our directory of newsletters, articles, therapies, videos, policies, communities and other LINKs about childhood disability
Constraint-Induced Movement Therapy (CIMT)
Evidence reviewed as of before
01-01-2021 Author(s): Ogourtsova, T. (PhD OT); Steven, E. (MSc App OT); Iliopoulos, G. (MSc App OT); Deleva, V. (MSc App OT) & Majnemer, A. (PhD, OT, FCAHS)Share this
intervention:
CIMT
Introduction
Use of the weaker arm is promoted during play by constraining the dominant limb. Accessed on June 28, 2022 from https://scottishriteforchildren.org/news-items/a-collaborative-research-program-advances-care-for
Constraint Induced Movement Therapy (also referred to as CI, CIT or CIMT) was first developed for adults who suffered strokes, to improve the function of their most affected upper limb. It has been used in other adult populations, such as traumatic brain injury and focal hand dystonia, and later with pediatric populations, such as hemiplegic cerebral palsy (CP). All of these populations present with weakness, poor muscular control and sensory impairments affecting one side of their body. Often, people with these difficulties learn that it is more effective to use their unaffected limb, ignoring their affected arm in daily activities. By doing this, ‘learned non-use’ of the affected arm occurs, which can worsen impairment.
CIMT attempts to change the behavioral aspect of ‘learned non-use’ by creating the opportunity, experience and environment in which a person can learn how to use their affected limb. CIMT involves 3 main strategies: 1) the prolonged constraint of the non-affected limb (usually by a mitt, sling, or splint); 2) intensive repetitive practice of motor activities with the affected limb; 3) breaking down a goal into smaller functional movements and rewarding even approximations until the target task is achieved.
Modified CIMT (mCIMT) was developed as a more child-friendly approach with its main difference being the frequency and duration of a restraint wearing schedule (e.g. shorter wearing schedule with longer period of intervention). Compared to traditional CIMT which asks a person to wear a restraint device 90% of waking hours (approximately 13 hours/day) for a 2-week period, mCIMT is done for fewer hours per day (usually 3 hours total with only 30 min at a time) but for more weeks.
Constraint Induced Movement Therapy (CIMT) attempts to increase the likelihood that someone will use their affected upper limb, thereby improving its function.
It involves the use of a device (such as a specialized mitt, sling, triangular bandages, a half glove or a splint) to prevent the use of the less affected hand/arm (restraint). This forces the use of the affected limb during therapeutic activities.
The restraint device is kept in place for a predetermined amount of time. The duration depends on an individual’s personalized program. The wearing schedule can range from minutes in a mCIMT program (child-friendly version of CIMT) to hours, days or weeks at a time.
An important element of CIMT is the shaping procedure: 1) feedback and encouragement is given by the therapist in response to any small improvements; 2) activities are selected that are motivating for the client but also help work on specific difficulties; 3) therapists help their clients break down activities into smaller parts so that they can achieve their goals one step at a time; 4) tasks are selected to systematically increase the level of difficulty.
CIMT or mCIMT sessions are often received in a clinic or home environment by a skilled therapist (typically occupational or physiotherapist). Home programs are a common element and are used to transfer new skills into daily tasks (e.g. play, dressing, eating). For young children, caregivers are often involved in leading mCIMT sessions at home and receive coaching from therapists to learn how to put on/take off the constraint device and practice certain exercises (activities can include reaching, grasping, manipulating objects or toys, dressing and undressing, eating, grooming according to a child’s age and capabilities).
CIMT is used with persons that have impairment to predominantly one upper limb. It is used to improve motor skills in the upper limb (e.g. grasping, using fingers, picking up objects) as well as enhancing use of both hands together (bimanual tasks) which can improve numerous activities in a person’s daily life.
Modified constraint induced therapy (mCIMT) is a form of CIMT that was developed for children. The main difference is that sessions using devices for restraint tend to be in shorter intervals (e.g. 30 minutes at a time for up to 3 hours per day). The non-intensive approach tends to be more easily accepted by children.
There is a significant body of evidence that supports the effectiveness of CIMT and mCIMT in improving the motor function of the more affected upper limb in children over the age of 2 with hemiplegic CP. In the treatment of infants (under 2 years) with suspected or diagnosed unilateral CP, mCIMT has shown promise that it can have a similar degree of effectiveness, but more research is needed.
When comparing CIMT or mCIMT to other intensive activity-based, goal-directed interventions (e.g. bimanual training), there is little to no difference in the level of effectiveness. However, CIMT, mCIMT and bimanual training were all more effective than conventional treatment (non-intensive occupational therapy or physiotherapy). One exception was the use of electrical stimulation and CIMT together. By combining these modalities, children with CP were able to improve muscle recruitment and coordination more than by using CIMT alone.
A challenging aspect of CIMT is the compliance of clients in using a (removeable) restraint device. There is some evidence to suggest that mCIMT in the home environment versus in a clinic helped children practice more daily and make greater improvements in their affected limb. It was also observed that the amount of time spent practicing therapeutic activities at home was greater for the infants who were prescribed a restraint device as opposed to when exercises were done using manual restraint by a caregiver.
It is important to note that results can vary from person to person.
You and your child will likely see an occupational therapist (OT) or physiotherapist (PT) for an initial meeting and evaluation that will help the therapist understand how the child uses their hands to handle objects in daily activities, assess their strength and sensory function as well as establish client and family goals. The initial meeting will also determine if your child is a candidate for mCIMT and if so, what type of constraint will be used and whether it will be removable or nonremovable.
For mCIMT treatments, there is no exact guideline for the number of hours of constraint therapy (i.e. dosing). Your therapist will take into consideration the individual needs and goals of your child to determine the best wearing schedule and treatment duration/frequency.
Your child’s OT or PT will develop a mCIMT program that offers intensive repetitive practice with activities that will gradually increase in difficulty. A home program may also be provided if appropriate for your child. In some facilities the program can be assigned by an OT or PT but carried out by a therapy assistant during individual sessions. There may also be opportunities to do sessions as a group (e.g. play groups).
Your OT or PT will likely re-evaluate your child’s upper-limb function after the completion of the mCIMT program to determine the effectiveness.
CIMT and mCIMT is provided by occupational therapists and physiotherapists in a clinical setting (hospital, out-patient clinic), home or community (school, daycare). In many cases, initial treatment sessions and training of caregivers will be done in an out-patient clinic, but a home program with exercises and activities will be carried out at home or school between treatments.
Traditional CIMT for adults usually prescribes restraint devices for 90% of waking hours (about 13 hours per day) for a 2-week period. mCIMT is done for fewer hours a day and may only be done on certain days of the week but can last for many weeks.
In a mCIMT treatment plan, shorter intervals are suggested for wearing a restraint device to ensure that a child has greater compliance. For example, 30 minutes (during therapeutic activities) multiple times a day until 3 hours total are achieved, 2-3 times a week. A skilled therapist can help determine what is appropriate for a child.
Not much is known about the long-term effects of CIMT. There are some safety considerations when using a constraint device. For example, monitoring skin integrity and joint pain.
If the child using the restraint device has cognitive difficulties or difficulty communicating, closer supervision by a therapist or caregiver is required to prevent complications.
There are a number of recent studies that demonstrate that CIMT and mCIMT are treatment approaches that can improve upper limb motor function for children as well as infants (mCIMT) with hemiplegic CP. However, there is little evidence that CIMT or mCIMT are more effective than other types of treatments (e.g. bimanual occupational therapy) executed at a similar level of intensity.
A professional can help determine if CIMT or mCIMT is appropriate for your child. Important considerations to discuss are: accessibility of treatment, acceptance of a restraint device by your child as well as your ability to facilitate a home program.
Information on this website is provided for informational purposes only and is not a substitute for professional medical advice.
One high quality RCT (Chamudot et al., 2018) investigated the effects of a modified constraint induced (mCIMT) home program (focus: unilateral activities with affected arm or bimanual activities) on bimanual hand use in infants with spastic hemiplegic CP. This high quality RCT randomized infants to receive mCIMT vs. a bimanual training (BIM) home program. Bimanual hand use was assessed using the Mini-Assisting Hand Assessment and the Functional Inventory – Bilateral Hand Use at post-treatment (8 weeks). No significant between-group differences were found.
Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that a mCIMT home program is not more effective than a comparison intervention (BIM home program) in improving bimanual hand use in infants with hemiplegic CP.
One high quality RCT (Chamudot et al., 2018) investigated the effects of a modified constraint-induced movement therapy (mCIMT) home program (focus: unilateral activities with affected arm or bimanual activities) on gross motor skills in infants with hemiplegic CP. This high quality RCT randomized infants to receive mCIMT vs. a bimanual training (BIM) home program). Gross motor function was assessed using the Functional Inventory Gross Motor Skills at post-treatment (8 weeks). No significant between-group difference was found.
Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that a mCIMT home program is not more effective than a comparison intervention (BIM home program) in improving gross motor function in infants with hemiplegic CP.
One high quality RCT (Eliasson et al., 2018) investigated the effects of a baby constraint-induced movement therapy (baby-CIMT) home program (focus: unilateral activities with affected arm) on manual abilities among infants with unilateral CP. In this high quality RCT, infants were randomized to receive a home program of baby-CIMT or a home program of baby massage. Manual abilities were assessed at post-treatment (18 weeks) using the Hand Assessment for Infants (HAI: both hands, non-affected hand, affected hand). A significant between-group difference was found in HAI: affected hand at post-treatment, favoring baby-CIMT vs. baby massage.
Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that a baby-CIMT home program is not more effective than a comparison intervention (baby massage) in improving manual abilities of the affected hand in infants with unilateral CP.
One high quality RCT (Eliasson et al., 2018) investigated the effects of a baby constraint induced (baby-CIMT) home program (focus: unilateral activities with affected arm) on parents’ sense of confidence and satisfaction of parenting among fathers of infants with unilateral CP. In this high quality RCT, infants were randomized to receive a home program of baby-CIMT or a home program of baby massage. Fathers’ sense of confidence and satisfaction of the parenting were assessed by the Parents Sense of Competence Scale (PSCS) at post-treatment (18 weeks). A significant between-group difference was found, favoring baby-CIMT vs. baby massage.
Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that a baby-CIMT home program is more effective than a comparison intervention (baby massage) in improvingfathers’sense of confidence and satisfaction of parenting infants with unilateral CP.
One high quality RCT (Eliasson et al., 2018) investigated the effects of a baby constraint induced (baby-CIMT) home program (focus: unilateral activities with affected arm) on parents’ sense of confidence and satisfaction of parenting among mothers of infants with unilateral CP. In this high quality RCT, infants were randomized to receive a home program of baby-CIMT or a home program of baby massage. Mothers’ sense of confidence and satisfaction of the parenting were assessed by the Parents Sense of Competence Scale at post-treatment (18 weeks). No significant between-group difference was found.
Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that a baby-CIMT home program is not more effective than a comparison intervention (baby massage) in improving mothers’ sense of confidence and satisfaction of parenting infants with unilateral CP.
One high quality RCT (Chamudot et al., 2018) investigated the effects of a modified constraint-induced movement therapy (mCIMT) home program (focus: unilateral activities with affected arm or bimanual activities) on unilateral hand use in infants with hemiplegic CP. This high quality RCT randomized infants to receive mCIMT vs. a bimanual training (BIM) home program. Unilateral hand use was assessed using The Functional Inventory – Unilateral Hand Use at post-treatment (8 weeks). No significant between-group difference was found.
Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that a mCIMT home program is not more effective than a comparison intervention (BIM home program) in improving unilateral hand use in infants with hemiplegic CP.
One high quality RCT (Wallen et al., 2011) investigated the effects of a modified constraint-induced (CI) therapy on occupational performance among children with hemiplegic cerebral palsy (including GMFCS level I-III; MACS level I-IV). In this high quality RCT, children were randomized to receive modified CI therapy or intensive occupational therapy. Occupational performance was assessed using the Canadian Occupational Performance Measure and the Goal Attainment Scale at post-treatment (10 weeks), and follow-up (6 months from baseline). No significant between-group differences were found.
Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that modified CI therapy is not more effective than a comparison intervention (intensive occupational therapy) in improving occupational performance in children with hemiplegic CP (including GMFCS level I-III; MACS level I-IV).
One high quality RCT (Wallen et al., 2011) investigated the effects of a modified constraint-induced (mCI) therapy on upper limb motor function among children with hemiplegic cerebral palsy (including GMFCS level I-III, MACS level I-IV). In this high quality RCT, children were randomized to receive mCI therapy or intensive occupational therapy. Motor function was assessed using the Assisting Hand Assessment, the Revised Pediatric Motor Activity Log (frequency and quality), and the Modified Tardieu Scale (elbow flexors, pronators, wrist flexors) at post-treatment (10 weeks) and follow-up (6 months from baseline). No significant between-group differences were found.
Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that modified CI therapy is not more effective than a comparison intervention (intensive occupational therapy) in improving upper limb motor function in children with hemiplegic CP (including GMFCS level I-III; MACS level I-IV).
One high quality RCT (Aarts et al., 2010) investigated the effects of a modified constraint-induced movement therapy combined with bimanual training (mCIMT- BiT) on bimanual performance among children with unilateral cerebral palsy (including GMFCS level I-II; MACS level I-III). In this high quality RCT, children were randomized to receive mCIMT followed by BiT or usual care. Bimanual performance was assessed using the Assisting Hand Assessment and ABILAND-Kids at post-treatment (9 weeks) and follow-up (17 weeks). Significant between-group differences were found at post-treatment on both measures, favoring mCIMT-BiT vs. usual care.
Note: Between-group differences not provided at follow-up but improvements were maintained for the intervention group.
Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that modified constraint-induced movement therapy combined with bimanual training is more effective than a comparison intervention (usual care) in improving bimanual performance in children with unilateral CP (GMFCS level I-II; MACS level I-III).
One high quality RCT (Aarts et al., 2010) investigated the effects of a modified constraint-induced movement therapy combined with bimanual training (mCIMT + BiT) on goal attainment among children with unilateral cerebral palsy (including GMFCS level I-II; MACS level I-III). In this high quality RCT, children were randomized to receive mCIMT followed by BiT or usual care. Goal attainment was assessed using the Goal Attainment Scale at post-treatment (9 weeks) and follow-up (17 weeks). A significant between-group difference was found at post-treatment, favoring mCIMT-BiT vs. usual care.
Note: Between-group differences were not reported at follow-up.
Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that modified constraint-induced movement therapy combined with bimanual training is more effective than a comparison intervention (usual care) in improving goal attainment in children with unilateral CP (GMFCS level I-II; MACS level I-III).
One high quality RCT (Aarts et al., 2010) investigated the effects of a modified constraint-induced movement therapy combined with bimanual training (mCIMT + BiT) on parent perception of child’s performance among parents of children with unilateral cerebral palsy (including GMFCS level I-II; MACS level I-III). In this high quality RCT, children were randomized to receive mCIMT followed by BiT or usual care. Parent perception of the child’s performance were assessed using the Canadian Occupational Performance Measure (COPM – Performance) at post-treatment (9 weeks) and follow-up (17 weeks). A significant between-group difference was found at post-treatment, favoring mCIMT-BiT vs. usual care.
Note: Between-group differences at follow-up were not reported.
Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that modified constraint-induced movement therapy combined with bimanual training is more effective than a comparison intervention (usual care) in improving parent’s perception of the child’s performance among parents of children with unilateral CP (GMFCS level I-II; MACS level I-III).
One high quality RCT (Aarts et al., 2010) investigated the effects of a modified constraint-induced movement therapy combined with bimanual training (mCIMT + BiT) on parent satisfaction with child’s performance among parents of children with unilateral cerebral palsy (including GMFCS level I-II; MACS level I-III). In this high quality RCT, children were randomized to receive mCIMT followed by BiT or usual care. Parent satisfaction with the child’s performance was assessed using the Canadian Occupational Performance Measure (COPM – Satisfaction) at post-treatment (9 weeks) and follow-up (17 weeks). A significant between-group difference was found at post-treatment, favoring mCIMT-BiT vs. usual care.
Note: Between-group differences at follow-up were not reported.
Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that modified constraint-induced movement therapy combined with bimanual training is more effective than a comparison intervention (usual care) in improving parent’s satisfaction with the child’s performance among parents of children with unilateral CP (GMFCS level I-II; MACS level I-III).
One high quality RCT (Aarts et al., 2010) investigated the effects of a modified constraint-induced movement therapy combined with bimanual training (mCIMT + BiT) on quality of upper limb movement among children with unilateral cerebral palsy (including GMFCS level I-II; MACS level I-III). In this high quality RCT, children were randomized to receive mCIMT followed by BiT or usual care. Quality of upper limb movement was assessed using the Melbourne Assessment of Unilateral Upper Limb Function at post-treatment (9 weeks) and follow-up (17 weeks). No significant between-group difference was found at post-treatment.
Note: Between-group differences were not reported at follow-up.
Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that modified constraint-induced movement therapy combined with bimanual training is not more effective than a comparison intervention (usual care) in improving quality of upper limb movement in children with unilateral CP (GMFCS level I-II; MACS level I-III).
One fair quality RCT (Facchin et al., 2011) investigated the effects of a modified constraint-induced movement therapy (mCIMT) on activities of daily living among children with hemiplegic cerebral palsy (including GMFCS level I-III). In this fair quality RCT, children were randomized to receive (1) mCIMT, (2) bimanual intensive rehabilitation program (IRP), or (3) standard treatment (ST). Activities of daily living in 2-6- and in 7-8-year-olds were assessed using the Besta Scale ADL subscale) at post-treatment (10 weeks). A significant between-group difference was found for 7-8-year-olds, favoring ST vs. mCIMT.
Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that mCIMT is less effective than a comparison intervention (standard treatment) in improving activities of daily living in 7- to 8-year old children with hemiplegic CP (GMFCS level I-III).
One fair quality RCT (Facchin et al., 2011) investigated the effects of a modified constraint-induced movement therapy (mCIMT) on quality of upper limb movement among children with hemiplegic cerebral palsy (including GMFCS level I-III). In this fair quality RCT, children were randomized to receive (1) mCIMT, (2) bimanual intensive rehabilitation program (IRP), or (3) standard treatment (ST). Quality of upper limb movement was assessed using the Quality of Upper Extremity Skills Test and the Besta Scale (Grasp; Bimanual spontaneous use) at post-treatment (10 weeks). Significant between-group differences were found on all measures, favoring mCIMT vs. ST.
Note: No significant between-group differences were found when comparing mCIMT vs. IRP.
Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that mCIMT is more effective than a comparison intervention (standard treatment) in improving quality of upper limb function in children with hemiplegic CP (GMFCS level I-III).
Three high quality RCTs (Hoare et al., 2013; Gelkop et al., 2015; Christmas et al., 2018) investigated the effects of constraint-induced movement therapy (CIMT) on bimanual performance in children with unilateral CP.
The first high quality RCT (Hoare et al., 2013) randomized patients to receive mCIMT or bimanual occupational therapy; both groups also received botulinum toxin A. Bimanual performance was assessed using the Assisting Hand Assessment (AHA) at post-treatment (8 weeks). No significant between-group difference was found.
The second high quality RCT (Gelkop et al., 2015) randomized patients to receive mCIMT vs. hand-arm bimanual intensive therapy, following a baseline period of conventional therapy (occupational therapy and physiotherapy). Bimanual performance was assessed using the AHA at post-treatment (8 weeks). No significant between-group difference was found.
The third high quality RCT (Christmas et al.,2018) randomized children to receive either a 24-hour short arm restraint device (prolonged restraint) or intermittent holding restraint (manual restraint) during play/daily tasks. Bimanual performance was assessed using the AHA at post-treatment (10 weeks) and the Birmingham Bimanual Questionnaire at post-treatment (10 weeks) and follow-up (24 weeks). A significant between-group difference was found on the Birmingham Bimanual Questionnaire at post-treatment (10 weeks) only, favoring prolonged vs. manual restraint. No other significant between-group differences were found.
Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that CIMT is not more effective than the comparison interventions (bimanual occupational therapy; hand-arm bimanual intensive therapy) in improving bimanual performance in children with unilateral CP. However, one high quality RCT found prolonged CIMT more effective than intermittent holding restraint.
One high quality RCT (Hoare et al., 2013) investigated the effects of modified constraint-induced movement therapy (mCIMT) goal attainment in children with unilateral CP. In this high quality RCT, children were randomized to receive mCIMT or bimanual occupational therapy (BOT); both groups also received botulinum toxin A. Goal attainment was assessed using the Goal Attainment Scale at post-treatment (8 weeks), and follow-up (6 months post BoNT-A treatment). No significant between-group difference was found.
Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mCIMT is not more effective than a comparison intervention (BOT) in improving goal attainment in children with unilateral CP.
One high quality RCT (Xu et al., 2015) investigated the effects of constraint-induced movement therapy (CIMT) on grip strength among children with hemiparetic cerebral palsy. In this high quality RCT, children were randomized to receive CIMT, CIMT and electrical stimulation, or traditional occupational therapy only. Grip strength was assessed using a Sphygmomanometer at post-treatment (2 weeks) and follow-up (3 months and 6 months from baseline). No significant between-group differences were found at any time point.
Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that CIMT is not more effective than the comparison interventions (CIMT with electrical stimulation; traditional occupational therapy) in improving grip strengthin children with hemiparetic CP.
One high quality RCT (Xu et al., 2015) investigated the effects of constraint-induced movement therapy (CIMT) on muscle recruitment and coordination among children with hemiparetic cerebral palsy. In this high quality RCT, children were randomized to receive CIMT, CIMT and electrical stimulation (ES), or traditional occupational therapy only. Muscle recruitment and coordination (root mean square (RMS) of involved/uninvolved wrist extensors/flexors; integrated EMG (iEMG) of involved/uninvolved wrist extensors/flexors; cocontraction ratio) were assessed using surface EMG at post-treatment (2 weeks from baseline) and follow-up (3 months and 6 months from baseline). Significant between-group differences were found only for 2 measures (iEMG of the involved wrist extensors and cocontraction ratio) at follow-up (both 3 and 6 months from baseline), favoring CIMT + ES vs. CIMT only.
Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that CIMT is not more effective than the comparison interventions (CIMT with electrical stimulation; traditional occupational therapy) in improving muscle recruitment and coordination in children with hemiparetic CP.
One high quality RCT (Hoare et al., 2013) investigated the effects of modified constraint-induced movement therapy (mCIMT) on occupational performance in children with unilateral CP. In this high quality RCT, children were randomized to receive mCIMT or bimanual occupational therapy (BOT); both groups also received botulinum toxin A. Occupational performance was assessed using the Paediatric Evaluation of Disability Inventory and the Canadian Occupational Performance Measure, at post-treatment (8 weeks) and follow-up (6 months post BoNT-A treatment). No significant between-group differences were found.
Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mCIMT is not more effective than a comparison intervention (BOT) in improving occupational performance in children with unilateral CP.
One high quality RCT (Christmas et al., 2018) investigated the effects of two constraint-induced movement therapies (focus: caregiver directed) on quality of life among children with hemiplegic CP. This high quality RCT randomized children to receive either a 24-hour short arm restraint device (prolonged restraint) or intermittent holding restraint (manual restraint) during play/daily tasks. Quality of life was assessed using the Pediatric Quality of Life Inventory 4.0 Generic Core Scale (for children 2 years and above) or The Pediatric Quality of Life Inventory Infant Scale (for children less than 2 years) at post-treatment (10 weeks) and follow-up (24 weeks). A significant between-group difference was found only for the Pediatric Quality of Life Inventory Infant Scale at follow-up, favoring prolonged vs. manual restraint.
Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that prolonged constraint-induced movement therapy is more effective than a comparison intervention (caregiver directed, manualconstraint-induced movement therapy) in improving quality of life in children with hemiplegic CP.
Three high quality RCTs (Hoare et al., 2013; Gelkop et al., 2015; Christmas et al., 2018) investigated the effects of constraint-induced movement therapy (CIMT) on quality of upper limb movement in children with unilateral CP.
The first high quality RCT (Hoare et al., 2013) randomized patients to receive mCIMT or bimanual occupational therapy (BOT); both groups also received botulinum toxin A. Quality of upper limb movement was assessed using the Quality of Upper Extremity Skills Test (QUEST – Grasp; Dissociated movement) at post-treatment (8 weeks) and follow-up (6 months post BoNT-A treatment). A significant between-group difference was found for QUEST (Grasp) at follow-up, favoring mCIMT vs. BOT.
The second high quality RCT (Gelkop et al., 2015) randomized patients to receive mCIMT vs. hand-arm bimanual intensive therapy (HABIT), following a baseline period of conventional therapy (occupational therapy and physiotherapy). Quality of upper limb movement was assessed using the QUEST (Grasp; Dissociated movement; Protective extension; Weight bearing) at post-treatment (8 weeks). A significant between-group difference was found for QUEST (Grasp), favoring mCIMT vs. HABIT.
The third high quality RCT (Christmas et al.,2018) randomized patients to receive either a 24-hour short arm restraint device (prolonged restraint) or intermittent holding restraint (manual restraint) during play/daily tasks. Quality of upper limb movement was assessed using the QUEST (Grasp; Dissociated movement; Protective extension; Weight bearing) at post-treatment (10 weeks). No significant between-group difference was found.
Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that CIMTis not more effective than the comparison interventions (bimanual occupational therapy; hand-arm bimanual intensive therapy) in improving quality of upper limb movement in children with unilateral CP.
One high quality RCT (Christmas et al., 2018) investigated the effects of two constraint-induced movement therapies (focus: caregiver directed) on therapy dose among children with hemiplegic CP. This high quality RCT randomized children to receive either a 24-hour short arm restraint device (prolonged restraint) or intermittent holding restraint (manual restraint) during play/daily tasks. Therapy dose was assessed using Parent Diaries/Questionnaires at post-treatment (10 weeks). A significant between-group difference was found, favoring prolonged vs. manual restraint.
Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that prolonged constraint-induced movement therapy is more effective than a comparison intervention (caregiver directed manual restraint constraint-induced movement therapy) in improving therapy dose in children with hemiplegic CP.
One high quality RCT (Xu et al., 2015) and two fair quality RCTs (Taub et al., 2004; Deluca et al., 2006) investigated the effects of constraint-induced movement therapy (CIMT) on upper limb motor function in children with hemiparetic CP.
The high quality RCT (Xu et al., 2015) randomized children to receive CIMT, CIMT and electrical stimulation, or traditional occupational therapy. Upper limb motor function was assessed using the Upper Extremity Functional Test and Global Rating Scale at post-treatment (2 weeks) and follow-up (3 months and 6 months from baseline). No significant between-group differences were found at any time point.
The first fair quality RCT (Taub et al., 2004) randomized children to receive pediatric CIMT or conventional therapy. Upper limb motor function was assessed using the Emerging Behaviours Scale (EBS), the Pediatric Motor Activity Log (PMAL), and the Toddler Arm Use Test at post-treatment (3 weeks). Significant between-group differences were found on all three measures, favoring CIMT vs. conventional therapy.
The second fair quality cross-over RCT (Deluca et al., 2006) randomized children to receive pediatric CIMT or to receive conventional physiotherapy. Upper limb motor function was assessed using the Quality of Upper Extremity Skills Test, the PMAL, and the EBS at post-treatment (3 weeks) and at follow-up/crossover (6 weeks). Significant between-group differences were found on the PMAL at post-treatment and follow-up and on the EBS at post-treatment, favoring pediatric CIMT vs. conventional therapy.
Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that CIMT is not more effective than the comparison interventions (CIMT + electrical stimulation, traditional occupational therapy) in improving upper limb motor function in children with hemiplegic CP. However, two fair quality RCTs found that CIMT is more effective than conventional therapy.
References
Aarts, P. B., Jongerius, P. H., Geerdink, Y. A., van Limbeek, J., & Geurts, A. C. (2010). Effectiveness of modified constraint-induced movement therapy in children with unilateral spastic cerebral palsy: a randomized controlled trial. Neurorehabilitation and neural repair, 24(6), 509–518. https://doi.org/10.1177/1545968309359767
Chamudot, R., Parush, S., Rigbi, A., Horovitz, R., & Gross-Tsur, V. (2018). Effectiveness of Modified Constraint-Induced Movement Therapy Compared With Bimanual Therapy Home Programs for Infants With Hemiplegia: A Randomized Controlled Trial. The American journal of occupational therapy : official publication of the American Occupational Therapy Association, 72(6), 7206205010p1–7206205010p9. https://doi.org/10.5014/ajot.2018.025981
Christmas, P. M., Sackley, C., Feltham, M. G., & Cummins, C. (2018). A randomized controlled trial to compare two methods of constraint-induced movement therapy to improve functional ability in the affected upper limb in pre-school children with hemiplegic cerebral palsy: CATCH TRIAL. Clinical rehabilitation, 32(7), 909–918. https://doi.org/10.1177/0269215518763512
Deluca, S. C., Echols, K., Law, C. R., & Ramey, S. L. (2006). Intensive pediatric constraint-induced therapy for children with cerebral palsy: randomized, controlled, crossover trial. Journal of child neurology, 21(11), 931–938. https://doi.org/10.1177/08830738060210110401
Eliasson, A. C., Nordstrand, L., Ek, L., Lennartsson, F., Sjöstrand, L., Tedroff, K., & Krumlinde-Sundholm, L. (2018). The effectiveness of Baby-CIMT in infants younger than 12 months with clinical signs of unilateral-cerebral palsy; an explorative study with randomized design. Research in developmental disabilities, 72, 191–201. https://doi.org/10.1016/j.ridd.2017.11.006
Facchin, P., Rosa-Rizzotto, M., Visonà Dalla Pozza, L., Turconi, A. C., Pagliano, E., Signorini, S., Tornetta, L., Trabacca, A., Fedrizzi, E., & GIPCI Study Group (2011). Multisite trial comparing the efficacy of constraint-induced movement therapy with that of bimanual intensive training in children with hemiplegic cerebral palsy: postintervention results. American journal of physical medicine & rehabilitation, 90(7), 539–553. https://doi.org/10.1097/PHM.0b013e3182247076
Gelkop, N., Burshtein, D. G., Lahav, A., Brezner, A., Al-Oraibi, S., Ferre, C. L., & Gordon, A. M. (2015). Efficacy of constraint-induced movement therapy and bimanual training in children with hemiplegic cerebral palsy in an educational setting. Physical & occupational therapy in pediatrics, 35(1), 24–39. https://doi.org/10.3109/01942638.2014.925027
Hoare, B., Imms, C., Villanueva, E., Rawicki, H. B., Matyas, T., & Carey, L. (2013). Intensive therapy following upper limb botulinum toxin A injection in young children with unilateral cerebral palsy: a randomized trial. Developmental medicine and child neurology, 55(3), 238–247. https://doi.org/10.1111/dmcn.12054
Taub, E., Ramey, S. L., DeLuca, S., & Echols, K. (2004). Efficacy of constraint-induced movement therapy for children with cerebral palsy with asymmetric motor impairment. Pediatrics, 113(2), 305–312. https://doi.org/10.1542/peds.113.2.305
Wallen, M., Ziviani, J., Naylor, O., Evans, R., Novak, I., & Herbert, R. D. (2011). Modified constraint-induced therapy for children with hemiplegic cerebral palsy: a randomized trial. Developmental medicine and child neurology, 53(12), 1091–1099. https://doi.org/10.1111/j.1469-8749.2011.04086.x
Xu, K., He, L., Mai, J., Yan, X., & Chen, Y. (2015). Muscle Recruitment and Coordination following Constraint-Induced Movement Therapy with Electrical Stimulation on Children with Hemiplegic Cerebral Palsy: A Randomized Controlled Trial. PloS one, 10(10), e0138608. https://doi.org/10.1371/journal.pone.0138608
A group of lifelong disorders affecting a person’s movement, coordination, and muscle tone and which are the result of damage to the brain before, during, or shortly after birth.
A type of therapeutic intervention which uses electric impulses to elicit muscle contraction. It can be used for many reasons such as increasing muscle strength and activation, improving joint pain and swelling, and improving blood flow and circulation, among others.
