Running Head: CONSTRAINT-INDUCED MOVEMENT THERAPY POST STROKE 1

An Evidence-Based Review of the Effectiveness of Constraint-Induced Movement Therapy

Among Adults Post Stroke

Hazley Kelly, Jarrett Henderson, Jordan Fish

University of Utah
CONSTRAINT-INDUCED MOVEMENT THERAPY POST STROKE 2

Constraint-Induced Movement Therapy Post Stroke

Stroke is the fifth leading cause of death in the United States and is the number one cause

of long term impairments in adults; , causing decreased functional mobility in half of stroke

survivors over the age of 65 according to the CDC (2017). The risk for having a stroke increases Commented [AT1]: Write out

with age, and is almost doubled for African Americans (CDC, 2017). The timing of care is

important, and can have a huge impact on the individual’s recovery. A stroke occurring in

someone 65 and older can be the most dangerous because at this age they are more likely to live

alone, increasing the time of care and time spent in a care facility. These factors, combined with

an increased age, decreases recovery time and increasing increases the impact a stroke has on an

individual. The National Stroke Association states that stroke can impact someone’s life, by

affecting their physical, cognitive, visual or speech functions (2015).

With stroke being at such a high prevalence in the United States, it is important to know

which rehabilitation treatments work best for recovery. Upper extremity (UE) function

drastically affects how people participate in their everyday activities, and their occupations of

choice. Increased UE function would mean an increase in daily life participation, and patient

satisfaction. Through our research we found the standard protocol for constraint-induced

movement therapy (CIMT) to be: six hours a day, constraining the unaffected limb 90% of

waking hours, for a total of ten consecutive days (Thrane et. Alal., 2015). In particular, we were

interested in whether CIMT was an effective treatment for regaining function in the affected UE.

The healthcare field is always advancing, and it is important for occupational therapists

(OTs) to provide current evidence- based treatments and continue to do our due diligence for our

patients and community. Insurance companies also want to see that the care they’re paying for is

effective and will help their clients recover faster.

CONSTRAINT-INDUCED MOVEMENT THERAPY POST STROKE 3

We conducted this evidence-based review to find the current evidence, that either

supports or disproves the effect, that CIMT has on improving the function of a hemiplegic UE

post stroke. This evidence-based review will not only influence what we think is appropriate

treatment for adults post stroke, but help us identify areas that possibly need more research. Commented [AT2]: Nicely done – you edited your intro
well. Aside from some “rogue” punctuation, looks good!
Methods

Literature Search Strategy

The initial search for articles was conducted through the Spencer S. Eccles Health

Science Library at the University of Utah. The objective of this search was to see if CIMT is an

effective intervention for increasing UE movement for adults (18 years and older) who have

experienced a stroke. Various databases were utilized in finding articles that were relevant to the

PICO question. These databases included CINAHL, Embase Google Scholar, OT Seeker,

PubMed, EBSCOhost and MEDLINE Complete. In finding articles that would be useful, key

terms such as CIMT, modified constraint movement therapy (mCIMT), stroke, adults,

randomized controlled trial (RCT), meta-analysis, UE, arm, CVA, effects, rehabilitation, limb,

hemiparesis and cerebral stroke were entered in databases. Another strategy utilized was cross

referencing through articles initially searched. Finding other useful related research within one

study was helpful in narrowing down the search.

Study selection. The initial screening for this study began February 2018 where three

different individuals researchers performed independent searches to identify relevant

articles. Each quest used the previously mentioned key terms, leading to the identification of

326 articles. Inclusion of articles were based off selected key terms (i.e. stroke, UE, CIMT, and

adults) in the article’s title along with being published between 2008-2017. After applying

inclusion criteria and removing duplicated articles 56 articles remained.

CONSTRAINT-INDUCED MOVEMENT THERAPY POST STROKE 4

Electronic copies of articles were secured through the Eccles Library and authors

performed a secondary screening by reviewing article abstracts to qualify them for the

review. The level of evidence (LOE) for each article was considered and only articles with a

LOE of one or two were retained. Favor was given to RCTs and studies that accessed assessed

long term outcomes of CIMT. Once 15 articles were identified, remaining articles were

discarded, and a final screening began. PeDRO scores were assessed on all RCTs and any with a

PEDro six or higher were included. Commented [AT3]: As noted in your draft, your methods
section is terrific!
Results

Out of the 15 studies initially analyzed, nine have been used for this systematic review.

There are eight articles with a LOE of one, and one with a LOE of two. The studies consisted of

six RCTs and one meta-analysis, systematic review and two-group study. See Table 1 for an

overview of studies included in the review. Commented [AT4]: good

Fleet et al. (2014) reviewed multiple research studies to see if modified constraint Commented [AT5]: incorrect APA citation

induced movement therapy (mCIMT) is as effective as CIMT in improving UE

function. Standard CIMT requires a significant amount of the therapist time, which is not always

feasible. Because of this demand, the authors wanted to see if modification of the original

protocol would produce similar outcomes. The modifications included such things as switching

from a minimum of six hours of treatment per week, to two hours per week. Assessment

outcomes were analyzed and compared showing significant clinical difference for recovery of

UE while using mCIMT as opposed to traditional methods. A secondary analysis is needed to

conclude that mCIMT is effective for both chronic and acute stroke survivors. In this review

three independent reviewers were used to select articles reducing the bias of just one reviewer.
CONSTRAINT-INDUCED MOVEMENT THERAPY POST STROKE 5

The article does lack support of large RCTs. Hence a moderate level of evidence was given for

the effectiveness of mCIMT compared to a high level of evidence given for CIMT.

Thrane et al. (2015) compared use of CIMT to standardized therapy in early stroke

rehabilitation. Their rationale is that most research does not study the effects of CIMT within

four weeks post stroke. They have found that neuroplasticity is best utilized within weeks after a

stroke, hence the need to see effects of immediate intervention. Participants were separated into

two groups, one received standard therapy and the other CIMT. The CIMT group received three

hours of specialized therapy for ten consecutive work days along with UE restriction for 90% of

the time they were awake. The control group received standard care with no specific guidelines

or methods. This project lasted over two and a half years, which provided some limitations as it

could produce bias in the outcome measurements. Statistical analysis showed CIMT had notable

difference in functional motor movement of the UE. However, at six-months, there were no

significant difference between CIMT and other typical treatments. Thus, they conclude that

CIMT may produce quicker UE functional movement but when looking long term, six months or

more post intervention, CIMT does not provide any added benefit over traditional stroke

rehabilitation methods. A strength of this study was that added measures were performed to

increase reliability and control for variables. This study received a PEDro score of eight.

Singh and Pradhan (2013) performed an RCT to find if mCIMT was just as effective as

CIMT in comparison to standard treatment. Their rationale for the study was based on the fact

that standard CIMT methods required a significant amount of resources and dedication from the

therapist and patient. This PEDro six study sought to find if similar outcomes could be found by Commented [AT6]: interesting way of putting it

shortening the protocol. Participants were selected and separated into one of the following two

groups. The mCIMT group received shaping-based interventions for two hours a day, five days a
CONSTRAINT-INDUCED MOVEMENT THERAPY POST STROKE 6

week, for a total of two weeks. They were also required to wear a restrictive mitt on the

unaffected UE for ten hours a day during the two-week period. The control group received

conventional rehabilitation methods for the same amount of time. Findings were in favor of

mCIMT as an effective intervention for improving motor function in UE especially with distal

dexterity. This study did lack comparison of long term outcomes, longer than two weeks, and

had a relatively small sample size. However, it being small, no participants withdrew from the

study increasing the among of data that could be utilized.

Ju and Yoon (2018) acknowledged that many therapy methods are used to increase

neuroplasticity. The rationale for this study was to further understand the validity of different

stroke rehabilitation methods. They identified two common interventions and searched to find if

one would provide greater performance in activities of daily living (ADLs). Participants had

either right or left hemiplegia due to stroke. Participants were pseudo-randomly assigned to

receive mirror or mCIMT. Each participant experienced three weeks of treatment which

consisted of 20 minutes of the associated intervention along with 40 minutes of ADL practice

and muscle strengthening activities. Pre-intervention assessments showed no outliers of data.

After three weeks of treatment, participants were again assessed, and findings showed mCIMT to

have a notable benefit in relation to increased motor function which translated to greater

performances of ADLs. Mirror therapy also show improvement in UE function however these

did not translate to increased ADL performance. One down fall of this comparison is that mirror

therapy is known to require longer than three weeks before manifesting effects on neural

plasticity, so a longer study would be needed to increase validity. A strength of this study was

that there were a similar number of participant with left or right hemiplegia helping to prove that

mCIMT is valuable for both kinds of stroke.

CONSTRAINT-INDUCED MOVEMENT THERAPY POST STROKE 7

Past studies have touted that CIMT or mCIMT provide superior findings in relations to

UE functional performance. Brunner, Skouen, and Strand (2012) saw the evidence behind

bilateral training and questioned if one treatment was more superior. The original study planned

to follow 60 participants. Due to the amount of time (greater than two years) it took to recruit 30

eligible participants; an interim analysis was performed. Findings were consistent amongst the

participants warranting an early termination of the study with just 30 participants. Each

participant received equal time in assigned therapeutic method along with individualized self-

training exercises two to three hours a day. No clinically significant differences were noticed

after analyzation. Findings suggested that both methods produced similar outcomes. One

weakness of this PEDro eight study was it did not include a third group that would have received

standard therapy. One strength of this study was that four different outcome measures were used

to help draw conclusions, increasing its construct validity.

An RCT study done by Dahl et al. (2008), with a PEDro score of 7, studied CIMT on

patients that had unilateral hand impairment after a stroke. The aim was to determine if CIMT

was an effective treatment, in comparison to traditional rehabilitation. The CIMT group showed

a greater improvement in WMFT and FIM scores than the control group. At the 6-month

checkup however, the CIMT group maintained their levels of improvement but the control group

had also improved to the point where there were no marked differences between both groups.

Weaknesses of this study was that the sample size was smaller, which they thought could be the

reason for finding no statistical difference between the two groups (Dahl et al., 2008).

Researchers also suspected a possible Hawthorn effect for the group receiving traditional

therapy. The strengths of this article were that it was an RTC, patients were randomly assigned

via opaque envelopes and the procedures were done through independent and blind assessors.
CONSTRAINT-INDUCED MOVEMENT THERAPY POST STROKE 8

An RCT by Wolf et al. (2010), PEDro score of eight, wanted to study the effective CIMT

had on patients at three to nine months post-stroke (E-CIMT), and comparing them to patients

getting CIMT 15-21 months post-stroke (D-CIMT). Evaluators were not aware of which group

they were examining during the assessments. See Table 1 for the time frame of assessment

follow ups. The D-CIMT group were allowed to seek traditional therapies in the year after

enrollment before they received CIMT but were not allowed to have any kind of CIMT or

modified CIMT (mCIMT) during that period. When the D-CIMT group was ready for the CIMT

intervention they were reassessed to find their baselines so that data gathered didn’t include the

treatment they received while waiting. While both groups showed improvement after CIMT

treatment, the E-CIMT group showed a greater improvement of functional hand use (Wolf et al.,

2010). The E-CIMT group showed faster improvement than the D-CIMT, but there seemed to be

no difference between the two groups over 24 months in WMFT, and MAL measurements (Wolf

et al., 2010). The E-CIMT group showed significantly greater improvement in WMFT and MAL

scores from baseline to 12 months. The E-CIMT showed more improvement over the D-CIMT

group. Even though the two groups were similar 24 months after treatment, this study shows that

there is a faster improvement the earlier CIMT is given. The strengths of this article are that it is

a RCT, the sample size was larger, and their participants didn’t drop out though some missed

some of the follow-ups. The outcome measures were done using valid and reliable tests.

A meta-analysis performed by Thrane et al. (2014) looked at various trials of adult stroke Commented [AT7]: incorrect citation

patients who were participating in constraint-induced movement therapyCIMT. As part of the

objectives they wanted to look at different treatment modalities, and the impact of time since

their stroke. Databases such as PubMed, EMBASE, CINAHL, Cochrane, PEDro Trial, were used

in searching for trials that met certain criteria. Studies consisted of RCTs or quasi-randomized
CONSTRAINT-INDUCED MOVEMENT THERAPY POST STROKE 9

controlled trial. Patients needed to be older than 18 years, diagnosed with ischemic or

hemorrhagic stroke, and used CIMT/mCIMT for two to seven hours per day, lasting for 8-28

days. A positive effect was found for patients UE motor function when CIMT was implemented

immediately after stroke. The effect size of this study was believed to be underestimated due to

an a priori decision to standardize the mean differences based off the post intervention standard

deviations. A weakness of the study is that they did not consider the possible lasting effects of

various behavioral techniques that can be used with CIMT. A strength of the study found that

more research needs to be done with CIMT in the early stages after the stroke occurs.

El-Helow et al. (2015) looked at 60 acute stroke patients to see if mCIMT helps improve

motor function on the affected side of the UE. Their aim wasis to compare mCIMT to

conventional rehabilitation therapy. The intervention consisted of randomly dividing patients

into two groups, the mCIMT group and the conventional rehabilitation program group (CRP).

The mCIMT group wore an arm sling or a padded mitt on the unaffected UE. Each patient was

required to complete a neurological examination and an MRI of the brain. The CRP group

showed no significant improvements while the CIMT group showed significant improvement in

the pre and post assessment scores. A strength of this study was that zero participants were lost

to attrition. This study also received an eight on the PEDro scale. Limitations of this study

include a gender difference in participants, and findings are only limited to outpatient settings. Commented [AT8]: as noted in your draft, your results
are very well done!!
Discussion

The overall goal of this review was to assess whether CIMT is an effective modality to

treat post stroke survivors. The types and number of assessments used to measure UE function

varied between studies with the wolf Wolf motor function test appearing to be the favored

assessment in six out of the nine studies. Despite the variance of assessments, 100% of the level
CONSTRAINT-INDUCED MOVEMENT THERAPY POST STROKE 10

one studies, found improvement in UE function with the use of CIMT. This does not mean the

outcomes were better in comparison to other forms of therapy, but overall there was notable

improvement post treatment.

Not only has CIMT been shown to restore UE movement but it has restored it faster

than other types of therapy. Multiple studies agreed with Dahl et al. (2008) findings that showed

favorable outcomes post treatment. However, when looking past post treatment many found Commented [AT9]: This sounds weird, maybe use long-
term
similar, if not equal, outcomes to other therapies during post six month follow ups. This may

easily be interpreted to mean that CIMT is no better than any other well-known treatment. Commented [AT10]: Maybe traditionally used
treatment?
However, this view may be disputed by considering the psychological effects that a more

efficient intervention can have on a patient. Further analysis is needed to consider those effects

(i.e. quality of life, increased volition, and mood). Commented [AT11]: nice

When comparing the data across studies, CIMT protocols were not standardized as seen

in Table 1. For this reason, a systematic analysis was included in this review to give validity to

the fact that any mCIMT protocol could still be categorized in the realm of CIMT. Due to the

dearth of large RCTs, Fleet et al. (2014) gave mCIMT an intermediate LOE in relation to

increasing UE function. However, the majority (100% on the MAL and ART, 79% on the FM)

of the 133 participants receiving mCIMT, experienced outcome scores greater than the minimal

clinically important difference. Thus, it is reasonable to compare mCIMT and CIMT as similar in

purpose.

This research concludes that CIMT is an effective treatment and has been reproduced in

various settings. From the findings of this review, CIMT is level A clinical treatment that

increases functional use of affected UE in adults post stroke. This recommendation comes with

Class IIa benefit/risk variable due to the fact that further studies are needed to discover the most
CONSTRAINT-INDUCED MOVEMENT THERAPY POST STROKE 11

effective time to implement CIMT (acute vs. chronic). OTs have an important role in helping Commented [AT12]: no abbreviation at beginning of
sentence
stroke survivors return to participation in everyday activities. This review finds that CIMT is

one useful intervention that will improve the use of an affected UE, thus increasing a client’s

ability to participate in meaningful occupation and find satisfaction in life. Commented [AT13]: your discussion is terrific! Well
done, team CIMT!
CONSTRAINT-INDUCED MOVEMENT THERAPY POST STROKE 12

References

Brunner, I., Skouen, J., & Strand, L. (2012). Is modified constraint-induced movement therapy

more effective than bimanual training in improving arm motor function in the subacute

phase post stroke? Clinical Rehabilitation, 26(12), 1078-1086.

doi:10.117/0269215512443138

Centers for Disease Control (2017, September 06). Stroke. Retrieved April 09, 2018, from

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

Dahl, A., Askim, T., Stock, R., Langørgen, E., Lydersen, S., & Indredavik, B. (2008). Short- and

long-term outcome of constraint-induced movement therapy after stroke: a randomized

controlled feasibility trial. Clinical Rehabilitation,22(5), 436-447.

doi:10.1177/0269215507084581

El-Helow M., Zamzam M., Fathalla M., El-Badawy M., Nahhas N., El-Nabil L., Awad M., & K.

Von Wild, K. (2015). Efficacy of modified constraint-induced movement therapy in acute

stroke. European Journal of Physical and Rehabilitation Medicine, 51(4), 371-379.

Fleet, A., Page, S. J., MacKay-Lyons, M., & Boe, S. G. (2014). Modified constraint-induced

movement therapy for upper extremity recovery post stroke: What is the evidence?.

Topics in Stroke Rehabilitation, 21(4), 319-331.

Ju, Y., & Yoon, I. (2018). The effects of modified constraint-induced movement therapy and

mirror therapy on upper extremity function and its influences on activities of daily living.

The Journal of Physical Therapy Science, 30(1), 77-81.

National Stroke Association. (2015, November 17). Rehabilitation Therapy after a Stroke.

Retrieved March 19, 2018, from http://www.stroke.org/we-can-help/stroke-

survivors/just-experienced-stroke/rehab
CONSTRAINT-INDUCED MOVEMENT THERAPY POST STROKE 13

Singh, P., & Pradhan, B. (2013). Study to assess the effectiveness of modified constraint-induced

movement therapy in stroke subjects: A randomized controlled trial. Annals of Indian

Academy of Neurology, 16(2), 180–184.

Thrane, G., Askim, T., Stock, R., Indredavik, B., Gjone, R., Erichsen, A., & Anke, A. (2015).

Efficacy of constraint-induced movement therapy in early stroke rehabilitation.

Neurorehabilitation & Neural Repair, 29(6), 517-525.

Thrane, G., Friborg, O., Anke, A., & Indredavik, B. (2014). A meta-analysis of constraint-

induced movement therapy after stroke. Journal of Rehabilitation Medicine, 46(9), 833-

842. doi:10.2340/16501977-1859

Wolf, S. L., Thompson, P. A., Winstein, C. J., Miller, J. P., Blanton, S. R., Nichols-Larsen, D. S., Commented [AT14]: Incorrect APA for this many authors

Morris, M.M., Uswatte, G., Taub, E., Light, K., Sawaki, L. (2010). The EXCITE Stroke

Trial: Comparing Early and Delayed Constraint-Induced Movement Therapy. Commented [AT15]: Use sentence case

Stroke,41(10), 2309-2315. doi:10.1161/strokeaha.110.588723

CONSTRAINT-INDUCED MOVEMENT THERAPY POST STROKE 14

Table 1 Commented [AT16]: Fyi the table print is really tiny and
when I enlarged it, it got blurry… I can see it well enough to
know this looks good; however, a reviewer would never let
this fly…. “the more you know”
Field Code Changed