al. (2015) examined the efficacy of home constraint-induced movement therapy

in order to understand whether home CIMT programs are as effective as other CIMT programs.

Barzel et al. (2015) compared home CIMT programs to standard stroke home therapies. After

four weeks of intervention, both groups showed an increase in the quality of arm use and

improved performance time. The home CIMT group showed more increase in the quality of arm

use, but there was no significant difference between the two groups and performance time based

on the Wolf Motor Function Test of Performance Time (WMFT-PT). Both groups showed

improvement in functional ability of their arm use. After a six-month follow up was conducted,

the home CIMT group showed a greater increase in quality of arm movement, and a significant

increase in use of the affected arm. These results show that a home CIMT program can improve

quality of arm use, and an increase of use of the affected arm after CIMT treatments.

Barzel et al. (2015) discussed the lack of measurements that assess perceived

performance or actual performance in daily life. The authors discussed that the limitations of

using measurements that only measure function in the sense of capacity, rather than using

measurements that measure arm use in activities of daily living that are relevant to the person

could alter results as participants might not be motivated if the tasks are not pertinent to them.

Barzel et al. (2015) also examined bias in their study from using a non-professional as a personal
CIMT IN ADULTS AFTER STROKE 9

coach to motivate and monitor the participants in the home CIMT study. This introduces a

limitation of introducing CIMT intervention at the participant's home as there becomes a lack of

professional supervision of treatment.

Sawaki et al. (2014) conducted a study to measure the effectiveness of CIMT for stroke

treatment and the timeliness of treatment. The WMFT was considered the primary outcome

measure, and transcranial magnetic stimulation (TMS) was conducted on three occasions:

baseline, two-weeks post intervention, and at a four- month follow up. There were no significant

differences between the two groups at baseline. Results showed that the early group had greater

improvement in the WMFT compared to the late group. Both groups showed TMS enlargement,

however, the later group showed greater cortical recognition than the early group. The study

concludes that CIMT will lead to greater improvement in motor function of the affected limb

when the individual seeks treatment early after stroke. Sawaki et al. (2014) discussed using a

small sample size with unequal groups as a limitation to their study. Sawaki et al. (2014) also

stated that the unequal sample size in the two groups could be considered a confounding

variable.

Discussion

Interpretation of Findings

Drawing from the conclusions of Wu et al. (2011), Smania et al. (2012), and Wolf et al.

(2006), it appears that CIMT, or some modified version of it, has significant improvements in

motor function as well as perceived function. All three of those studies used similar performance

measures to assess the outcomes of the groups receiving CIMT treatment. The design layout of

these studies were similar, with the types of intervention and duration being comparable. The

major difference between these three studies was the amount of time that the CIMT groups wore
CIMT IN ADULTS AFTER STROKE 10

the restraining mitt. Lin et al. (2007) also recorded significant improvements for their CIMT

group, concluding that the CIMT group improved significantly in perceived functional

performance (MAL) and during the functional independence measure. This study was focused on

reach-to-grasp functional movements and therefore used different performance measures than the

three studies above. In contrast, Dromerick et al. (2009) did not find significant improvements in

their standard CIMT group compared to the control group, suggesting that CIMT has comparable

benefits as traditional post-stroke rehabilitation.

Constraint-induced movement therapy appears to have comparable or improved benefits

in rehabilitation than traditional stroke therapy. It did not appear to have any adverse effects on

patients, suggesting that it may be a useful therapy technique when working with a post-stroke

hemi-paretic population.

Strengths and Limitations

One common theme among the studies was the difficulty in dose-matching the intensities

of CIMT, mCIMT, and standard therapy. It is important to note that Wu et al. (2011) had their

participants wear the mitt for 6 hours/day and Wolf et al. (2006) instructed their participants to

wear it for 90% of waking hours. In Dromerick et al. (2009), high-intensity CIMT was

considered to be wearing the mitt for 90% of waking hours.This variability in duration makes it

difficult to ascertain what is considered standard CIMT versus high-intensity CIMT. In addition,

both Smania et al. (2012) and Wolf et al. (2006) both specifically identified the difficulties with

matching intensities and interpreting results based on potential intensity differences. It was also

noticed that there were differences in what is considered standard therapy which the vast

majority of the control groups received. Without having a universal standard for comparison, it is

difficult to interpret the effects of the techniques used.

CIMT IN ADULTS AFTER STROKE 11

Another common limitation among the studies was the differing levels of ability among

the participants and how the type of stroke and resulting deficits would respond differently to the

interventions. Three studies also had difficulties with controlling outside treatments such as

medication and additional therapy, which could confound the results.

Researchers also noted a lack of long-term evidence within the research, as follow-up

measures ranged from one month to twelve months. This leaves a hole in the evidence for the

long-term effects of CIMT on upper extremity mobility and function.

Strengths among the research included the use of established measures such as the Wolf

Motor Function Test, Motor Activity Log, and Functional Independence Measure. Several

studies used one or more of these outcome measures, which made the results more comparable

across the different studies. In addition, there was a large amount of Level 1 evidence on this

topic, with several studies implementing baseline similarity comparisons, blind assessors, and

intention to treat protocols to increase the power of their study.

Recommendations

As established from the above studies, CIMT appears to significantly improve functional

performance and motor control in affected upper extremities after stroke in adults. None of the

studies resulted in adverse effects due to the CIMT intervention, and therefore the benefits of the

intervention outweigh any risk. It is recommended that CIMT be considered as a therapeutic

intervention when working with adults with upper extremity hemiparesis following a stroke.

According to the AHA chart, multiple RCTs were performed with the majority concluding that it

was a useful intervention, thus this would be a Level A-Class IIa recommendation, meaning it is

reasonable to perform this intervention. Because CIMT is very time consuming, there may be a

lack of professionals that are able to effectively supervise their patient participating in CIMT
CIMT IN ADULTS AFTER STROKE 12

treatments due to the time constraints. It is important to implement effective training and

education to professionals before using CIMT in order to ensure proper technique and

implementation of this intervention.

CIMT IN ADULTS AFTER STROKE 13

References

Centers for Disease Control and Prevention. (2015). Stroke Facts. Retrieved from:

http://www.cdc.gov/stroke/facts.htm

American Stroke Association. (2014). Life After Stroke. Retrieved from:

http://www.strokeassociation.org/STROKEORG/LifeAfterStroke/RegainingIndependenc

e/PhysicalChallenges/Constraint-Induced-Movement-Therapy_UCM_309798_Article.jsp

Barzel, A., Ketels, G., Stark, A., Tetzlaff, B., Daubmann, A., Wegscheider, K., . . . Scherer, M.

(2015). Home-based constraint-induced movement therapy for patients with upper limb

dysfunction after stroke (HOMECIMT): A cluster-randomised, controlled trial. Lancet

Neurology, 14(9), 893-902. doi: http://dx.doi.org/10.1016/ S1474-4422(15)00147-7

Blanton, S., Wilsey, H., & Wolf, S.L. (2008). Constraint-induced movement therapy in stroke

rehabilitation: Perspectives on future clinical applications NeuroRehabilitation, (23)1, 15-

28.

Dromerick, A.W., Lang, C.E., Birkenmeier, R.L., Wagner, J.M., Miller, J.P., Videen, T.O., . . .

Edwards, D.F. (2009). Very early constraint-induced movement during stroke

rehabilitation (VECTORS): A single-center RCT. Neurology, 73(3), 195-201. doi:

10.1212/WNL.0b013e3181ab2b27

Lin, K.C., Wu, C.Y., Wei, T.H., Lee, C.Y., & Liu, J.S. (2007). Effects of modified constraint-

induced movement therapy on reach-to-grasp movements and functional performance

after chronic stroke: A randomized controlled study. Clinical Rehabilitation, 21(12),

1075-1086. doi: 10.1177/0269215507079843

CIMT IN ADULTS AFTER STROKE 14

National Institute of Neurological Disorders and Stroke. (2016). NINDS Stroke Information

Page. Retrieved from: www.ninds.nih.gov/disorders/stroke/stroke.htm

Pedlow, K., Lennon, S., & Wilson, C. (2014) Application of constraint-induced movement

therapy in clinical practice: An online survey. Archives of Physical Medicine and

Rehabilitation, 95(2), 276-282. doi: http://dx.doi.org/10.1016/j.apmr.2013.08.240

Sawaki, L., Butler A. J., Leng, X., Wassenaar P. A., Mohammad, Y., Blanton, S., . . .

Wittenberg, F. (2014). Differential patterns of cortical reorganization following

constraint-induced movement therapy during early and late period after stroke: A

preliminary study. NeuroRehabilitation, 35(3), 415-426. doi: 10.3233/NRE-141132

Smania, N., Gandolfi, M., Paolucci, S., Iosa, M., Ianes, P., Recchia, S., . . . Farina, S. (2012).

Reduced-intensity modified constraint-induced movement therapy versus conventional

therapy for upper extremity rehabilitation after stroke: a multicenter trial.

Neurorehabilitation and Neural Repair, 26(9), 1035-1045. doi:

10.1177/1545968312446003

Wolf, S.L., Winstein, C.J., Miller, J.P., Taub, E., Uswatte, G., Morris, D., . . . Nichols-Larsen, D.

(2006). Effect of constraint-induced movement therapy on upper extremity function 3 to

9 months after stroke: The EXCITE randomized clinical trial. Journal of American

Medicine, 296(17), 2095-2104.

Wu, C.Y., Chuang, L.L., Lin, K.C., Chen, H.C., & Tsay, P.K.. (2011). Randomized trial of

distributed constraint-induced therapy versus bilateral arm training for the rehabilitation

of upper-limb motor control and function after stroke. Neurorehabilitation and Neural

Repair, 25(2), 130-139. doi: 10.1177/1545968310380686

 CIMT IN ADULTS AFTER STROKE
Table 1: Summary of details of selected studies.
Author(s) Type of Participants Study Design and
Study/Level of Measures
Evidence
Wu et al. RCT/Level 1 -66 patients recruited from 4 stroke rehab Design:
(2011) units -Pretest/posttest
-average age of 53.11 yrs
-average time since stroke = 16.20 months Measures:
-unilateral stroke 1. Kinematic analysis
(unilateral desk bell
-inclusion criteria: task/bilateral drawer
> 6 months post stroke, no significant opening and object
cognitive deficits, significant nonuse of retrieval)
affected UE, no balance problems or 2. Wolf Motor Function
rehab/drug studies, limited spasticity, Test (WMFT) [Time,
Brunnstrom stage 3 or above Functional ability (FA), and
strength]
3. Motor Activity Log
(MAL) [Amount of use
(AOU) and Quality of
movement (QOM)]
Smania et al. RCT/Level 1 -66 participants aged 32-84 Design:
(2012) -17% female, 83% male -Pretest, posttest, 3 month
follow-up
-inclusion criteria:
3-24 months poststroke, 10 degrees Measures:
extension of wrist and fingers, no balance 1. WMFT (quality of
problems, able to stand without arm movement [FA] and
support, passive ROM requirements performance [T])
hi 2. MAL (AOU/QOM)
3. Ashworth Scale (AS)-
resistance to passive stretch
on paretic elbow
Wolf et al. RCT/Level 1 -222 participants recruited from Design:
(2006) participating sites -Pretest, Posttest,, 4-, 8-,
-stratified by sex, prestrike dominant side, 12-month follow-up
side of stroke, level of function in paretic
arm Measures:
1. Wolf Motor Function
-inclusion criteria: 3-9 months poststroke, Test (WMFT)- 15 timed
first stroke incident, wrist and finger tests, 2 strength tests
extension, adequate balance, low 2. Motor Activity Log
spasticity, ability to stand without support (MAL)- given to participant
and caregiver. Measures
how well (QOM) and how
much (AOU) affected arm
was used during ADLs.
3. Stroke Impact Scale-
measures impairment,
function, QOL following
stroke
15
Intervention
-3 groups: dCIT, BAT, CT
-All groups had therapy 2
hrs/day, 5x/week, 3-weeks
-dCIT group wore mitt for 6
hrs/day
-2 groups: mCIMT, CG
-Both groups: 1 hour
outpatient individual session,
1 hour household activities
5x/week x 2 weeks.
-household activities were
same for mCIMT and CG
groups
-mCIMT group restrained
unaffected limb for 12
hrs/day, not during individual
treatment sessions
-2 groups: CIMT, control
-2 weeks
-control group: ranged from
no treatment, orthotics,
PT/OT techniques
-intervention group: shaping
and task training for 6hrs/day
on weekdays. Wore restraint
on non-affected limb for 90%
of waking hours. Instructed
to complete 2-3 practice
tasks every day after
treatment
-Participants encouraged to
do 30 minutes of task
practice daily after
intervention
-control group was offered
CIMT after 12-month
 CIMT IN ADULTS AFTER STROKE
Lin et al. RCT/Level 1 -32 chronic stroke patients Design:
(2007) -mean age of 57.9 years -Pretest/posttest
-11 women, 21 men
-mean stroke onset: 16.3 months Measures:
1. Kinematic analysis-
-inclusion criteria: evaluate motor control
at least 12 months poststroke, cognitively during reach-to-grasp task
stable, Brunnstrom stage 3, significant 2. Motor Activity Log
non-use of affected UE, no balance or interview about amount of
cognitive problems, no excessive use and quality of
spasticity movement of affected UE
3. Functional Independence
Measure functional
performance
Dromerick RCT/Level 1 -52 participants Design:
et al. (2009) -mean age 63.9 years -Pretest, posttest, 90-day
-mean stroke onset 9.65 days follow-up
-ischemic stroke
-inclusion criteria: stroke within 28 days Measures:
of admission, hemiparesis, no cognitive 1. NIH Stroke Scale
deficits, no prior UE conditions, proximal (NIHSS)-assess stroke
UE voluntary activity severity through cognitive,
sensory, motor impairments
2. Action Research Arm
Test (ARAT)- UE
limitations in grasp, pinch,
grip, gross movement
3. Functional Independence
Measure (FIM)-based on
performance during
inpatient, phone survey
after discharge
4. Stroke Impact Scale
(SIS)-hand function while
performing functional tasks
5. Pain ratings (Wong-
Baker Faces Scale)
6. Depression (The
Geriatric Depression-15
Scale)
Barzel et RCT/Level 1 -156 patients with mild to moderate Design:
al.(2015) impairment of arm function due to stroke. -Pretest, posttest (after 4
weeks of intervention), 6
-inclusion criteria: at least 6 months after month follow up.
stroke, mild to moderate impairment of
arm function, friend or family member Measures:
that was willing to act as a coach. 1 Motor Activity Log
(MAL)-measures activity
2 Wolf Motor Function Test
(WMFT)-measures stroke
specific functional ability.
3 Motor Activity Log-
16
evaluation
-2 groups: mCIMT, control
-5 days/week, 2hrs/day, x 3
weeks
-mCIMT group: wore
restraint for 6 hrs/day,
practice activities
-control group: strength,
balance, fine motor training,
etc.
-3 groups: control, standard
CIMT, high-intensity CIMT
- 5days/week x 2 weeks
-Standard CIMT group: 2hrs
shaping therapy/day, wore
constraint 6hrs/day.
-High intensity CIMT group:
3hrs shaping therapy/day,
wore constraint for 90% of
waking hours.
-control group received
routine inpatient
interdisciplinary stroke
rehab. 1hr ADL retraining,
1hr bilateral training
-37 patients were randomly
assigned to provide 4 weeks
of home CIMT.
- 34 patients were assigned to
provide 4 weeks of standard
therapy.
-Patients of both therapy
groups received 5 hours of
professional therapist contact
in 4 weeks.
-All assessments were done
by masked outcome
assessors at baseline, after 4
 CIMT IN ADULTS AFTER STROKE 17

Quality of Movement weeks of intervention, and at

(MAL-QOM)-measures 6 month follow-up
quality of arm usage
4 Motor Activity Log-
Amount of Arm Usage
(MOL-AOU)-measures
amount of arm usage.
-All measurements were
done on a scale of 0-5

Sawaki et 2 group non- 26 stroke patients were enrolled in the
al.(2015) randomized study.
study/Level 2 -17 participants were considered early
in getting CIMT < 9 months post stroke.
-9 participants were considered late in
receiving treatment > 10-12 months
-inclusion criteria: identical to the
EXCITE trial: active movement in the
paretic arm had to include at least 20
degrees of wrist extension and 10 degrees
of extension at the thumb and 2 other
digits. No history of seizures, alcohol and
drug abuse, cognitive deficits that would
prevent participant from the ability to
consent. Participants were also excluded
if they were pregnant or were childbearing
age.
Design: -Each subject participated in
-Pretest, posttest 10 weekdays of CIMT based
upper extremity therapy.
Measures: -Subjects wore a padded mitt
1 Wolf Motor Function Test that covered the non-paretic
(WMFT)-measures upper hand. The mitt was to be
extremity motor function worn 90% of the time,
2 Neurological Assessment- including two weekends.
Transcranial Magnetic
Stimulation (TMS)-
measures cortical
recognition
 CIMT IN ADULTS AFTER STROKE 18

Table 2: PEDro Scale for selected RCTs.

Study Random Concealed Baseline Blind Blind Blind Measures Intention- Between Point PEDro
Allocation Allocation Similarity Subjects Therapists Assessors of key to-treat group measures Score
outcomes analysis comparison and
measures of
variability

Wu et Yes No Yes No No Yes Yes No Yes Yes 6

al.
(2011)

Smania Yes Yes Yes No No Yes No Yes Yes Yes 7

et al.
(2012)

Wolf et Yes No Yes No No Yes No Yes Yes Yes 6

al.
(2006)

Lin et Yes Yes Yes No No Yes Yes No Yes Yes 7

al.
(2007)

Dromer Yes No Yes No No Yes Yes Yes Yes Yes 7

ick et
al.
(2009)

Barzel Yes No Yes No No Yes Yes Yes Yes Yes 7

et al.
(2015)