The Effectiveness

of Constraint
Therapy: A
Systematic Review
Meggan Hunt
Aman Dhaliwal
Laura Peterson
Behnad Honarbakhsh
Michael Hales
Supervisor: Lori Roxborough
Collaborator: Lousia Pulfrey
 Outline
History of Constraint
3 types of intervention
Overview of 15 studies
Clinical questions discussed
Conclusions
What is Constraint
Therapy?
History of the idea
 Cortical Reorganization
• After stroke, cortical areas
responsible for the affected area(s)
receive less neuronal stimulation.
• After CIMT, cortical reorganization
occurs, leading to an enlargement of
the previously affected area and
improvement in motor function4.
 3 types of intervention
1) Constraint Induced Movement Therapy
(CIMT)

Constraint + Structured Practice +

Feedback + Repetition
Eg. All waking hours, 6-8 hrs/day 1:1
therapy, 2-3 consecutive weeks
 3 types of intervention
2) Modified Constraint Induced
Movement Therapy
(modified CIMT)

Constraint + Practice + modified times

 3 types of intervention
3) Forced Use Therapy

Constraint Only (no added therapy)

 Constraint Therapy in
Children – The Evidence
Past reviews suggest a positive trend in the
effectiveness of constraint therapy, but
evidence is weak.

Our Review, Inclusion criteria:

- All three types of Constraint Therapy
- Children 0-18 years old with hemiplegia
- All outcomes
- English language
- All research designs
Methods: Search Strategy
• Electronic search terms:
– "(hemiparesis OR hemiplegia OR
cerebral palsy OR diplegia OR diparesis
OR quadriplegia OR quadriparesis)
– AND ("constraint induced therapy" OR
"constraint therapy" OR "constraint
induced movement therapy" OR "learned
nonuse" OR “CIMT” OR "forced use" OR
"physical restraint" OR "CI therapy")
– AND (Ped$ OR child$).
Methods: Search Strategy
• Databases:
– Medline, CINAHL, EMBASE, PubMed, PEDRO,
Cochrane, Cochrane Central, ACP Journal Club,
DARE, EBM Reviews, Psycinfo, and ProQuest
Dissertations and Theses
• Hand searched:
– Physical Therapy, Physiotherapy Canada,
Australian Journal of Physiotherapy,
Physiotherapy (1995- March 2006)
– Physiotherapy Research International,
Physiotherapy Theory and Practice (1998-
March 2006).
• Authors contacted
• Reference lists searched
 Methods: Screening
Initial Search: 61 articles

After title screen: 39 articles

After abstract screen: 28 articles

Authors contacted

After full-text screen:

15 articles included in systematic review
 Quality Assessment and
Data Abstraction
• Review followed the AACPDM
methodology.
• Group Designs:
– Sackett’s Levels of Evidence
– AACPDM Quality Assessment Scale
• SSRDs:
– SSRD Levels of Evidence
– Quality Rigor and Evaluative Criteria
• Data Abstraction forms
 Levels of Evidence-Group
Level Intervention (Group) studies

I Systematic Review of randomized controlled trials (RCT’s)

Large RCT (with narrow confidence intervals)
II Smaller RCT’s (with wider confidence intervals)
Systematic Reviews of cohort studies
“Outcomes research” (very large ecologic studies)
III High quality cohort studies (must have concurrect control
group)
Systematic Reviews of Case Control Studies
Case-control Study
IV Case Series
Poor quality cohort and poor quality case-control study
V Expert opinion
Bench research
Expert opinion based on theory or physiologic research
Common sense/ anecdotes
 Levels of Evidence-
Single Subject Design
Level Intervention (Single Subject) studies

I N-of-1 randomized controlled trial

II ABABA design
Alternating treatments design
Multiple baseline designs (concurrent or non-concurrent;
across subjects, settings or behaviors)

III ABA design

IV AB design (with replication on >1 subject)

V AB design (with 1 subject only)

 Grading the Research
Effective Level Quality Score
GROUP
Charles et al 2006 Yes II 5/7
Taub et al 2004 Yes II 5/7
Sung et al 2005 Yes II 3/7
Willis et al 2002 Yes II 3/7
Elaisson et al 2005 Yes III 4/7
Bonnier et al 2005 Yes IV 6/7
Gordon et al 2006 Yes IV 5/7

SSRD
Deluca et al 2003 Yes II 3/7
Naylor et al 2005 Yes III 4/7
Charles et al 2001 Yes III 3/7
Crocker et al 1997 Yes III 2/7
Pierce et al 2002 Yes III 2/7
Karman et al 2003 Yes IV 3/7
Glover et al 2002 Yes IV 1/7

Quality Score: strong = 6 or 7, moderate = 4 or 5, and weak = 3 or less

Group Design:
Charles et al, 2006
• Level II
• 22 subjects
• Age range: 4-8 yrs
• Intervention Group: Sling via CIMT for
6hrs/session, 10/12 consec. Days
• Therapy: play/shaping/functional tasks
• Outcomes: Jebson Taylor Hand Test,
Bruininks-Oseretsky[subset 8] (motor
proficiency), Caregiver Functional Use
Survey, Hand Held Dynamometer, Modified
Ashworth Scale
Single Subject Design:
Naylor & Bower, 2005
• Level III SSRD
• 9 subjects
• Age range: 21 mo-61 mo
• Intervention: Gentle restraint, mCIMT, 1
hour/day, 7 days/week for 4 weeks.
• Therapy: Fine motor and play activities, 1
hour/day, 7 days/week for 4 weeks.
• Outcomes: Quality of Upper Extremity
Skills Test
 Goals of this Review

1) Is there a general benefit?

Is there a long term effect?
2) Is there a particular age that is appropriate?
3) Is there improvement in ICF components?
4) Are there any complications?
5) Is one protocol or type of therapy best?
1) Is there a general benefit?
Long term effects?

• All 15 studies showed improvement

• 7 of 15 studies reported follow up data
• Maintenance of function was reported in 4
studies- including fine motor function,
dexterity & movement efficiency
• 2 studies showed maintenance of improved
frequency of use of affected limb at both 3 &
6 month follow up
 2) International
Classification of Function
• Functioning and disability:
– Body Structure/ Function
– Activities/ Participation

• Contextual Factors
– Environmental Factors
– Personal Factors
ICF: Body Function/Activity
• Body functions are the physiologic
functions of body systems.

• Activity is the execution of a task or

action by an individual.

• Body function and activity

were the primary outcomes
of interest in our studies.
ICF: Body Function/Activity
Statistically significant improvements in:

– coordination, dexterity, & hand manipulation

– movement efficiency
– fine motor function, dissociated movement,
grasp, protective extension, & weight
bearing through the affected limb
– speed and precision of movement.
– new motor patterns
– amount of use of the affected limb.
ICF: Body Function/Activity
• Follow up results:
– 6 studies demonstrated
maintenance or improvement of
upper extremity function, however,
only 3 studies showed statistical
significance.
ICF: Environmental Factors
• The physical, social, and attitudinal
environment in which people live and
conduct their lives.
ICF: Environmental Factors
Improvements found in:
• care-givers’ perception of amount and
quality of use
(at post intervention in one study and
at 1 & 6 month follow-up in another
study).
 3) Age Appropriateness
Gordon et al., 2006: Studied age-dependence
of the effectiveness of CIMT.

Children divided into older

group (9-13), and younger
group (4-8).

No difference in outcomes
between older and younger
children.
 Age Appropriateness
Coordination of fine finger force development
during grasping approximates that of adults
by the age of 8 years

• Age range in studies: 7 mos - 18 yrs

• Positive results obtained in both age groups
across studies.
• 4 studies with different age groups showed
significant improvements in quality of
movement.
 Age Appropriateness
• Further research is necessary to
determine optimal age for constraint.

• Difficult to compare outcomes across

studies because of differences in
the:
– Methodology
– Mode of constraint
– Restraint duration
– Outcome measure
 Age Appropriateness
• Age specific detrimental effects:

– Potentially permanent repercussions

for motor skill development in the
constrained limb due to corticospinal
tract development during the first
years of life.
4) Documented Complications
• No specific report of complications and/or
adverse effects of treatment
• Participant withdrawal/dropouts, safety
and side effect considerations
Documented Complications
Withdrawal/dropouts:
• 15 studies 5 with dropout reports
3 with reason provided
– Eliasson et. al, 2005: 3 subjects
rejected the glove constraint
– Willis et. al, 2002: 1 withdrawal due to
uncooperative child
– Charles et. al, 2006: 1 withdrawal due to
lack of subject’s tolerance of the
intervention
 Documented Complications
Safety and side effect considerations
• No long term complications or side effects
noted in any of the studies under review
– Taub et al., 2004: reports of mild skin
redness, rash, pinching due to the cast
constraint (all treated with Neosporin and
band aids)
– Crocker et al., 1997: an irritated subject
that withdrew from play activities,
removed constraint and would not stick to
protocols
Documented Complications
• The lack of reported side effects does
not mean that we ignore complications.
• A potential for complications should
always be considered prior to any
application of constraint therapy.
• Individualized assessment and
treatment needs to be considered at all
time
• Perhaps a trial period would be
appropriate
5) The Million Dollar Question….
Is there a specific PROTOCOL?
Variability in study parameters
– Of the 15 studies: 5 used CIMT, 8 used
mCIMT, 2 used a forced use protocol
– There is a wide variety of frequency and
duration of therapy and constraint
– Several different types of restraints
were used throughout the intervention
period in all 15 studies (ie: glove, casts,
slings, splints, gentle episodic physical
restraint)
 Is there a specific
PROTOCOL?
• No study has compared one protocol
to another
• Is it:
– Constraint alone?
– Therapy?
– Duration and frequency of constraint?
 Is there a Specific
PROTOCOL?
• Lack of adequate rationale for the
choice of protocol
– It remains unclear as to which
parameters are most effective in
achieving the desired outcomes
Conclusions
 Recommendations
• Constraint therapy appears
suitable for children of all ages
• Various forms of restraint show
success
• No single protocol is better than
another
 Protocol Summary
• Ages 7 mo – 18 yrs
• Study Population size 1 – 45
• Avg time wearing constraint 12hrs/day
• Avg time in therapy 5 hrs/day
• Avg duration of intervention 20 days
• Common outcome measures: Jebsen-Taylor
test, PMAL, Peabody, Bruininks-Oseretsky
 Limitations
• Limited clinical experience of authors
• English language studies
• Depth of our search
• Reliability and validity of scales absent
• Unable to compare across studies due to
variety of variables
• Small sample sizes
• Low level of evidence within selected
research
 Future Research
• Comparison of protocols
• Long term outcomes greater than 8
months
• RCT’s or higher level studies
• Structured practice alone compared
to a constraint intervention
• Critical age of development and use
with the very young
• Researchers from various areas
 Bottom Line
• All three forms of constraint
therapy reviewed appear to promote
a positive change in functional use of
an affected upper limb in children
with hemiplegia. However, further
research is required to determine
any specific protocol.
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Thank You
Lori Roxborough
Lousia Pulfrey
Susan Harris
Audience