DEVELOPMENTAL DISABILITIES
RESEARCH REVIEWS 15: 102 – 111 (2009)
CONSTRAINT-INDUCED MOVEMENT THERAPY
(CIMT): PEDIATRIC APPLICATIONS
Kathleen Brady1* and Teressa Garcia2
1
Department of Clinical Neuropsychology, Kennedy Krieger Institute, Baltimore, Maryland
2
Department of Occupational Therapy, Kennedy Krieger Institute, Baltimore, Maryland
The purpose of this article is to describe theoretical and research
bases for constraint-induced movement therapy (CIMT), to discuss key
features and variations in protocols currently in use with children, and to
review the results of studies of efficacy. CIMT has been found to be an
effective intervention for increasing functional use of the hemiparetic
upper extremity in adults with chronic disability from stroke. CIMT devel-
oped out of behavioral research on the phenomenon of ‘‘learned non-
use’’ of an upper extremity, commonly observed following sensory and/
or motor CNS injury, in which failure to regain use persists even after a
period of partial recovery. CIMT includes three key elements: (1) con-
straining the use of the less-impaired upper extremity (UE); (2) intensive,
repetitive daily therapist-directed practice of motor movements with the
impaired UE for an extended period (2–3 weeks); and (3) shaping of
more complex action patterns through a process of rewarding successive
approximations to the target action. Mechanisms responsible for success
are thought to be separate but complementary, that is, operant condi-
tioning (reversal of learned nonuse) and experience-driven cortical reor-
ganization. CIMT has recently been extended to children with hemipare-
sis secondary to perinatal stroke or other CNS pathology. Numerous case
studies, as well as a small number of randomized controlled or controlled
clinical trials have reported substantial gains in functional use of the
hemiplegic UE following CIMT with children. Protocols vary widely in
terms of type of constraint used, intensity and duration of training, and
outcome measures. In general, all report gains in functional use, with
minimal or no adverse effects. Continued research is needed, to clarify
optimal protocol parameters and to further understand mechanisms of
efficacy. ' 2009 Wiley-Liss, Inc.
Dev Disabil Res Rev 2009;15:102–111.
Key Words: cerebral palsy; constraint-induced movement therapy; neu-
roplasticity; hemiplegia; rehabilitation
A
cquired brain injury in children can occur at any time in
the developmental period, both before and after birth.
Cerebral palsy (CP) is the term given to a cluster of neu-
rodevelopmental movement disorders typically acquired during
the prenatal/perinatal period as a result of a nonprogressive lesion
to the brain. CP is the most common pediatric physical disability,
with an incidence of 2–2.5 cases per 1,000 births in the United
States [Capute and Accardo, 1990]. Approximately one-third of
children with CP have spastic hemiplegia, in which one side of
the body is significantly more impaired than the other. Decreased
strength and motor control of one upper extremity interfere with
exploration, play, self-care, and other activities of daily living
(ADLs), and thus interfere with development in multiple
domains. Conventional treatments, including physical therapy,
occupational therapy, pharmacotherapy for muscle tone, and sur-
' 2009 Wiley -Liss, Inc.
gery, focus on teaching compensatory skills and preventing defor-
mity, but none has demonstrated success in ameliorating the pri-
mary disorder. Recently, a new approach to treatment of hemi-
paresis has emerged from the confluence of behavioral
psychology/learning theory and discoveries in neuroscience
regarding neuroplasticity. The new approach, called constraint-
induced movement therapy (CIMT), is an example of an emerg-
ing ‘‘paradigm shift’’ in rehabilitation of CNS injury, from an
emphasis on compensatory skills to a hope for partial restoration.
Early reviews (Charles and Gordon, 2005; Hoare and Carey,
2007) have reported positive outcomes in children treated with
CIMT. This article reviews the theoretical foundations of CIMT,
early behavioral and imaging evidence of effectiveness in adults,
and the evolution of the method to pediatric applications. We
summarize the numerous published pediatric case studies, as well
as recent randomized controlled trials (RCTs), and finally, high-
light ongoing issues, potential applications beyond hemiplegia,
and directions for future research.
THEORETICAL FOUNDATIONS OF CIMT
Current implementation of CIMT varies, as described
below, but all programs have three essential features: (1) some
method of constraint of use of the unimpaired upper extrem-
ity, (2) intensive, repetitive practice of motor activities, for up
to 6 hr per day, for 2–4 weeks, and (3) shaping of more com-
plex, functional motor acts by breaking the desired task into
its component movements and rewarding successive approxi-
mations to the target task. CIMT developed out of basic ex-
perimental psychology research by Edward Taub and his col-
leagues, beginning in the late 1960s, on sensory contributions
to motor learning in non-human primates [Taub et al., 1994].
They began by replicating previous work showing that, when
somatic sensation is surgically abolished from a single forelimb
by severing all dorsal spinal nerve roots enervating that limb,
the animal did not make use of the limb in a natural setting
again, without intervention, even though outgoing motor sig-
nals via ventral roots remained unimpeded. Even allowing for
*Correspondence to: Kathleen Brady, Specialized Transition Program, 1750 E. Fairmount
Ave., Baltimore, MD 21231. E-mail: bradyk@kennedykrieger.org
Received 22 February 2009; Accepted 24 February 2009
Published online in Wiley InterScience (www.interscience.wiley.com).
DOI: 10.1002/ddrr.59

a period of spinal shock in which
motor outflow is depressed, failure to
use the deafferented limb persisted well
after recovery of motor function should
have occurred. In the course of their
studies, they had occasion to restrain
the intact limb, and noted that, very
soon after introduction of the restraint,
the animal began to use the deaffer-
ented limb in a clumsy but effective
manner, even if it had not been used
for several years. They further observed
that, if the restraint was removed within
a day, the animal quickly reverted to
use of the normal limb only, but if the
restraint was left on for several days or
weeks, the animal continued to use
both the normal and the deafferented
limb after removal of the restraint, and
the new use persisted for the life of the
animal [Taub et al., 2002]. At first, the
monkeys demonstrated use of the deaf-
ferented limb only in the laboratory,
and not in naturalistic settings. The
movement repertoire with the weaker
limb was limited to only those minimal
movements needed to survive. How-
ever, if an operant behavioral technique
called shaping was used, more complex
functional motor skills could be built
up through reinforcement of successive
approximations, and the animals were
then able to generalize their training to
the open environment.
Taub et al. [1994] hypothesized
that the monkeys’ failure to use a single
deafferented limb was an operant condi-
tioning phenomenon referred to as
‘‘learned nonuse.’’ They noted that, in
the immediate postsurgical period, the
animal’s attempts to use the deafferented
limb resulted in aversive consequences,
such as falling and dropping food, while
use of the unaffected limb was rein-
forced. This resulted in a learned sup-
pression of movement that persisted
even after some recovery of movement
was possible. Constraint of the stronger
forelimb essentially reverses the contin-
gencies of reinforcement, so that use of
the affected limb is now rewarded. If
the constraint remains in place for sev-
eral days or longer, and if repetitive
practice, including shaping of more
complex functional motor acts, is pro-
vided, new motor patterns become
strong enough to reverse learned non-
use. Thus the basic tenets of CIMT,
that is, restraint, repetitive practice, and
shaping, were established.
EVIDENCE OF EFFICACY OF
CIMT IN ADULTS
At this point, Taub [1980] moved
the applicability of his research forward
Dev Disabil Res Rev  PEDIATRIC CIMT
considerably by linking the phenom-
enon of learned nonuse after sensory
impairment to a previously recognized
failure of patients to regain use of a
hemiparetic limb after stroke and other
motor impairments. Lack of use of the
limb contralateral to the stroke was
noted to persist, even after some poten-
tial for movement returned in the post-
acute phase. Taub proposed that this
unexplained motor impairment was an
example of learned nonuse. He and his
colleagues tested this hypothesis in a
number of studies [e.g., Taub et al.,
1994, 1998] with adults disabled from
chronic stroke. In one study (1998), 40
patients with chronic (average 4.5 years
poststroke) hemiparesis were randomly
assigned to CIMT or placebo groups.
Numerous studies showed
that the brain
continuously reorganizes
itself to adapt to
environmental demands,
and the size of the
cortical representation of
a body part in adults
depends on the amount of
use of that part. CIMT,
with its emphasis on
repetitive practice, was
viewed as a possible
model of the application
of principles of
neuroplasticity to
rehabilitation.
The CIMT group wore a resting hand
splint/sling assembly on the less
impaired upper extremity (UE), and
received motor training/shaping of the
hemiparetic UE for 6 hr per day for 14
consecutive days. The placebo group
participated in a general fitness program
that controlled for duration and inten-
sity of patient–therapist interaction/
attention. The CIMT group showed
significant gains from pretreatment to
post-treatment on quality and amount
of hand use for ADLs, and improve-
ments in speed on laboratory tests,
which persisted at 2-year follow-up.
Controls showed no change. Shaw et al.
 BRADY AND GARCIA
19405529, 2009, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/ddrr.59 by Readcube (Labtiva Inc.), Wiley Online Library on [19/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
[2005] in the same laboratory, extended
these results to a sample of 22 adults
with chronic hemiparesis secondary to
traumatic brain injury. Subsequently,
these results have been replicated in
other laboratories. Van der Lee et al.
[1999] completed a rater-blinded,
randomized clinical trial with 66 adult
chronic stroke patients randomly
assigned to CIMT or to a control group
who received equally intense bimanual
therapy (Neuro-Developmental Treat-
ment). At 1-week post-treatment, the
CIMT group demonstrated significantly
greater improvement on measures of
dexterity and amount of functional use.
Small but significant gains persisted over
the 1-year follow-up period. In 2006,
Wolf et al. published results of a large,
NIH-funded multisite single-blind
randomized clinical trial called EXCITE
(Extremity Constraint-Induced Therapy
Evaluation), which included 222 indi-
viduals who were 3–9 months postpre-
dominantly ischemic stroke. The CIMT
group (n 5 106) showed statistically sig-
nificant and clinically relevant improve-
ments in motor function with the hem-
iparetic arm compared to pretreatment
levels, which persisted for at least 12
months. The matched controls, who
received their ‘‘usual and customary
care,’’ which ranged from no treatment
to day treatment programs with OT and
PT, showed no preto post-treatment
improvements. Since these early studies,
200 reports of successful CIMT with
adults have been published.
NEUROPLASTICITY
Concurrent with the emergence
of CIMT as a behaviorally based treat-
ment for hemiparesis, discoveries in ba-
sic neuroscience were dramatically alter-
ing assumptions about the ability of the
brain to change as a result of experience
The traditional view that changes in
brain structure were limited to a brief,
early developmental period gave way as
new imaging technologies demonstrated
that the human CNS retains the
capacity for plasticity throughout life.
Numerous studies showed that the brain
continuously reorganizes itself to adapt
to environmental demands, and the size
of the cortical representation of a body
part in adults depends on the amount of
use of that part. CIMT, with its empha-
sis on repetitive practice, was viewed as
a possible model of the application of
principles of neuroplasticity to rehabili-
tation. Nudo, in a series of studies
[Nudo et al., 1996a,b] demonstrated
that repetitive practice with specific UE
muscles in the adult squirrel monkey
103

resulted in expansion of the motor cor-
tex representing those muscles, and fur-
ther, that training with the affected limb
following motor cortex lesioning in
monkeys resulted in cortical reorganiza-
tion, so that the area surrounding the
lesion, which is not normally involved
in control of the hand, was recruited to
participate in movement of that hand.
Liepert et al. [2000], in a direct evalua-
tion of the ability of CIMT to produce
cortical reorganization, used focal trans-
cranial magnetic stimulation (TMS) to
map the cortical motor output area of a
hand muscle in 13 chronic stroke
patients before and after CIMT. They
found an approximate doubling of the
size of the excitable motor cortex that
could elicit movement in the more
involved arm and hand after CIMT, in a
pattern suggesting recruitment of cortex
adjacent to lesioned areas. They
described their results as ‘‘. . . the first
demonstration in humans of long-term
alteration in brain function associated
with a therapy-induced improvement in
the rehabilitation of movement after
neurological injury.’’ Grotta et al. [2004]
recently replicated these findings in a
small pilot study with eight adults who
had a stroke and were in the acute phase
(2-weeks poststroke). They also found a
strong correlation between the number
of TMS activation points and functional
test scores. They concluded that, if
implemented within the first 2 weeks af-
ter stroke, CIMT ‘‘. . . is probably not
harmful and it may accelerate recovery.
TMS noninvasively demonstrates the bi-
ological effect of CIMT on brain reor-
ganization.’’ Levy et al. [2001] used func-
tional magnetic resonance imaging
(fMRI) to investigate cortical reorganiza-
tion after CIMT in two adults disabled
from chronic stroke. In addition to their
functional gains, both patients showed
new cortical activity post-CIMT during
a sequential finger-tapping task, including
in areas bordering the infarcted region,
in bilateral association motor cortices,
and in ipsilateral primary motor cortices.
MECHANISMS FOR
EFFECTIVENESS OF CIMT:
CURRENT FORMULATION
As these and other imaging stud-
ies have demonstrated, learned nonuse,
in addition to preventing the individual
from attempting to regain use of the
affected UE after a period of recovery,
also leads to a contraction of the corti-
cal motor and sensory representation of
the affected limb. The conditions cre-
ated by CIMT, particularly intensive,
massed, repetitive practice, are precisely
104
those shown to be effective in inducing
cortical plasticity and adaptive reorgan-
ization after injury. Explanations for the
efficacy of CIMT have thus been modi-
fied to incorporate evidence of use-de-
pendent cortical reorganization after
CIMT. Taub et al. [2002] propose that
CIMT produces a permanent increase
in hemiparetic arm use through two
linked, but independent mechanisms.
First, by providing a situation in which
the patient now receives positive rein-
forcement for use of the weaker arm,
while at the same time experiencing
negative consequences for efforts to use
the constrained stronger arm, the nonuse
of the more impaired arm learned in the
acute and early subacute periods is coun-
terconditioned. At the same time,
increased use of the more impaired arm
through sustained, repetitive practice,
induces cortical reorganization; specifi-
cally expansion of the cortical region
controlling the arm to areas adjacent to
the lesion and to homologous areas of
ipsilateral cortex. Once a ‘‘critical mass’’
of intensity and duration of therapy is
reached, the impaired limb has ‘‘recap-
tured’’ sufficient cortical space to sustain
its use. Given the presumed heightened
plasticity of the developing brain, the
next logical step was to extend CIMT
to the pediatric population, as first pro-
posed by Taub and Crago [1995].
APPLICATION OF CIMT WITH
CHILDREN WITH HEMIPARESIS
With the clinical success of
CIMT with adult patients, implementa-
tion with children began on a case-by-
case basis. Over the last 8 years, over 15
case studies have been published with
children with both congenital [e.g.,
Charles et al., 2001; Pierce et al., 2002;
DeLuca et al., 2003] and later-acquired
hemiparesis [Karman et al., 2003]. Most
of these case studies, as well as at least
two group studies, have employed modi-
fied CIMT protocols, sometimes referred
to as ‘‘child friendly’’ techniques. These
studies may differ from the conventional
adult protocol in a variety of ways, but
typically involve an alternative to casting
for constraint, such as a mitt, splint, or
sling, reduced hours per day using the
constraint, reduced hours of shaping per
day, reduced number of treatment days,
provision of therapy in the home envi-
ronment, and embedding therapy activ-
ities within the context of play.
Some protocols have included
daily therapy for consecutive days over
a period of 2–3 weeks [e.g. Charles
et al., 2006; Gordon et al., 2006], while
others have extended treatment to 2
Dev Disabil Res Rev
19405529, 2009, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/ddrr.59 by Readcube (Labtiva Inc.), Wiley Online Library on [19/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
months [Eliasson et al., 2005]. In addi-
tion, some therapy sessions have been
provided on an individual basis
[Crocker et al., 1997; DeLuca et al.,
2003; Karman et al., 2003; Miller and
Hale, 2005; Dickerson and Brown,
2007; Naylor and Bower, 2005; Cope
et al., 2008; Fergus et al., 2008; Martin
et al., 2008] while others are group
based [Eliasson et al., 2003; Gordon
et al., 2006; Charles and Gordon, 2007],
or have combined both group and indi-
vidual treatment sessions [Kuhnke et al.,
2008]. Treatment environments have
included home, clinic, and camp models,
while interventionists have also varied
from study to study including mostly
Occupational and Physical Therapists but
also trained caregivers, aides, and teach-
ers. Amount of time spent with the
restraining device applied has varied
widely, from 24 hr per day [DeLuca
et al., 2003] to only 2 hr per day [Eli-
asson et al., 2005]. Number of hours of
formal treatment has ranged from 2 hr
per day [Glover et al., 2002; Eliasson
et al., 2005] to 6 hr per day [DeLuca
et al., 2003]. In a variation referred to as
‘‘forced use’’, no treatment is provided
beyond regularly scheduled OT and/or
PT sessions 1-2 times per week [Willis
et al., 2002]. A wide variety of outcome
measures have been employed, including
standardized instruments, lab-developed
research tools, and qualitative caregiver
reports. Case studies have reported
improvements in both the involved (hem-
iparetic) and the noninvolved (restrained)
arm after treatment [e.g., Gordon et al.,
2006]. All protocols have used a con-
straining device, and have included some
form of shaping. All studies have reported
gains after treatment compared to pre-
treatment levels, though the degree of
improvement and reports of the retention
of gains over time have varied widely.
DeLuca et al. [2003], noting that
most of the case studies using CIMT
with children have employed modifica-
tions of the protocol developed by
Taub, advocated greater adherence to
the adult protocol in order to fully test
the effectiveness of CIMT in pediatric
populations. They reported a case study
of a child with quadriparetic CP sec-
ondary to prenatal Grade IV left intra-
ventricular hemorrhage, who received
two courses of CIMT using a protocol
more similar to that utilized with adults.
At age 15 months, the child received 6
hr of daily individual intervention at
home for 15 weekdays, with application
of behavioral techniques of reinforce-
ment and shaping. In addition, con-
straint of the stronger UE was accom-
 PEDIATRIC CIMT  BRADY AND GARCIA

plished through use of a fiberglass, fin-
gertip to axilla bivalved cast, which
remained in place except for weekly
skin checks. The use of the cast is a de-
parture from the adult protocol, but was
thought to be both necessary and ad-
vantageous with children. Casting elim-
inates the need for frequent removals
and reapplications of the constraining
device, which can be distressing to the
child, as well as the need for continuous
negative feedback in the form of
reminders not to use the stronger hand.
Before CIMT, DeLuca’s patient had no
use of the right UE, even for protective
reactions, in spite of 11 months of
weekly OT and PT. By CIMT inter-
vention Day 4, however, she demon-
strated a purposeful grasp, and went on
to acquire a number of functional skills
with the previously inert arm, including
self-feeding finger foods. Also of interest
is the parent report that her child ‘‘. . .
definitely notices her right hand and is
looking at it a lot . . . she just seems
more aware of her entire right side.’’
The second course of CIMT occurred 5
months later, and resulted in even
greater gains. There were no adverse
effects of casting, and, in fact, the tod-
dler was described as cooperative during
the second application of the cast.
Over the past 4 years, following
these initial case study reports of posi-
tive outcomes with pediatric applica-
tions of CIMT, five articles have
reported RCTs or controlled clinical
trials (CCTs) with larger groups. These
studies are summarized in Table 1.
They are identified for comparison pur-
poses as RCT casted, RCT modified,
or CCT modified, to reflect study
design and treatment protocol.
Based on their initial positive
findings described above, DeLuca and
colleagues completed a clinical trial
with 18 children, aged 7–96 months,
diagnosed with hemiparesis associated
with CP, who were randomly assigned
to CIMT or to a conventional therapy
group (outpatient and/or school-based
PT and/or OT for a mean of 2.2 hr per
week) [Taub et al., 2004]. They again
implemented the more intensive proto-
col, involving bivalved fiberglass casting
of the hemiparetic UE (fingertips to
upper arm), and 6 hr per day of therapy,
this time for 21 consecutive days
(including weekends). Therapy was pro-
vided by licensed and trained OT’s and
PT’s on a 1:1 basis in the child’s home,
using games and other play activities
selected to maintain interest and to
address specific motor goals. Shaping
and positive reinforcement were used to
Dev Disabil Res Rev  PEDIATRIC CIMT
advance to more complex movement
patterns in a planned progression.
Motor function was assessed immedi-
ately before and after treatment, and at
3 weeks and 6 months post-treatment,
using standardized instruments, lab-
developed tools, and parent report.
Assessments were completed by staff
blind to group assignment when possi-
ble. Children in the CIMT group
acquired a significantly greater number
of novel motor skills, showed significant
gains in the amount and quality of use
of the hemiparetic UE at home, and
showed significant increases in sponta-
neous use of the impaired UE com-
pared to the non-CIMT controls, when
measured on a standardized motor test,
a lab-developed instrument for quantifi-
cation of newly emerging motor behav-
iors, and parent interview. Benefits per-
sisted at 6 months. Parents also reported
important social-emotional benefits that
the treated children derived from their
enhanced play and other motor skills. It
is interesting to note that improvements
in gross motor function and in commu-
nication skills were also observed in the
CIMT group, even though these areas
had not been targeted by therapy. For a
small subsample of six children for
whom scores were available on a general
developmental screening measure, chil-
dren with higher scores tended to gain
more from CIMT, though it should be
emphasized that all children showed sig-
nificant improvement as a result of
CIMT, regardless of developmental level.
All children adjusted well to the cast by
treatment Day 2. Four of nine children
had some mild redness, rash, or pinching
observed during weekly cast checks.
These occurrences were effectively
treated with lotion and/or additional
padding. No children resisted cast reap-
plication, and, in fact, the authors report
that ‘‘. . . several specifically asked to have
it put back on their arm.’’ The authors
acknowledge that the possible beneficial
effect of 1:1 attention from the therapist
was not controlled for in this study,
though this variable has been controlled
in adult studies [e.g., Taub et al., 1999].
In discussing the basis for efficacy of
CIMT, the authors pointed out that
children with congenital hemiparesis
may be described as evidencing ‘‘devel-
opmental disregard’’ rather than learned
nonuse, in that they have never estab-
lished normal motor functions with the
affected limb. Nevertheless, the same
principles of CIMT, that is, constraint
concurrent with repetitive, shaped prac-
tice, were effective in eliciting new skills.
 BRADY AND GARCIA
19405529, 2009, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/ddrr.59 by Readcube (Labtiva Inc.), Wiley Online Library on [19/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
DeLuca et al. [2006], building on
their earlier work described above,
completed a crossover phase with their
original control patients. Following
casting and 21 days of therapy as
described above, the crossover partici-
pants were assessed using a standardized
measure of upper extremity skills,
including dissociated movements, grasp,
protective extension, and weight bear-
ing, as well as the lab-developed tool to
quantify emergence of new movements
and the parent report used previously.
Significant effects for measurement
occasion were found for the children in
the crossover group (i.e., the original
control group), with significant
improvement after CIMT on all meas-
ures. After 3 weeks of CIMT, the chil-
dren had acquired an average of 8.4
entirely new functional motor behaviors
that they had not been observed to per-
form before, including pointing, grasp-
ing, gesturing, and crawling.
In a recent review, Taub et al.
[2007] emphasize the importance of ad-
herence to key components of CIMT
when adapting the intervention for
children, specifically (1) prolonged
restraint of the arm not being trained,
and (2) intensive, repetitive practice of
behaviorally relevant movement patterns
and shaping of more complex move-
ments through reinforcement. They also
note that the basic protocol can be
adapted for children by embedding
motor practice in attractive play activ-
ities, and by providing a ‘‘transfer pack-
age’’ of parent training and home exer-
cises, with weekly monitoring of com-
pliance via phone for the first month
post-treatment. They report on a RCT
of CIMT in 20 children (age range 2–6
years, mean age 5 43.8 months) with
hemiparesis secondary to prenatal or
neonatal stroke. Children in the CIMT
group received 6 hr per day of shaping/
training embedded in play and func-
tional ADLs in their home environ-
ments, each weekday for 3 weeks (total
of 21 casted days and 15 treatment
days). In addition to conventional analy-
sis of variance statistics, results are also
reported in terms of the within-subject
measure of change based on standard
deviation units that is often used in
meta-analyses, referred to as effect size
(ES). An ES above 0.8 is regarded as
large, 0.5–0.8 is medium, and 0.2–0.5 is
a small effect. Children receiving CIMT
exhibited more new classes of motor
skills, (ES 5 2.05), significant gains in
spontaneous use of the hemiparetic limb
at home, (ES 5 7.3), and significant
improvement in scores on a laboratory
105
 106
Table 1. Randomized Controlled Trials and Controlled Clinical Trials of Pediatric CIMT
Direct Treatment
Study Type Author Participants Constraint Time/Intensity Control Group Results

RCT-casted Taub et al. N 5 18; Long arm cast; 6 hr/day; 21 Conventional PT and : spontaneous use, : scores on lab tests of motor
[2004] Ages 7 months–8 yr; 24 hr/day and consecutive OT; mean function of CIMT group
Hemiplegic CP 21 days days; Interventionists: of 2.2 hr per week Maintained gains at 3 and 6 months follow-up testing.
(Control:9CIMT:9) OT, PT, PTA
RCT-casted Deluca et al. N 5 18; Long arm cast; 6 hr/day; 21 Traditional or CIMT group : in all measures; average of 8.4 new
[2006] Ages 7 months–8yr; 24 hr/day and consecutive days; ongoing functional motor behaviors after 3 weeks
Hemiplegic CP 21 days Interventionists: PT and OT of CIMT. Gains maintained at 3 week follow-up.
(Same sample as Taub OTs/PTs
et al., 2004)
Crossover design
RCT-casted Taub et al. N 5 20; Long-arm cast; 6 hr/day; 15 treatment Conventional CIMT group reported more new classes of motor skills, :
[2007] Ages 2–6 yr; 24 hr/day and days; Interventionists: treatment spontaneous use, : scores on lab tests of motor function.
Hemiplegic CP 21 days not specified 70–100% retention of gains at 6 months post-treatment.
Crossover design
RCT- Charles et al. N 5 22; Sling 6 hr/day 6 hr/day; 10/12 Usual and CIMT group had :speed.
modified [2006] Ages 4–8 yr (breaks from sling, consecutive days; customary care : dexterity
Hemiplegic CP not to exceed 30 min Interventionists: : functional use CIMT greater than control group.
(Control: 11 daily) and 10–12 days ‘‘trained No changes in measures of level of grip strength,
CIMT: 11) interventionists’’ sensation and tone.
significant inclusion Maintenance of gains 6 months postintervention.
criteria

Dev Disabil Res Rev

CCT- Fabric glove with 1–2 hr/day; 2 months


Eliasson et al. N 5 41; Not specified; Authors CIMT group demonstrated : with gross UE test tasks.
modified [2005] Ages 18 months–4 yr; thermoplastic Interventionists: state that ‘‘[therapy] Maintained gains 6 months post.
Hemiplegic CP splint; 1–2 hr/day and preschool teachers service program was
(Control:20 2 months and parents checked for and
CIMT:21) found
to be congruent’’

PEDIATRIC CIMT

BRADY AND GARCIA
19405529, 2009, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/ddrr.59 by Readcube (Labtiva Inc.), Wiley Online Library on [19/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License

measure of motor function, when com-
pared to nontreated controls. Scores
(other than parent report) were based
on ratings of videotaped behaviors by
trained observers blind to group assign-
ment. Retention of gains over 6 months
ranged from 70 to 100%. Treatment ES
did not vary by age within this sample
of children 2- to 6-years-old. In com-
paring these and other data from studies
with children and adults, the authors
conclude that ‘‘. . . the ES for the preto
post-treatment change in spontaneous
real-world use of the more affected arm
is close to twice as great in children as
in adults.’’ Gordon et al. [2006], in a
study of age effects on efficacy of pedi-
atric CIMT, also found equivalent gains
across their sample of children aged
4–13 years.
Eliasson et al. [2005] reported on
a study in Sweden comparing a highly
modified form of CIMT to conven-
tional treatment. Twenty-one children
aged 18 months to 4 years with hemi-
plegic CP of varying etiologies and
degrees of severity wore a restraining
fabric glove with built-in stiff plastic
splint on the less-affected hand for 2 hr
a day, 7 days a week, for 2 months.
Three additional children were initially
enrolled, but discontinued treatment
because of rejection of the constraining
glove. One additional patient withdrew
due to family circumstances. It should
be noted that, although the protocol
called for a total of 120 hr of glove use,
authors report that this rarely occurred.
Actual time wearing the constraint
ranged from 16 to 120 hr; average total
wearing time was 59 hr. Treatment,
which consisted primarily of encourag-
ing the child to engage in voluntary
play activities involving repetition of
movements thought to be at a mildly
challenging level for that child, was
provided by parents or preschool teach-
ers within the child’s home or pre-
school, with weekly supervision by a
trained therapist. The comparison group
consisted of 20 children who received
their typical interventions, generally PT
two times per month and OT once per
month. Assignment to treatment or
control groups was not random due to
the requirement that children receiving
the modified CIMT live near treatment
centers, but groups were matched in
terms of age and degree of impairment.
Outcome was measured through the
Assisting Hand Assessment (AHA),
which involves ratings of the extent of
use of the affected (assisting) hand dur-
ing bimanual play activities. The AHA
was administered at the beginning and
Dev Disabil Res Rev  PEDIATRIC CIMT
at the end of the treatment interval, and
6 months post-treatment. Children in
the modified CIMT group improved
their ability to use the hemiplegic hand
more than children in the control
group. Only the CIMT group showed
significant gains in AHA scores immedi-
ately post-therapy. However, the mean-
ingfulness of this change is obscured
somewhat by the finding that both
groups showed significantly better bima-
nual hand function at the 6-month fol-
low-up compared to their initial assess-
ment scores. The ES of CIMT immedi-
ately after treatment was 1.16, which is
considered a large effect. The ES
remained at 0.72 (medium) at 6 months
post-treatment. Children with greater
initial impairment showed greater gains
than less-impaired children. In addition,
in this study of children 18 months to
4-years-old, age was positively corre-
lated with improvement, in contrast to
Gordon et al. [2006], and Taub et al.
[2007], who found no differences by
age in degree of improvement in their
samples of children aged 4–13 years and
2–6 years, respectively.
Charles et al. [2006] completed a
randomized controlled study of a modi-
fied form of CIMT with 11 children
with hemiplegic CP, aged 4–8 years.
Children in the intervention group
wore a sling on their noninvolved upper
limb for 6 hr per day for 10 out of 12
consecutive days, with up to 15 min of
the 6-hr treatment interval spent out of
the sling for designated activities such as
toileting. Therapy was delivered at the
clinic/lab in groups of 2–4 with one
therapist for each child, and consisted of
shaping and repetitive practice of tar-
geted movements within the context of
age-appropriate games, crafts, gross
motor activities, and functional self-
care. Children in the control group
continued with their regular school
and/or outpatient-based therapies. Out-
come measures included standardized
assessment of upper extremity functional
ability, basic motor strength and speed,
muscle tone, and two-point discrimina-
tion. Testing was completed prior to
treatment, and at 1 week, 1 month, and
6 months after intervention by raters
blind to group assignment. Caregiver
impressions were also collected, as were
data on frequency of ‘‘disruptive, non-
compliant, and inattentive behaviors’’
displayed during evaluations sessions.
Results of the study were mixed.
Children in both groups showed
improvements on a number of measures
of speed and dexterity, but the CIMT
intervention group improved to a sig-
 BRADY AND GARCIA
19405529, 2009, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/ddrr.59 by Readcube (Labtiva Inc.), Wiley Online Library on [19/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
nificantly greater extent on the primary
outcome measure (Jebsen-Taylor Test of
Hand Function), as measured at 1 week
post-treatment. However, there were no
significant differences between groups
on this measure at the 1-month or 6-
month follow-up. The same pattern was
seen for performance on the Speed and
Dexterity subtest of the Bruininks-
Oseretsky Test. Caregivers of children
in the intervention group reported
greater improvement in frequency of
use than did caregivers of children in
the control group. No improvements
were noted for either group on tests of
two-point discrimination, hand grip
strength, or tone. In addition, surpris-
ingly, control children who subse-
quently were crossed-over to the treat-
ment group did not show additional
gains as a result of treatment. Behavior
problems and initial severity were nega-
tively correlated with outcome. The
authors concluded that ‘‘. . . for a care-
fully selected subgroup of children with
hemiplegic CP, CI therapy modified to
be child-friendly, appears to be effica-
cious in improving movement efficiency
of the involved upper extremity.’’ Taub
et al., in their 2007 review, note that,
though ESs in this study are large, ‘‘. . .
they are only 1/6 to 1/12 the size of
the effect sizes’’ reported with the ‘‘full’’
pediatric protocol (i.e., continuous cast-
ing for 21 days with 15–21 days of 6 hr
of shaping/repetitive movement ther-
apy).
In an extension of this study with
eight original participants, aged 5–11
years, Charles and Gordon [2007] found
that multiple treatment epochs of
CIMT therapy fostered additional
improvement in upper extremity func-
tion. Children were found to build on
skills established during initial CIMT
treatment, as well as develop new skills.
As a result of a second treatment session
given 12 months after the first session,
‘‘caregivers perceived an increased fre-
quency of UE use after both interven-
tions. However, our objective measures
demonstrate increased movement effi-
ciency as well with moderate effect
sizes’’ [Charles and Gordon, 2007].
Additionally, this study tracked partici-
pants over time and found retention of
new skills acquired during the first
intervention at 12 months postinterven-
tion [Charles and Gordon, 2007].
IMAGING FINDINGS IN
PEDIATRIC CIMT
There are as yet few studies of
possible neuroplastic cortical changes in
children following CIMT, such as those
107

described above with adults, but early
reports are positive. Sutcliffe et al.
[2007] report a case study with an 8-
year-old boy with congenital right
hemiplegic CP and left caudate infarc-
tion, who received a modified form of
CIMT. The protocol included 3 weeks
of continuous casting of the unaffected
arm, in conjunction with conventional
OT 1 hr per week. Clinical measures of
motor function, fMRI, and magnetoen-
cephalography were done before and af-
ter therapy and 6 months later. Both
frequency of use and quality of move-
ment of the hemiplegic hand were
improved following removal of the cast,
compared to pretreatment testing. In
addition, fMRI showed increased corti-
cal activation in the sensorimotor cortex
contralateral to the hemiparetic hand af-
ter the 3-week treatment interval.
These changes were maintained at the
6-month follow-up. The authors con-
clude that, ‘‘This is the first report, to
our knowledge, of cortical reorganiza-
tion after modified constraint-induced
movement therapy in a child with hem-
iplegic CP.’’ Interestingly, the timing of
the magnetoencephalography amplitude
changes, which were coregistered with
the fMRI data, supported the conclu-
sion that increased contralateral cortical
activation after CIMT was due to
increased peripheral feedback to the
sensorimotor cortex, rather than to
increased activation of contralateral
motor cortex. Since this feedback is
necessary for perceptual awareness of
movement, CIMT may contribute to
increased hand use through the reduc-
tion/resolution of inattention to con-
tralesional space, or hemispatial neglect.
SUMMARY; ISSUES FOR
FUTURE RESEARCH
CIMT is a theoretically derived
intervention for hemiplegia that has
accumulated a strong body of evidence
of success with adults. The efficacy of
the technique with children has been
consistently documented by a rapidly
growing body of research. CIMT offers
a number of advantages over conven-
tional management of hemiplegia. Spe-
cifically, it involves no medications or
surgery, and virtually no side effects or
risks. Comparing results across studies
to define optimal protocol parameters,
however, is complicated by the use of a
wide variety of intervention schedules,
treatment conditions, and outcome
measures, including lab-specific research
tools such as the Pediatric Motor Activ-
ity Log [Taub et al., 2004]. Recently,
researchers [e.g., Charles et al., 2006]
108
have attempted to organize results in
terms of three types or ‘‘levels’’ of evi-
dence, such as (1) scores on standar-
dized measures of upper extremity
movement efficiency with each arm
separately and/or bimanual use; (2)
qualitative caregiver reports of func-
tional changes in the natural environ-
ment; and (3) measures of basic sensori-
motor abilities such as two-point dis-
crimination, strength, and tone.
Though scoring by blinded raters on
standardized, norm-referenced instru-
ments administered in the laboratory
may appear to be the ‘‘gold standard,’’
many researchers and clinicians have
commented on the failure of these
measures to capture the gains that result
from CIMT. As Taub et al. [2006] note,
performance ‘‘on demand’’ in the labo-
ratory may be quite different than spon-
taneous use in a natural context, and
‘‘spontaneous use of the limb is where
this intervention has by far its greatest
effect.’’ Clearly, significant questions
remain regarding optimal parameters of
the protocol. Given these caveats, how-
ever, a number of tentative conclusions
can be drawn at this time.
Published studies have employed
varying criteria for participation. Some
have been very inclusive, requiring little
to no active movement [DeLuca et al.,
2003, 2006; Taub et al., 2004], while
others have required up to 20 degrees
of active wrist and finger movements
for participation [Charles et al., 2006].
In general, successful outcome does not
appear to be dependent on the presence
of active movement prior to treatment,
and, in fact, one study [Eliasson et al.,
2005] reported greater improvements in
children who initially had more motor
impairment. This is an important find-
ing in pediatric hemiplegia, since chil-
dren, unlike those with adult-onset
stroke, often have a congenital impair-
ment and have no history of previous
active, functional use of the affected
limb. That is, developmental disregard
may be more likely to result in little or
no active movement than does learned
nonuse. This difference between the pe-
diatric and adult populations also
emphasizes the importance of shaping,
as a way of eliciting completely new
motor patterns in children. Other
reported exclusionary criteria have
included severe contractures of the
affected UE, and active or uncontrolled
seizures or other acute serious medical
illness that would prevent participation
in an intensive therapy program. Chil-
dren who demonstrate unsteady ambu-
lation tend to require increased supervi-
Dev Disabil Res Rev
19405529, 2009, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/ddrr.59 by Readcube (Labtiva Inc.), Wiley Online Library on [19/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
sion with the constraint donned, but
are not necessarily inappropriate for this
type of intervention. Cognitive impair-
ment is not a reason for exclusion, as
long as the child can understand simple
oral directions. Taub et al. [2004], how-
ever, report that, though all children in
their study showed gains after CIMT, in
a small subsample (n 5 6) higher devel-
opmental level was correlated with
stronger gains. The role of ‘‘cognitive
reserve,’’ as reflected in pretreatment
level of cognitive function, in treatment
efficacy is an area for further research.
Identifying appropriate exclusionary cri-
teria is an important clinical research
goal. Use of more homogeneous partic-
ipant populations within studies is also
desirable, to begin to identify subgroups
who may respond differently to the
intervention.
Research may eventually allow
therapists to match individual patient
characteristics to specific protocol pa-
rameters. One recent study [Kuhnke
et al., 2008] noted that prenatal disrup-
tion of corticospinal projections may
result in two patterns of cortical adapta-
tion: persistence of normally transient
ipsilateral projections, which then gain
some control over the hemiparetic limb,
or preservation of the more typical
crossed projection pattern in weakened
form. They determined type of cortico-
spinal organization in adolescents and
adults aged 10–30 with congenital
hemiparesis through TMS. Nine
patients with ipsilateral projections to
the hemiparetic limb and seven patients
with preserved contralateral projections
underwent modified CIMT (constraint
with a glove/sling 10 hr per day, with
2 hr per day of shaping therapy, for
12 consecutive days). Both groups
showed preto post-treatment improve-
ments in quality of upper extremity
movements, but only the contralateral
projections group showed significant
gains in speed of movement. This sug-
gests that individual patient variables
may be important in designing optimal
protocols, and that subgrouping of
patients in research may be indicated.
The issue of optimal age for
intervention requires further investiga-
tion. In general, children show greater
ESs due to CIMT than do adults. Stud-
ies have shown essentially equivalent
benefits for children aged 2 and over
[Gordon et al., 2006; Taub et al.,
2007], but a possible decreased efficacy
in children younger than 2 years [Eli-
asson et al., 2005]. This may be related
to differences in endurance, motivation,
awareness, attention, or other factors.
 PEDIATRIC CIMT  BRADY AND GARCIA

Future research may identify adaptations
of the basic protocol that would in-
crease its effectiveness with the very
youngest children, such as a shortened
treatment day. The role of location in
which CIMT is provided (home vs.
clinic), and possible interactions be-
tween age and location are also not
clear. As yet, no large group studies
have attempted to implement the more
extensive Taub/DeLuca protocol in a
clinic or lab, rather than in the home.
The role of therapist contact alone
(regardless of type of intervention) in
facilitating improvements in function also
requires systematic investigation. Though,
as noted above, some adult studies have
controlled for this variable, to date none
of the pediatric studies has provided non-
CIMT controls with an equivalent num-
ber of hours of 1:1 attention from the
therapist. Control groups typically con-
tinue to receive their ‘‘regular care,’’ which
may vary from no therapy to a few hours
of therapy per week. Thus, time with
therapist cannot be ruled out as the source
of improved function in these studies.
Questions regarding optimal num-
ber of hours per day of therapy, as well as
number of days of the program, are also
unresolved at this point. ESs with the
Taub/DeLuca model of 6 hr of therapy
per day for at least 15 days are substan-
tially larger than ESs for protocols of 6 hr
of therapy per day for 10 days [Gordon
et al., 2006] or 2 hr per day for 2 months
[Eliasson et al., 2005] (though these stud-
ies also differed in terms of type of con-
straint, as discussed below). Given the
time, effort, and health care resources
required, maximizing ES is highly desira-
ble. As Wolf [2007] points out, however,
costs for providing ‘‘signature’’ CIMT are
high, and this may reduce the accessibil-
ity of the intervention for some children.
Future research should explore alterna-
tives to the intense 1 on 1 treatment
model, such as group intervention.
The issue of persistence of gains
over time is, of course, also of great im-
portance. Studies have shown good
retention over the longest interval for
which follow-up data have been
obtained, that is, 12 months, but little is
known as yet regarding longer-term
outcomes in human populations.
The utility of repeated epochs of
care, and optimal spacing of ‘‘touch-up’’
or ‘‘boost’’ treatments is another issue
requiring further study. At least one
study [Charles and Gordon, 2007]
addressed this question directly, and
reported significant additional gains for
children who repeated their modified
CIMT protocol 12 months after com-
Dev Disabil Res Rev  PEDIATRIC CIMT
pleting an initial course. This model of
repeated, spaced ‘‘bursts’’ of intensive
therapy, with shaping and repetitive
practice, contrasts with the traditional
practice of more frequent but less
intense episodes of care, such as
30–60 min of OT and/or PT weekly
for many months or even years. It may
be that the standards of care for chronic
pediatric hemiparesis may evolve to
accommodate both approaches, with
weekly ‘‘maintenance’’ therapy provided
through outpatient, school-based, and/or
supervised home programs, and more
intense, conventional CIMT delivered by
therapists in the patient’s home, or in
outpatient and day hospital settings at
longer intervals. Creative ways to find the
most cost effective manner to deliver this
evidence-based treatment will be a future
challenge for the health care system.
The issue of defining appropriate
outcome measures for evaluating the effi-
cacy of CIMT remains unresolved. As
Charles and Gordon [2006] point out,
unilateral improvements in quality and
quantity of hemiparetic arm and hand use
do not automatically translate into
improvements in functional bilateral
hand use. Both symmetric and asymmet-
ric bimanual tasks require complex coor-
dination of movement of the two hands
in space and time that presumably must
be learned through experience. The fail-
ure of CIMT to address bimanual coordi-
nation is of particular concern for chil-
dren with very early acquired hemiparesis
who have never experienced typical
bimanual function. Charles and Gordon
[2006] have proposed a bimanual training
protocol called HABIT (hand-arm bima-
nual intensive training), which incorpo-
rates elements of CIMT, including inten-
sive, repetitive practice and shaping of
targeted two-handed tasks, but does not
involve constraint. Rather, children are
given explicit directions regarding the
desired contribution of each hand to the
selected bimanual tasks, to discourage use
of ingrained compensatory movement
patterns. They report success with 20
children with mild to moderate hemipa-
resis (i.e., wrist extension > 20 degrees,
finger extension > 10 degrees) [Gordon
et al., 2007b]. It may be that functional
gains in upper extremity use can be maxi-
mized by following CIMT with a period
of bimanual training. Research is needed
to determine the optimal proportion and
sequencing of unimanual and bimanual
treatment days, and to identify patient
variables that predict response to different
protocols.
Use of constraint of the more
functional upper extremity has generally
 BRADY AND GARCIA
19405529, 2009, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/ddrr.59 by Readcube (Labtiva Inc.), Wiley Online Library on [19/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
been well accepted as an option for
adult patients who are able to give
informed consent. However, use of
constraint of any type with children has
been more controversial. Concerns have
been expressed about possible loss of
bimanual skills or dominant hand skills
as a result of restraint of the unaffected
upper extremity, particularly during a
period of rapid motor development
[Hart, 2005]. To date, there have been
no documented reports of decrease or
deterioration in dominant hand skills
following CIMT, using any of the mul-
tiple types of constraint devices and
across the various constraint durations
cited above.
There are, however, disadvantages
to using casting as the method of con-
straint. During the first few days of cast-
ing, the child may experience greater
frustration when attempting to com-
plete previously mastered dominant
hand tasks such as eating and toileting.
This issue also highlights the role of the
therapists, who must not only guide
practice of motor tasks but also prevent
compensations and cumulative trauma/
overuse syndromes from poor ergonom-
ics during task completion. They must
be experienced in and comfortable with
working with children, and must be
very skilled in embedding repetitive
practice and shaping of targeted motor
skills in ‘‘child-friendly’’ play activities.
Therapists may also provide adaptive
equipment for ADL completion, such
as adapted utensils, for temporary use
during the period of constraint. This
can decrease frustration and increase in-
dependence during constraining peri-
ods, while continuing to encourage
greater use of the affected upper ex-
tremity. Parents should be prepared for
the role that they may play in providing
greater assistance to their child during
casting/constrained periods. For chil-
dren who demonstrate unsteady ambu-
lation, greater supervision will be
required in the first few days as they
adjust to the constraint’s weight and/or
limitation on their protective extension.
In addition, some parents report that, as
children adjust to the cast, they may ex-
perience one or two nights of disrupted
sleep.
Given these concerns regarding
24-hr casting, a number of studies have
advocated alternative types of con-
straints, such as mitts, splints, slings, or
hand holding, which are used for only a
portion of the day, in what are termed
‘‘child-friendly’’ modifications of the
standard protocol [e.g., Eliasson et al.,
2005; Gordon et al., 2007a; Naylor and
109

Bower, 2005]. Because of the child’s
decreased self-monitoring and decreased
ability to inhibit strong habitual patterns
of use, however, these readily removable
constraints have the disadvantage of cre-
ating a situation in which the therapist
must continuously remind the child to
use the weaker upper extremity, and
distract the child from efforts to remove
the constraint. This interferes with rap-
port, prolongs the adjustment period,
and ultimately may result in decreased
cooperation and greater frustration for
the child. Studies that have used con-
straints that are put on and taken off
daily, and sometimes multiple times
daily, have reported both decreased
actual compliance with the constraint
[Eliasson et al., 2005] and behavioral
problems [Charles et al., 2006]. In con-
trast, studies using currently available,
lightweight, colorful casting material,
and precut, univalved or bivalved casts
that can be removed weekly for skin
checks without the need for cast saws
or scissors, consistently report either no
adjustment problems or very rapid reso-
lution of any problems, and remarkably
smooth and rapid habituation. That is,
casting with careful monitoring appears
to be both the more effective as well as
the less intrusive and less disruptive
constraint option.
Moreover, 24-hr casting also
seems more likely to create optimal
conditions for neuroplasticity in that it
eliminates both motor activation of and
sensory and sensorimotor feedback
input to the contralesional hemisphere.
This may facilitate activity of the
lesioned hemisphere in a number of
ways. Reducing neural activity in the
stronger hemisphere may reduce the in-
hibitory effects of that hemisphere on
the lesioned hemisphere and hemipa-
retic limb. This phenomenom of inter-
hemispheric inhibition, which facilitates
control of complex bimanual activity in
the intact brain, has been demonstrated
to be enhanced in patients following
stroke [Murase et al., 2004], and thus
interferes with recovery of the lesioned
hemisphere. Reduced neural activity
through casting may also cause a shift in
attention away from the now ‘‘silenced’’
stronger hemisphere and toward the
lesioned hemisphere, which reverses or
decreases hemispatial neglect. This is
consistent with Sutcliffe et al. [2007],
who postulate that the neural mecha-
nism underlying the efficacy of CIMT
may be sensorimotor rather than motor,
that is, reduction of attentional neglect
rather than activation of motor cortex.
The greater relative activation of the
110
lesioned hemisphere that casting pro-
vides may confer an advantage in the
competition for attentional resources
and cortical representation. Both Levy
et al. [2001] and Kuhnke et al. [2008]
provide evidence that cortex ipsilateral
to the hemiparetic limb may play a role
in recovery of that limb after stroke.
Casting reduces both the motor and
sensory neural activity in that hemi-
sphere that is driven by the intact
(casted) limb, thus providing greater op-
portunity for the now-active weaker
UE to ‘‘capture’’ space there. It remains
for research to determine whether inter-
mittent, removable constraint is as effec-
tive in inducing neuroplasticity as the
continuous constraint afforded through
casting. It is, of course, essential that
CIMT programs continue to document
and report any adverse reactions to cast-
ing, or to other methods of constraint.
The issue of the ‘‘collateral bene-
fits’’ sometimes reported anecdotally as
outcomes of CIMT in children, such as
improved balance and ambulation,
decreased sensory avoidance, and
increased initiation of language usage, is
intriguing and deserves direct investiga-
tion. In addition, a number of studies
have reported success in using CIMT to
treat motor deficits other than upper
extremity hemiplegia secondary to
stroke, as well as deficits in non-motor
domains secondary to brain injury. Ele-
ments of CIMT have been applied to
patients with spinal cord injury and hip
fracture [reviewed in Taub et al., 1999],
and hemiparesis following traumatic
brain injury [Karman et al., 2003;
Miller and Hale, 2005; Shaw et al.,
2005]. Variations on CIMT have been
shown to have benefit for patients with
focal hand dystonia [Candia et al., 1999],
phantom limb pain [Weiss et al., 1999],
and aphasia [Pulvermuller et al., 2001;
Meinzer et al., 2005]. Though these pos-
itive outcomes may be side effects of in-
tensive 1:1 interaction with therapists,
increased self-confidence, and/or other
non-CIMT specific variables, they may
also reflect, at least in part, the increased
activation of the lesioned hemisphere
fostered by CIMT as described above.
That is, is there a component of neuro-
plasticity that is more generalized in na-
ture than the experience-dependent
examples of neuroplasticity discussed
above, and that is mediated by arousal/
attention pathways? fMRI and other
imaging studies would be of great value
in clarifying the mechanisms underlying
the functional success of CIMT. At this
time, pediatric CIMT is a very promis-
ing intervention for hemiparesis. Addi-
Dev Disabil Res Rev
19405529, 2009, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/ddrr.59 by Readcube (Labtiva Inc.), Wiley Online Library on [19/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
tional research is needed, both to deter-
mine optimal treatment parameters, and
to explore broader implications of tenets
of CIMT for rehabilitation. n
REFERENCES
Candia V, Ebert T, Altenm€ uller E, et al. 1999.
Constraint induced movement therapy for
focal hand dystonia in musicians. Lancet
353:42.
Capute A, Accardo P. 1990. Developmental dis-
abilities in infancy and childhood. Baltimore,
MD: Paul H Brookes Publishing Company.
Charles J, Gordon A. 2006. Development of
hand-arm bimanual intensive training
(HABIT) for improving bimanual coordina-
tion in children with hemiplegic cerebral
palsy. Dev Med Child Neurol 48:931–936.
Charles J, Gordon AM. 2005. A critical review of
constraint—induced movement therapy and
forced use in children with hemiplegia.
Neural Plast 12:245–261.
Charles J, Gordon AM. 2007. A repeated course
of constraint-induced movement therapy
results in further improvement. Dev Med
Child Neurol 49:770–773.
Charles J, Lavinder G, Gordon A. 2001. Effects of
constraint-induced therapy on hand function
in children with hemiplegic cerebral palsy.
Pediatr Phys Ther 13:68–76.
Charles J, Wolf SL, Schneider JA, et al. 2006. Ef-
ficacy of a child-friendly form of constraint-
induced movement therapy in hemiplegic
cerebral palsy: a randomized control trial.
Dev Med Child Neurol 48:635–642.
Cope SM, Forst HC, Bibis D, et al. 2008. Modi-
fied constraint induced movement therapy
for a 12-month-old child with hemiplegia:
a case report. Am J Occup Ther 62:430–
437.
Crocker MD, MacKay-Lyons M, McDonnell E.
1997. Forced use of the upper extremity in
cerebral palsy: a single-case design. Am J
Occup Ther 51:824–883.
Deluca SC, Echols K, Law CR, et al. 2006. In-
tensive pediatric constraint-induced therapy
for children with cerebral palsy: randomized,
controlled, crossover trial. J Child Neurol
21:931–938.
DeLuca SC, Echols K, Ramey SL, et al. 2003.
Pediatric constraint-induced movement ther-
apy for a young child with cerebral palsy:
two episodes of care. Phys Ther 83:
1003–1013.
Dickerson AE, Brown LE. 2007. Pediatric con-
straint-induced movement therapy in a
young child with minimal active arm move-
ment. Am J Occup Ther 61:563–573.
Eliasson AC, Bonnier B, Krumlinde-Sundholm L.
2003. Clinical experience of constraint
induced movement therapy in adolescents
with hemiplegic cerebral palsy—a day camp
model. Dev Med Child Neurol 45:357–
360.
Eliasson AC, Krumlinde-Sundholm L, Shaw K,
et al. 2005. Effects of constraint-induced
movement therapy in young children with
hemiplegic cerebral palsy: an adapted model.
Dev Med Child Neurol 47:266–275.
Fergus A, Buckler J, Farrell J, et al. 2008. Con-
straint-induced movement therapy for a
child with hemiparesis: a case report. Pediatr
Phys Ther 20:271–283.
Glover JE, Mateer CA, Yoell C, et al. 2002. The
effectiveness of constraint induced move-
 PEDIATRIC CIMT  BRADY AND GARCIA

ment therapy in two young children with
hemiplegia. Pediatr Rehabil 5:125–131.
Gordon A, Connelly A, Neville B, et al. 2007a.
Modified constraint-induced movement
therapy after childhood stroke. Dev Med
Child Neurol 49:23–27.
Gordon A, Schneider J, Chinnan A, et al. 2007b.
Efficacy of a hand-arm bimanual intensive
therapy (HABIT) in children with hemiple-
gic cerebral palsy: a randomized control trial.
Dev Med Child Neurol 49:830–838.
Gordon AM, Charles J, Wolf SL. 2006. Efficacy
of constraint-induced movement therapy on
involved upper-extremity use in children
with hemiplegic cerebral palsy in not age-
dependent. Pediatrics 117:363–373.
Grotta JC, Noser EA, Ro T, et al. 2004. Con-
straint induced movement therapy. Stroke
35:2699–2701.
Hart H. 2005. Can constraint therapy be develop-
mentally appropriate and child-friendly? Dev
Med Child Neurol 47:363.
Hoare B, Carey L. 2007. Constraint induced
movement therapy in the treatment of the
upper limb in children with hemiplegic cer-
ebral palsy: a Cochrane systematic review.
Clin Rehabil 21:675–685.
Karman N, Maryles J, Baker R, et al. 2003. Con-
straint-induced movement therapy for hemi-
plegic children with acquired brain injuries.
J Head Trauma Rehabil 18:259–267.
Kuhnke N, Juenger H, Walther M, et al. 2008.
Do patients with congenital hemiplegia and
ipsilateral corticospinal projections respond
differently to constraint-induced movement
therapy? Dev Med Child Neurol 50:1–6.
Levy CE, Nichols DS, Schmalbrock PM, et al.
2001. Functional MRI evidence of cortical
reorganization in upper limb stroke hemipare-
sis treated with constraint induced movement
therapy. Am J Phys Med Rehabil 80:4–12.
Liepart J, Bauder H, Miltner WHR, et al. 2000.
Treatment-induced cortical reorganization
after stroke in humans. Stroke 31:1210– 1216.
Martin A, Burtner PA, Poole J, et al. 2008. Case
report: ICF-level changes in a preschooler
after constraint induced movement therapy.
Am J Occup Ther 62:282–288.
Meinzer M, Djundia D, Barthel G, et al. 2005.
Long-term stability of improved language
functions in chronic aphasia after constraint-
induced aphasia therapy. Stroke 36:1462.
Dev Disabil Res Rev  PEDIATRIC CIMT
Miller R, Hale L. 2005. Constraint-induced
movement therapy for a youth with a
chronic traumatic brain injury. NZ J Physi-
other 33:85–90.
Murase N, Duque J, Mazzocchio R, et al. 2004.
Influence of interhemispheric interactions on
motor function in chronic stroke. Ann Neu-
rol 55:400–409.
Naylor CE, Bower E. 2005. Modified constraint-
induced movement therapy for young children
with hemiplegic cerebral palsy: a pilot study.
Dev Med Child Neurol 47:365–369.
Nudo R, Milliken G, Jenkins W, et al. 1996a.
Use dependent alterations of movement
representations in primary motor cortex of
adult squirrel monkeys. J Neurosci 16:
785–807.
Nudo RJ, Wise BM, SiFuentes F, et al. 1996b.
Neural substrates for the effects of rehabilita-
tive training of motor recovery after ische-
mic infarct. Science 217:1791–1794.
Pierce SR, Daly K, Gallagher KG, et al. 2002.
Constraint-induced therapy for a child with
hemiplegic cerebral palsy: a case report.
Arch Phys Med Rehabil 83:1462–1463.
Pulverm€ uller F, Neininger B, Elbert T, et al.
2001. Constraint induced therapy of chro-
nic aphasia after stroke. Stroke 32:1621–
1626.
Shaw SE, Morris DM, Uswatte G, et al. 2005.
Constraint induced movement therapy for
recovery of upper-limb function following
traumatic brain injury. J Rehabil Res Dev
42:769–778.
Sutcliffe T, Gaetz W, Logan W, et al. 2007. Corti-
cal reorganization after modified constraint-
induced movement therapy in pediatric
hemiplegic cerebral palsy. J Child Neurol
22:1281–1287.
Taub E. 1980. Somatosensory deafferantation re-
search with monkeys: implications for reha-
bilitation medicine. In: Ince LP, editor.
Behavior psychology in rehabilitation medi-
cine: clinical applications. New York: Wil-
liams & Wilkins. p 371–401.
Taub E, Crago JE. 1995. Behavioral plasticity fol-
lowing central nervous system damage in
monkeys and man. In: Julesz B, Kovacs I,
editors. Maturational windows and adult
cortical plasticity. SFI Studies in the Sciences
of Complexity, Vol. 23. Redwood City, CA:
Addison-Wesley. p 201–215.
 BRADY AND GARCIA
19405529, 2009, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/ddrr.59 by Readcube (Labtiva Inc.), Wiley Online Library on [19/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Taub E, Crago JE, Burgio LD, et al. 1994. An
operant approach to rehabilitation medicine:
overcoming learned non-use by shaping. J
Exp Anal Behav 61:281–293.
Taub E, Crago JE, Uswatte G. 1998. Constraint-
induced movement therapy: a new approach
to treatment in physical rehabilitation. Reha-
bil Psychol 43:152–170.
Taub E, Griffin A, Nick J, et al. 2007. Pediatric
CI therapy for stroke-induced hemiparesis
in young children. Dev Neurorehabil 10:3–
18.
Taub E, Ramey SL, DeLuca S, et al. 2004. Effi-
cacy of constraint-induced movement ther-
apy for children with cerebral palsy with
asymmetric motor impairment. Pediatrics
113:305–312.
Taub E, Uswatte G, Elbert T. 2002. New treat-
ments in neurorehabilitation founded on
basic research. Nat Rev Neurosci 3:228–
246.
Taub E, Uswatte G, Mark VW, et al. 2006. The
learned nonuse phenomenon: implications
for rehabilitation. Eura Medicophys 42:
214–255.
Taub E, Uswatte G, Pidikiti R. 1999. Constraint
induced movement therapy: a new family of
techniques with broad application to physical
rehabilitation—a clinical review. J Rehabil
Res Dev 36:237–251.
Van der Lee JH, Wagenaar RC, Lankhorst GJ,
et al. 1999. Forced use of the upper extrem-
ity in chronic stroke patients: results from a
single-blind randomized clinical trial. Stroke
30:2369–2375.
Weiss T, Miltner WH, Adler T. 1999. Decrease in
phantom limb pain associated with prosthe-
sis-induced increased use of an amputation
stump in humans. Neurosci Lett 272:
131–134.
Willis JK, Morello A, Davie A, et al. 2002.
Forced use treatment of childhood hemipa-
resis. Pediatrics 110:94–96.
Wolf S. 2007. Revisiting constraint-induced
movement therapy: are we too smitten with
the mitten? Is all nonuse ‘‘learned’’? and
other quandaries. Phys Ther 87:1212–1223.
Wolf SL, Winstein C, Miller JP, et al. 2006. Effect of
constraint induced movement therapy on upper
extremity function among patients 3-9 months
following stroke: the EXCITE randomized
clinical trial. JAMA 296:2095– 2104.
111