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Lancet Neurol. Author manuscript; available in PMC 2016 February 01.
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Published in final edited form as:

Lancet Neurol. 2015 February ; 14(2): 224–234. doi:10.1016/S1474-4422(14)70160-7.

Constraint-Induced Movement Therapy after Stroke

Gert Kwakkel, PhD1,2, Janne M. Veerbeek, MSc1, Erwin E.H. van Wegen, PhD1, and Steven
L. Wolf, PhD, FPTA, FAHA3
Janne M. Veerbeek: J.Veerbeek@vumc.nl; Erwin E.H. van Wegen: E.vanWegen@vumc.nl; Steven L. Wolf:
swolf@emory.edu

1Department of Rehabilitation Medicine, MOVE Research Institute Amsterdam, VU University

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Medical Center; PO Box 7057; 1007 MB, Amsterdam, The Netherlands 2Amsterdam
Rehabilitation Research Center, Reade Centre for Rehabilitation and Rheumatology, Amsterdam,
The Netherlands 3Emory University School of Medicine, Department of Rehabilitation Medicine,
Division of Physical Therapy, Atlanta VA Center for Visual and Neurocognitive Rehabilitation,
1441 Clifton Road NE; Atlanta, Georgia 30322 USA

Abstract
Constraint-induced movement therapy (CIMT) was developed to overcome upper limb
impairments after stroke and is the most investigated intervention for treating stroke patients in the
previous decades. This review describes the current evidence regarding: original CIMT and
modified versions of CIMT (mCIMT). Meta-analysis showed strong evidence favoring both types
of CIMT in terms of motor function, arm-hand activities and self-reported arm-hand functioning
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in daily life, immediately after treatment and at long-term follow-up, whereas no evidence was
found for constraining alone (Forced Use (FU) therapy). No evidence was found that type of
CIMT, intensity of practice or timing did affect outcome. Although the underlying mechanism that

© 2015 Elsevier Ltd. All rights reserved.

Corresponding author: G. Kwakkel, PhD; Department of Rehabilitation Medicine, MOVE Research Institute Amsterdam, VU
University Medical Center; PO Box 7057; 1007 MB, Amsterdam, The Netherlands. Phone: +31-20-4440460; Fax: +31-20-4440787;
G.Kwakkel@vumc.nl.
Authors' contributions to the manuscript: 1) Dr. G. Kwakkel: conceptualization of the study, interpretation of the data, drafting and
revising the manuscript.
1) J.M. Veerbeek, MSc: conceptualization of the study, risk of bias assessment, performed the meta-analyses and interpretation of the
data, revising the manuscript.
2) Dr. E.E.H. van Wegen: conceptualization of the study, risk of bias assessment, interpretation of the data, revising the manuscript.
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3) Dr. S.L. Wolf: interpretation of the data, revising the manuscript.

Disclosure: Gert Kwakkel (PhD), Janne M. Veerbeek (MSc), Erwin E.H. van Wegen (PhD) and Steven L. Wolf (PhD) report no
disclosures.
Conflicts of interest: GK has received grants from the European Research Council, Dutch National Institutes of Health (ZonMw), The
Dutch Brain Foundation (Hersenstichting Nederland), The Dutch Hearth Foundation, and the Royal Dutch Society for Physical
Therapy.
JV has received grants from the Royal Dutch Society for Physical Therapy. EvW has received grants from the Stichting Parkinson
Fonds, the Beatrix Fonds, the Dutch Brain Foundation, Fonds Nuts-Ohra, the Dutch Parkinson Association, and ZonMw.
SW has received grants from the National Institutes of Health (National Institute of Neurological Diseases and Stroke and the Center
for Medical Rehabilitation Research within the National Institute of Child Health and Development).
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 Kwakkel et al. Page 2

drive (m)CIMT is still poorly understood, recent kinematic conducted studies suggests that
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improvements introduced by original CIMT or mCIMT are mainly based on adaptation by

learning to optimize the use of intact end-effectors by selecting patients with some voluntary
motor control of wrist and finger extensors post stroke.

Keywords
stroke; rehabilitation; upper limb; Constraint-induced movement therapy; forced use; systematic
review; meta-analysis

Introduction
Worldwide, 16.9 million people suffer a first stroke each year, resulting in about 33 million
stroke survivors and 5.9 million stroke-related death (1) making stroke the second or third
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most common cause of death and one of the main causes of acquired adult disability. (1, 2)
Approximately 80% of these survivors have motor impairments of the upper limb(3) that
gravely affect their ability to perform activities of daily living (ADL), as well as social
participation. Previously we showed that the severity of upper limb paresis is an independent
determinant of the outcome of basic activities of daily living (ADL) post stroke. (4)

A recent systematic review of 467 trials showed that the effectiveness of most interventions
for the upper and lower limbs is driven by repetition and principles of task- and context-
specific motor learning. (5) Constraint-induced movement therapy (CIMT) or modified
versions of CIMT (mCIMT) are currently considered the most effective treatment regimens
in physical therapy to improve the outcome of the upper paretic limb. (2, 5)
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Although several systematic reviews concerning have been conducted in the past, (6-13)
there is no recent meta-analysis of RCTs of (m)CIMT including thorough analyses of
possible effect modifiers and small-study effects. Of the currently available reviews, some
suffer from an incomplete literature search strategy,(6, 7, 14) while others are restricted to a
specific set of modified versions of CIMT(15), dose-matched controlled interventions(13), a
specific period post stroke(10, 12), or a best-evidence synthesis based on the methodological
quality of included trials. (11)

In the present review, first, we will briefly give a historical background and description of
the original CIMT protocol. Based on a systematic review of the literature and subsequent
metaanalysis of randomized controlled trials (RCTs), we will summarize the evidence for
CIMT, mCIMT and Forced Use (FU) therapy in adult patients with stroke. In a subsequent
sensitivity analysis of included RCTs, we will explore the effects of (1) CIMT type, (2)
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dosage of therapy, and (3) timing of therapy post stroke. Subsequently, we will discuss the
effects of in light of assumed underlying mechanisms that drives (m)CIMT and criteria for
selecting patients that will benefit most from (m)CIMT. Finally, we will summarize our
findings and offer suggestions for further research.

The theoretical framework for CIMT has a long history.(16, 17) The German scientist Munk
(1909) (18) was the first to document that non-human primates would use an impaired

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(deafferented) upper extremity if forced to do so, when the movement was purposeful and
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relevant. This work was quickly followed by the classical studies by Ogden and Franz
(1917) who observed monkeys freely moving following pyramidal tract lesions.(19)
Somewhat serendipitously, rather than by design, these animals were forced to use the
hemiparetic upper extremity after immobilization of the better limb, which they were rapidly
able to accomplish. This observation the authors to suggest that the limitation was not as
much an inability as it was one of disuse. This concept of “forced use” (FU) was resurrected
several decades later by Knapp(20) and in elegant studies by Taub(21), who applied the
deafferented monkey model to show that these animals would not use the insensate limb
unless a series of behavioral strategies was employed that resulted in ‘overcoming learned
non-use’ (Fritz et al.(17) for more detail).

Defining CIMT
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The signature protocol for the original form of CIMT contains three components or
‘treatment packages’: (1) intensive graded practice of the paretic upper limb aimed at
enhancing task-specific use of the affected limb for up to 6 hours a day for 2 weeks (i.e.,
shaping) (Figure 1); (2) constraining or FU of the non-paretic upper limb with a mitt to
promote the use of the more impaired limb during 90% of the waking hours; and (3)
adherence-enhancing behavioral methods designed to transfer the gains obtained in the
clinical setting or laboratory to the patients' real-world environment (i.e., transfer package).
(22, 23) Thus, CIMT uses operant training techniques applied in the context of rehabilitation
medicine, (24) while FU does not rely upon any conditioning. (25, 26) Since its
introduction, the first proof of the original CIMT concept was investigated in 9 chronic
stroke patients by Edward Taub and colleagues. (27) Their positive findings regarding motor
function, dexterity and self-reported arm-hand use in daily life were later replicated in a
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multicenter trial of 222 stroke patients.(28-30) Trials by other research groups have applied
“modified” forms of CIMT (mCIMT) that vary in dosage, timing and composition of
therapy. While embracing the fundamental components of the original form of CIMT, these
modifications are typically characterized by distributed training protocols with reduced time
spent in training, less time during which the non-paretic upper limb is restrained, and
absence of a transfer package including a contract with the patient, but a larger number of
training days. (31, 32) Treatment sessions for mCIMT vary from 30 minutes(33-35) to 6
hours(36-44) a day, and from 2(45) to 7(46) sessions a week, for 2(23, 36-45, 47-56) to 12
weeks. The wide variety of these adaptations justifies a systematic review and subsequent
meta-analysis of trials applying original or mCIMT. The definitions and description of
rehabilitation terminology for (m)CIMT in the present review are summarized in
supplementary web appendix 1.
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Effects of (m)CIMT
CIMT has been investigated in 51 RCTs,(23, 28-31, 33-82) including 1784 patients with
adult stroke, but only 15 trials included patients within the first three months post stroke.(34,
45, 47, 49, 50, 52, 53, 56, 59, 66, 67, 69, 76, 78, 82) Panel 1 shows the used search strategy
and selection criteria used for this systematic review of the literature. For details about the
search strategy, methods and flow-chart, see supplementary web appendix 2 to 4.

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Original CIMT
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Original CIMT, although seen as the ‘gold standard’ of CIMT, has been investigated in
merely one RCT(28-30) and included patients beyond 3 months post stroke (see for details
of the included trial of original CIMT supplementary web appendix 4). Significant positive
medium effect sizes post intervention were found for arm-hand activities, self-reported
amount of arm-hand use in daily life and self-reported quality of arm-hand movement in
daily life as shown in Figure 2 (see also supplementary web appendix 6). The favorable
effects of original CIMT for these three outcomes were sustained at follow-up (4 months) as
shown in Figure 3 (see also supplementary web appendix 7). In addition, significant positive
effect sizes in the long term were found for quality of life related to hand function and
quality of life related to ADL.

Modified versions of CIMT

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Contrary to original CIMT, mCIMT has been investigated in a vast amount of RCTs (n=44;
N=1397) (For details of included mCIMT trials see supplementary web appendix 4).(23, 31,
33-58, 61-64, 66, 70-78, 80-82) In favor of mCIMT, significant positive small to medium
summary effect sizes (SESs) have been found post intervention in terms of motor function
of the paretic arm, muscle tone, arm-hand activities, self-reported amount of arm-hand use
in daily life, self-reported quality of arm-hand movement in daily life, and basic ADL
(Figure 2) (see also supplementary web appendix 6). No significant summary effect sizes
were found for grip strength, sensibility, pain, quality of life related to hand function, and
quality of life related to ADL (Figure 2) (See supplementary web appendix 6). The effects
were sustained at follow-up (mean 21.58 (SD 13.21) weeks) for motor function of the
paretic arm, arm-hand activities, self-reported amount of arm-hand use in daily life, and self-
reported quality of arm-hand movement in daily life, but not for muscle tone or basic ADL
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(Figure 3) (see also supplementary web appendix 7).

Forced use
Forced use therapy was investigated in 6 RCTs (N=165)(59, 60, 65, 67-69, 79) (see
supplementary web appendix 5) and did not show an added value for self-reported amount
of arm-hand use in daily life and self-reported quality of arm-hand movement in daily life
(Figure 2) (see also supplementary web appendix 6).

Impact of CIMT-type, dosage of therapy, and timing of therapy post stroke and small study
effects
Sensitivity analysis shows no significant differences in effect sizes between original and
modified version of CIMT, dosage of (m)CIMT (additional time spent in exercise therapy
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5(51) to 60 hours(28, 36, 38, 40, 42)(mean 46.8 hours), and timing of (m)CIMT when
comparing trials that started within or beyond the first 3 months post stroke. In addition,
these robust effects for (m)CIMT seems not to be influenced by small-study effects,
publication bias, nor were they moderated by risk of bias (supplementary web appendix 6
and 7). Despite not finding evidence for small-study effects, meta-regression of mCIMT
trials showed that methodological quality was a significant effect modifier for motor
function post intervention and self-reported use in daily life at follow-up.

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What drives (m)CIMT?

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The underlying mechanism(s) that drive improvement by (m)CIMT are still poorly
understood. Firstly, we expected that intensity of task-specific practice (expressed as
treatment contrast in terms of duration) would be a significant moderator of (m)CIMT.
However, as shown in this meta-analysis, we found no evidence that the type of (m)CIMT or
treatment contrast - which amounted a mean of 47 hours - mattered. The absence of effects
of treatment contrast between trials does not imply that dosing of CIMT therapy is not
important. However, patients in (m)CIMT trials did practice much more intensively each
day than is usual. In addition, Wolf and colleagues showed in a retrospective analysis of 169
participants that the intensity of supervised original CIMT was modified by the amount of
repetitive task practice and also to some extent by the initial severity of motor impairment
on the WMFT.(83) This finding suggests that the effects of the therapy dose are confounded
by the initial severity of neurological deficits. Possible risks of bias, like blinding of
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assessors, did not seem to influence lack of difference between dose-matched trials and non-
dose matched trials. These findings are in agreement with a recent trial(82) and meta-
analysis(84) showing that dose-matched trials of mCIMT in which the control group
received an equal dose of bilateral arm training failed to report significant differences in
overall effect sizes. Despite the finding that (m)CIMT may increase short-term(50, 85) and
long-term cortical activation patterns, (42, 50, 86), the underlying mechanisms responsible
for improvements require further investigation. In particular, uncertainty continues to exist
about how observed improvements in motor performance after (m)CIMT relate to
recruitment of cortical activation patterns in the contralesional and ipsilesional cortex after
stroke, as revealed by Transcranial Magnetic Stimulation (TMS)(42, 86, 87) and functional
Magnetic Resonance Imaging (fMRI) (88-90) (See for a critical review: Buma et al. (91)).
For example, recent studies suggest that improved hand function assessed by WMFT is
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accompanied by increased recruitment of ipsilesional somatosensory cortex. (89, 90)

Although significant neural correlates have been found with upper extremity measurements,
such as WMFT, these studies do not address the question how cortical changes relate to the
quality of motor performance in terms of ‘neural repair’ or using compensation strategies.
(See for a review: Buma et al.(92)) For example, a recent controlled proof of concept study
of Kitago and colleagues failed to show significant changes in coordinative measures of the
paretic arm and wrist after (m)CIMT in chronic stroke, despite clinically meaningful
functional improvements in ARAT scores.(93) (See also references (33, 35, 37, 38, 43, 46,
57, 62, 64, 70-72, 80) (35)) This observation further suggests that improvements introduced
by original CIMT or mCIMT are mainly based on learning to optimize the use of intact end-
effectors (i.e., compensation strategies). These findings also suggest that the enhanced
cortical neuroplasticity found by TMS(42, 86, 87) and fMRI(90) in the subacute(49, 50) and
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chronic post stroke phases(42, 87) may reflect learned non-use and compensatory skill
learning rather than “true neurological repair” or “recovery” of impairments (see also
references (14, 92, 94)). This assumption is further supported by some recent longitudinal
3D-kinematic studies showing that the number of degrees of freedom that patients can
engage while performing meaningful tasks, such as reaching, is mainly completed in the first
8 weeks post stroke. (94, 95) These improvements in intra-limb coordination are
accompanied by a significant reduction in patients' variability(94) and improvement in the

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smoothness(95) of their motor performance. Interestingly, the 3D-kinematic improvements

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closely follow the clinical time course of impairments such as synergism(94, 96, 97) and are
also restricted to the first 3 months post stroke.(98, 99) Interestingly, the present meta-
analysis further suggests that the effects of mCIMT on motor function of the arm such as
FMA-arm scores is restricted to trials that started within this time window of 3 months post
stroke (Table 1 and supplementary web appendix 6 and 7) (References (34, 45, 49, 50, 82)).
This finding is in agreement with the growing evidence from animal studies in which the
first weeks after stroke onset are characterized by increased levels of homeostatic
neuroplasticity (100)

Who should be selected for (m)CIMT?

An important inclusion criterion for the original CIMT trial was that patients showed some
voluntary extension at the wrist and some minimal extension at the metacarpophalangeal
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and interphalangeal joints at baseline.(28) Within this selection criterion one may
discriminate between higher-functioning participants who demonstrate at least 20° of wrist
extension and at least 10° of active extension of each metacarpophalangeal and
interphalangeal joint of all digits, and lower-functioning participants who shows at least 10°
of active wrist extension, at least 10° of thumb abduction/extension, and at least 10° of
extension in at least 2 additional digits. Preferably, these movements had to be repeated 3
times in 1 minute. (101)

Although severity of stroke was not tested formally in this review, the ability to extend one
or more fingers of the paretic side seems to be natural due to the fact that active repetition of
movements and activities is not possible when there is no function at all. Recent transcranial
magnetic stimulation (TMS) (86) and diffusion tensor imaging (DTI) (102, 103) studies
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have shown that voluntary wrist and, particularly, finger extension are highly associated
with the integrity of the corticospinal tract (CST) system. This motor function is the
strongest clinical predictor of the return of some dexterity in the first days post stroke.
(103-106) Accordingly, Fritz and colleagues showed in 55 chronic stroke subjects that initial
presence of finger extension was the only significant predictor of outcome of the WMFT
after applying original CIMT. (107) Accordingly, the selection of patients with some
extension of wrist and fingers should be seen as a key factor determining the potential for
change(103, 105) and reversal of learned non-use by CIMT after stroke. (107) In addition,
due to concerns about the safety of the restraint by a sling or splint applied in the original
form of CIMT, (36) which might prevent adequate protective reactions to control standing
balance, the restraint has been replaced by a padded mitt,(108) and patients should be able to
stand for at least 2 minutes with or without support. (16) Other, more general criteria,
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included a Mini-Mental State Examination (MMSE) score of ≥24, no major medical

problems that could interfere with participation, no history of previous stroke, no excessive
pain or spasticity in the paretic extremity, enough stamina to participate, and age above 18
years. (16) Collectively, these inclusion criteria suggest that (m)CIMT is best restricted to
patients with a mild to moderate paresis with a predominantly favorable prognosis for
dexterity early post stroke. To date, about 10% (range 3(53) to 90%(59)) of the initially
screened patients of included trials in the present review was eligible for (m) CIMT.

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Synthesizing current evidence of (m)CIMT

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From systematic review of the literature and subsequent meta-analyses it is clear that
modified versions of CIMT (n=44) and FU (n=6) have been investigated in several mainly
small, underpowered trials, whereas original CIMT has only been investigated in one
sufficiently powered landmark trial. (28) Despite the heterogeneity among the forms of
mCIMT applied, meta-analyses show that original and modified versions of CIMT have a
robust, clinically meaningful impact on patient's outcomes for arm-hand activities, self-
reported amount and quality of arm-hand use in daily life, and basic ADL, making (m)CIMT
one of the most effective interventions for the upper paretic limb post stroke. (5) For
example, an anchor-based change of 12 to 17 points (21-30%) in dexterity following the
ARAT is considered as ‘clinically important’ or ‘meaningful’ in patients measured within
the first month post stroke. (109), whereas in chronic stroke victims, a distribution-based
change of about 6 points (10%) is found as clinically meaningful on the ARAT (110). This
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finding further emphasizes that the minimal clinically important difference (MCID) of used
upper extremity measures such as ARAT and WMFT are not only context specific but also
dynamic in time.(109)

With the exception of muscle tone and basic ADL, the significant positive effects were
sustained in the longer term, even though the size of SESs decreased after ending (m)CIMT.
In addition, original CIMT showed evidence of benefits in long-term health-related quality
of life.(28)

This review also suggests that (m)CIMT has no significant effects on grip strength,
sensibility, pain, or health-related quality of life post intervention. However, the statistical
power underpinning the evidence was limited by the insufficient numbers of patients in
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(m)CIMT trials using these outcomes. A summary of findings in terms of body functions,
activities and participation is shown in Table 1.

This review also suggests that, based on RCTs in which the only difference between the
experimental and control groups was wearing a mitt on the less affected arm without a
structured exercise program (i.e. FU), no superiority to the outcome was found. This finding
suggests that procedures involving shaping, repetitive exercises and instructions for
behavioural change are the most important components of (m)CIMT. Despite the large
number of trials identified, sensitivity analyses showed no significant differences between
types of CIMT regimen, timing of (m)CIMT post stroke, or treatment contrast between
experimental and control groups.

Overall, the methodological quality or treatment contrast did not significantly affect our
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results, however small mCIMT trials with lower methodological quality did significantly
overestimate the post intervention scores on motor function, while self-reported amount of
arm-hand use in daily life showed overestimation of its effect sizes in the long term (see
supplementary web appendix 6).

These findings further extend the knowledge of the effectiveness of CIMT and hypothetical
accompanying mechanisms from previous reviews,(6-10, 12, 13, 15, 111) by determining
the effects and especially their sustainability on all domains of the ICF, based on well-

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powered meta-analyses. The post intervention effects on the activities level were confirmed,
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but we the present review also shows that the effects are maintained for at least 4-5 months
after termination of the intervention. In addition, the present review showed strong evidence
that CIMT has greater effects on motor function only when applied in the earlier stages post
stroke, in which it is assumed that restitution of neurological functions is still possible, but
that in the later phases CIMT solely influences arm-hand activities by learning to use
adaptation strategies (i.e., compensation) to improve upper limb performance in ADLs.(14)

Limitations
The present systematic review has some limitations. First, we could only explore differential
effects between original type of CIMT and mCIMT by using forest plots. However, the 44
mCIMT trials are heterogeneous in terms of content and intensity. Second, although we did
not detect common threats to meta-analyses from small-study effects or publication bias,
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(112) we may have missed small negative trials. We synthesized only aggregate study level
data obtained from cited studies of sufficient methodological quality (i.e., PEDro > 4).
Including the 5 trials with low methodological quality would not have affected significantly
the overall medium sized effects and conclusions in the present review. Unfortunately, we
were unable to perform meta-analysis of individual patient data.(113) As a consequence, we
were unable to investigate possible effect modifiers, such as arm dominance and the
influence of cognitive limitations such as dyspraxia, age, or type of stroke. To investigate
long-term effects, we pooled data from trials with different follow-up intervals. Also, our
meta-analyses of measures such as grip strength and health-related quality of life were
underpowered, so the effect of (m)CIMT on these outcomes remains unclear. Our sensitivity
analyses should be interpreted with caution; due to uneven distribution across subgroups and
in some cases inclusion of only one trial in a subgroup, these analyses should mainly be seen
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as indications.(114)

Analyses of the statistical power of pooled trials showed that about half of the statistical
analyses for (m)CIMT and FU post intervention and in the longer term are sufficiently
powered (supplementary web appendix 5 and 6). The lack of statistical power applies more
to the pooled trials that started within the first three months post stroke, as well for those
studies that investigated the sustainability of (m)CIMT.

Finally, the optimal dosage of (m)CIMT remains unclear, but should range between the
numbers as described in the section ‘The CIMT protocol’. Although not tested formally in
this review due to the lack of a sufficient number of RCTs, the use of a transfer package to
enhance intensity of practice could be considered.
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Future directions
The present review shows that only 15 out of the 51 trials provided mCIMT within the first
weeks post stroke, whereas all these RCTs were small, phase II trials. This finding suggests
that more mCIMT trials are needed preferably starting within the first days post stroke using
different doses of upper limb training. There is growing evidence from animal studies that
the brain shows increased neuroplasticity in the early phases post stroke. This finding
suggests that normalization of motor control by true neurological recovery could be

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maximized within this time window.(92, 93, 100) Results from several animal studies(100,
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115-117) suggest that (m) CIMT in the first weeks after stroke may enhance up-regulation
of growth promoting factors such as protein 43, synaptophysin and other brain derived
neurotrophic factors. (117) In addition, Zhao and colleagues recently showed that applying
(m) CIMT from weeks 1 to 3 post stroke significantly suppressed the up-regulation of
growth inhibiting factors such as Nogo-A, Nogo receptors and RhoA expressed in the peri-
infarct cortex in Wistar rats.(117) In these animals, mCIMT resulted in significant structural
post-synaptic plastic changes in the denervated cervical spinal cord. (117) Applying mCIMT
for 4 weeks directly after stroke fosters reorganization of the somatosensory cortex and its
neural network.(118) One emerging question is whether the structural plasticity introduced
by early applied mCIMT also leads to true neurological repair beyond the existing
mechanisms of spontaneous neurological recovery in the first phase post stroke.(92) The
limited time window of neural mechanisms assumed to play a role in the natural logarithmic
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pattern of spontaneous neurological recovery of body functions (or reduction in

impairments) may further underline the need for more RCTs with intensive serial
assessments in time early post stroke. Preferably, to improve our understanding of skill
acquisition by mCIMT, these observed improvements in repeated assessments should be
associated with serial measures of kinematics, biomechanics and non-invasive neuroimaging
techniques post stroke.(2, 92)

Second, there is a need to investigate the assumptions of learned “misuse” when patients
learn to use their end-effectors in a different adaptive way to normalize motor control early
post stroke.(119) Such research should objectively and intensively monitor the quality of
motor control in terms of temporal-spatial activation patterns of the upper limb and trunk
using 3D-kinematics and EMG-controlled measures in addition to complementary clinical
outcomes. (92) This approach would allow investigation of changes in end-effectors of the
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paretic arm and trunk during stroke recovery. (94) Preferably, these coordination measures
should be related to neuronal correlates to allow appropriate interpretation of changes in
neuroplasticity observed in animal studies. (92, 120, 121)

Third, additional research is needed to investigate possible detrimental effects of very high
doses of early applied (m)CIMT (i.e., > 3 hours) within this time window of increased
homeostatic neuroplasticity, as suggested by some studies among animals (122-124) and
patients with stroke. (53) Interestingly, a recent meta-analysis involving 8 animal trials
showed no significant inverse dose-response relationship of (m)CIMT on infarct volume
(-3%, 95%CI 15-9; p= p=0.63).(121) This finding further emphasizes that animal models
may help us to efficiently explore the biological basis of rehabilitation interventions, but
also questions its generalizability to humans. (121)
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Fourth, none of the identified trials reported the influence of phenotypic factors such as
gender, age or type of stroke on the effects of (m) CIMT on outcome after stroke. One trial
claimed larger effects for chronic stroke patients with sensory deficits and neglect. (37)
Investigating the relation between individual patient characteristics and the effects of
(m)CIMT requires meta-analysis of individual patient data to identify possible effect
modification by patients' phenotypes.(113)

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Fifth, most mCIMT trials lack transparency in the treatment protocol with respect to content,
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timing post stroke and therapy dosage. Fortunately, most journals now accept online
submission of treatment protocols applied in trials. In addition, consensus is needed on the
content and timing of test batteries applied to evaluate (m) CIMT. (2)

Finally, the barriers to implementation of (m)CIMT and factors which may enhance real-
world use of the upper paretic limb require further investigation. (23) In view of the limited
health care resources in most countries, and the increasing numbers of stroke survivors,
there is a need to investigate the cost-effectiveness of (m)CIMT compared to usual care. (16)
Adding therapy time will result in a concomitant increase in health-care costs, however
effective therapy could potentially reduce rates of readmission to hospitals and admission to
long-term care institutions.(125) In addition, innovative, adaptive forms of (m)CIMT, such
as group sessions to reduce the staff-to-patient ratio and costs, self-training mCIMT
programs (e.g., (126)), caregiver-support, and supervised practice by e-health support and
Author Manuscript

telerehabilitation services, need to be investigated and compared with the usual face-to-face
(m)CIMT regarding cost-benefit.(11)

Supplementary Material
Refer to Web version on PubMed Central for supplementary material.

Acknowledgments
The authors would like to thank Hans Ket (Librarian VUmc) for his cooperation in the literature search and Mark
van den Brink for the illustration. The present study was funded by a grant from the Royal Dutch Society of
Physiotherapy (grant no. 8091.1) and supported by the EXPLICIT-stroke grant from The Netherlands Organisation
for Health Research and Development (ZonMw) (grant no. 89000001) and 4D-EEG (ERC advanced grant no.
291339-4D-EEG). We thank Paul Thompson PhD for providing additional EXCITE data used in the original CIMT
Author Manuscript

analyses.

The funding organizations had no role in the design or conduct of the study, the collection, management, analysis,
or interpretation of the data, or the preparation, review, or approval of the manuscript.

Study funding: The present study was funded by a grant from the Royal Dutch Society of Physiotherapy (/grant no.
8091.1; http://www.fysionet.nl), supported by the EXPLICIT-stroke grant from the Netherlands Organisation for
Health and development (ZonMw; grant no. 89000001; http://www.zonmw.nl; http://www.explicit-stroke.nl), and
4D-EEG (ERC advanced grant no. 291339-4D-EEG; http://erc.europa.eu/). The funding organizations had no role
in the design or conduct of the study or the collection, management, analysis, or interpretation of the data; or the
preparation, review, or approval of the manuscript.

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Panel 1
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Search strategy and selection criteria

We identified relevant publications by searching PubMed, EBSCO host/Excerpta Medica
Databank (EMBASE), EBSCOhost/Cumulative Index of Nursing and Allied Health
Literature (CINAHL), Wiley/Cochrane Library (Cochrane Database of Systematic
Reviews [CDSR], Cochrane Central Register of Controlled Trials [CENTRAL],
Cochrane Methodology Register [CMR], Database of Abstracts of Reviews of Effects
[DARE], Health Technology Assessment Database [HTA], NHS Economic Evaluation
Database [EED]) and Physiotherapy Evidence Database (PEDro) (all databases last
searched 24-09-2013 by JMV). The indexing terms and free-text terms with synonyms
and related terms in the title or abstract used were: “stroke” and “physical restraint” or
“constraint-induced movement therapy” or “forced use” or “immobilization” or “learned
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nonuse” and “randomized controlled trial” or “reviews” (supplementary web appendix

2). One reviewer (JMV) screened the titles, abstracts, if relevant full-text publications,
and references of included RCTs. The inclusion criteria were: (1) adult stroke patients;
(2) RCT design, including those with a two-group parallel, multi-arm parallel, crossover,
cluster or factorial design; (3) the experimental intervention conformed to the definitions
of original CIMT, mCIMT, or FU; (4) the comparator was usual care, another
intervention, the same intervention with a different dose, or no intervention; (5) outcomes
were measured post intervention and/or at follow-up; and (6) publication in the English,
French, German, or Dutch.
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Figure 1. Constraint-induced movement therapy

Illustration of task-oriented practice with the paretic limb in a Constrained Induced
Movement Therapy session. Use of the non-affected limb is restricted by a padded mitt.
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Figure 2. Forest plot of constraint-induced movement therapy post intervention

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This figure displays the summarized effects of original CIMT, modified CIMT and forced
use post intervention, classified according to the International Classification of Functioning,
disability and health (ICF; World Health Organization). Please consult supplementary web
appendix 5 for Hedges' g (95%CI) in numbers. Background colors represent the different
ICF-categories, body functions (pink), activities (blue), and participation (orange). The italic
numbers in the statistical power column indicate sufficient power (1-β ≥0.80). 95%CI, 95%

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 Kwakkel et al. Page 21

Confidence interval; ADL, Activities of daily living; C, Control group; CIMT, Constraint-
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induced movement therapy; E, Experimental group; N/A, Not applicable.

References: (a) 33-35, 37, 38, 43, 45, 46, 49, 50, 57, 62, 64, 70, 71, 73, 80, 82; (b) 39, 42;
(c) 55, 73; (d) 46, 82; (e) 46, 75; (f) 28; (g) 31, 33- 43, 45- 47, 51-56, 73, 75-78, 80-82; (h)
28; (i) 34, 37, 41, 43, 46, 52, 54, 55, 57, 61-64, 70-73, 75, 77, 78, 80-82; (j) 67, 69; (k) 28;
(l) 34, 36, 37, 41, 43, 46, 49-52, 54, 55, 57, 61, 62, 64, 70-73, 75, 77, 78, 80-82; (m) 67, 69,
79; (n) 41, 47, 52, 54, 62-64, 66, 71; (o) 53, 81, 82; (p) 81, 82.
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Figure 3. Forest plot of constraint-induced movement therapy in the long term

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This figure displays the summarized effects of original CIMT, modified CIMT and forced
use in the long term (4-5 months), classified according to the International Classification of
Functioning, disability and health (ICF; World Health Organization). Please consult
supplementary web appendix 6 for Hedges' g (95%CI) in numbers. Background colors
represent the different ICF-categories, body functions (pink), activities (blue), and
participation (orange). The italic numbers in the statistical power column indicate sufficient
power (1-β ≥0.80). 95%CI, 95% Confidence interval; ADL, Activities of daily living; C,

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 Kwakkel et al. Page 23

Control group; CIMT, Constraint-induced movement therapy; E, Experimental group; N/A,

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Not applicable.
References: (a) 37, 46, 49, 50, 82; (b) 55, 73; (c) 28; (d) 37, 41, 42, 46, 48, 49, 50, 52, 53,
55, 73, 75, 78, 82; (e) 28 ; (f) 37, 41, 46, 49, 50, 52, 55, 73, 75, 78, 82; (g) 28; (h) 37, 41, 46,
49, 50, 52, 55, 73, 75, 78, 82; (i) 41, 52; (j) 28; (k) 28.
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Table 1
Summary of evidence for constraint-induced movement therapy according to the ICF
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In this table, the evidence for original CIMT, modified CIMT, and forced use post intervention and in the long
term (4-5 months) are summarized according to the International classification of function, disability, and
health model (ICF). ✓, beneficial or likely to be beneficial based on significant positive summary effect sizes;
⨯, uncertain benefit based on non-significant summary effect sizes; ?, unknown effect based on the inability to
statistically pool data of RCTs; *, only beneficial or likely to be beneficial within the first 3 months post
stroke. ADL, Activities of daily living; AOU, Self-reported amount of arm-hand use in daily life; CIMT,
Constraint-induced movement therapy; FU, Forced use; QoL, Quality of life; QOM, Self-reported quality of
arm-hand movement in daily life.
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