Research Report

Bound for Success: A Systematic

Review of Constraint-Induced
Movement Therapy in Children With
Cerebral Palsy Supports Improved
Arm and Hand Use
Hsiang-han Huang, Linda Fetters, Jennifer Hale, Ashley McBride
H. Huang, MS, OT, is an ScD student in the Department of Physical
Therapy and Athletic Training, Boston University, Boston, Massachusetts, and currently is working in the
Department of Biokinesioiogy and
Physical Therapy, University of
Southern California, 1540 E Alcazar
St, CHP 155, Los Angeles, CA
90033 (USA). Address all correspondence to Ms Huang at:
hsiangha@usc.edu.
L. Fetters, PT, PhD, FAPTA, is Professor, Department of Biokinesioiogy and Physical Therapy, and
Department of Pediatrics, Keck
School of Medicine, University of
Southern California.
J. Hale, PT, DPT, is Physical Therapist, The Institute for Rehabilitation and Research (TIRR), Houston,
Texas.
A. McBride, PT, DPT, is Physical
Therapist, Providence Portland Medical Center, Portland, Oregon.
[Huang H, Fetters L, Hale ),
McBride A. Bound for success: a
systematic review of constraintinduced movement therapy in
children with cerebral palsy supports improved arm and hand use.
Phys Ther. 2009;89:1126-1141.]
2009 American Physical Therapy
Association

Background, constraint-induced movement therapy (CIMT) is a potentially effective intervention for children with hmiplgie cerebral palsy (CP).
Purpose. The objectives of this systematic review are: (1) to investigate whether
CIMT is supported with valid research of its effectiveness and (2) to identify key
characteristics of the child and intervention protocol associated with the effects of
CIMT.

Data Sources and Study Selection, A search of MEDLINE (1966 through

March 2009), Entrez PubMed (1966 through March 2009), EMBASE (1980 through
March 2009), CINAHL (1982 through March 2009), PsychlNFO (1887 through March
2009), and Web of Science (1900 through March 2009) produced 23 relevant studies.
Data Extraction and Synthesis. The 2 objectives of the review were addressed by: (1) scoring the validity and level of evidence for each study and calculating evidence-based statistics, if possible, and (2) recording and summarizing the
inclusion and exclusion criteria, type and duration of constraint, intervention and
study durations, and outcomes based on the International Classification of Functioning, Disability and Health (ICF).
Limitations, only studies published in journals and in English were included in
the systematic review.
Conclusions, studies varied widely in type and rigor of design; subject, constraint, and intervention characteristics; and ICF level for outcome measures. One
outcome measure at the body functions and structure level and 4 outcome measures
at the activity level had large and significant treatment effects (d>.80), and these
findings w^ere from the most rigorous studies. Evidence from more-rigorous studies
demonstrated an increased frequency of use of the upper extremity following CIMT
for children vs^ith hmiplgie CP. The critical threshold for intensity that constitutes
an adequate dose carmot be determined from the available research. Further research
should include a priori power calculations, more-rigorous designs and comparisons
of different components of CIMT in relation to specific children, and measures of
potential impacts on the developing brain.

Post a Rapid Response or

find The Bottom Line:
www.ptjournal. org
1126

Physical Therapy

Volume 89

Number 11

November 2009

CIMT in Children With Cerebral Palsy

ecent studies of constraintinduced movement therapy

(CIMT) support the improvement in use of the affected arm for
adults with stroke'-" and suggest
similar effects in children with
hmiplgie cerebral palsy (CP).^-
Constraint-induced movement therapy is based on studies of young
monkeys in which somatosensory
deafferentation was perfomied on a
single forelimb.^''" Following deafferentation, the monkeys failed to
use the affected forelimb, a phenomenon termed by Taub as "learned
non-use."^'" Wlien the unaffected
forelimb was constrained and could
not be used for ftmctional activities,
the monkeys overcame the learned
non-use. The new ftmctional movements of the deafferented forelimb
were sustained, but only if the period of constraint was greater than 7
days.'" Forced-use therapy for adult
humans was derived from this approach and revealed practical implications for rehabilitation."'^

Shaping techniques and repetitive

practice later were added to constraint.3'3 With shaping, a behavior
was progressively modified toward a
goal through successive approximation and reinforcement. This intervention is now termed "constraintinduced movement therapy."-^'''
Studies performed on monkeys in
utero and shortly after birth supported the idea that forced use or

Available With
This Article at
www.ptjournal.org
Invited Commentary by )eanne
Charles and Steven L. Wolf and
the Author Response
Audio Abstracts Podcast
This article was published ahead of
print on September 3, 2009, at
www.ptjournal. org.

November 2009

CIMT also might be effective early in

development.'"''^ Following deafferentation both in monkey fetuses
and on the day of birth, researchers
restrained the less-affected forelimb
and forced the use of the affected
forelimb with shaping techniques.'^
These newborn monkeys for the
first time were developing the use
of the affected forelimb in contrast
to releaming previous skilled movements, as occurred in the adult monkeys. The young monkeys progressed from a loose, 4-finger grasp
to thumb-forefinger prehension and
could self-feed with the affected
limb. These results supported the hypothesis that children with hemiplegic CP who have not yet developed
skilled arm use, or "developmental
disuse" as described by Gordon and
colleagues,"' also might achieve improved upper-extremity CUE) fonction following forced use or CIMT.
Of note is that the central nervous
system in these young children is still
in the early stages of development.
The impact on the developing brain
of constraining the unaffected limb
and the effects of intense practice on
this immature brain require careftil
study. If "true recovery" as defined
by Krakauer'^ is achieved, then undamaged brain regions may be recruited to support the developing
skills. However, this recruitment in
the developing brain must be understood in light of ftiture neurobiological development. Moreover, compensatory strategies might be
adopted that would allow for improved functional use of the UE,
with potentially little impact on the
underlying developmental neurobiology. Although the majority of pediatric studies emphasize the effects
of CIMT on improving UE ftinction,
there remains a significant gap in our
understanding of the implications of
CIMT for recovery or compensation
in the developing child.
Charles and Gordon^ reviewed 15
studies on the efficacy of CIMT or
Volume 89

forced-use therapy in children with

either traumatic brain injury (TBI) or
CP and suggested that both CIMT
and forced-use therapy were effective for improving UEftmction.However, they did not systematically appraise the validity of the studies or
compute evidence-based statistics.
Evidence-based statistics refer to the
treatment effects calculated from the
studies, such as effect size (ES) or
control and experimental event rate.
A narrative review by Taub et al*"
discussed the origin and mechanism
of pdiatrie and adult CIMT, but did
not systematically review each study
or compute relevant statistics. A
Cochrane review*"' included only 3
randomized controlled trials (RCTs)
and excluded studies that were considered less rigorous.
In this review, we add to the validity
of previous review^s and extend the
scope of review by: (1) appraising
only research on children with hemiplegic CP (previous reviews included subjects with TBI and children with late-onset stroke); (2)
including all published studies regardless of design; (3) applying levels of evidence and validity scores
for all studies; (4) calculating the
evidence-based statistics, as possible;
and (5) applying the International
Classification of Functioning, Disability and Health^*^ (ICF) levels to
all outcome measures. The ICF includes the levels of body ftmctions
and structure, activity, and participation'9 and provides a common language to express outcomes across
studies that used different measures.
Although in the Cochrane review**
the ICF was used to determine inclusion criteria for studies, it was not
used to determine the levels of the
outcomes. The specific objectives of
this review are: (1) to investigate
whether CIMT is supported with
valid research of its effectiveness and
(2) to identify key characteristics of
the child and intervention protocol
associated with effects of CIMT.
Number 11

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CIMT in Children With Cerebral Palsy

Table 1.
Levels of Evidence of Studies"
No. of
Studies

Grade of
Recommendation

Level of
Evidence

la

Systematic review with

homogeneity of RCT

1b

Individual RCT with

narrow confidence
interval

lc

All or none

None

2a

Systematic review of
cohort studies (with
homogeneity)

None

2b

Individual cohort study

(including lowquality RCT; eg,
<80% follow-up)

3a

Systematic review
(with homogeneity)
of case-control
studies

None

3b

Individual case-control
study

Case series (and poorquality cohort and

case-control studies)

Expert opinion without

explicit critical
appraisal on
physiology, bench
research, or "first
principles"

Description

Vaiidity Score
(Out of 16 or 11)

Study
Hoare et al, 2007'''
Hoare et al, 2007.''

11/16
10/16

Taub et al, 2 0 0 4 "

DeLuca et al, 20062''

8/16
7/16
9/16
9/16
8/16

Willis et al, 200221

Eliasson et al, 20052'^
Sung et al, 2 0 0 5 "
Cordon et al, 2006^'
Charles et al, 2006^3

s/n
7/11

Crocker et al, 19973'

Eliasson et al, 2003^8
Naylor et al, 2 0 0 5 "
Charles et al, 20073
Dickerson et al, 200733
Wallen et al, 20082
Charles et al, 200135
Clover et al, 200236
Pierce et al, 20023'
DeLuca et al, 200338
Sutclitfe et al, 20073
Fergus et al, 2008"
Martin et al, 2008"'
Cope et al, 20083"

Levels of evidence are based on Sackett and colleagues' description of levels of evidence and grades of recommendations.^" RCT=randomized controlled
trial.
*" The Cochrane Review' is a summarized version of the Cochrane Systematic Review.*

Method
Objective 1: Investigate Whether
CIMT Is Supported With Valid
Research of Its Effectiveness
Data sources and study selection.
We searched MEDUNE (1966 through
March 2009), Entrez PubMed (1966
through March 2009), EMBASE (1980
through March 2009), CINAHL (1982
through March 2009), PsychlNFO
(1887 through March 2009), and Web
of Science (1900 througli March 2009)
using the key words "hmiplgie,"
"cerebral palsy," "constraint-induced
movement therapy," and "forced-use
therapy." References found in other
l l 28

Physical Therapy

Volume 89

publications also were included, as ap- studies, 5 were RCTs,^'-^' 2 were

propriate. Articles not written in En- nonequivalent pretest-posttest conglish were excluded. Included studies trol group designs,2'^-27 3 were onemet the following criteria: (1) partici- group pretest-posttest designs,'-^"--^*' 3
pants were children with hmiplgie were single-subject research designs
CP (younger than 18 years of age),
,:^'-:^;^ and 8 were case re(2) CIMT or forced-use therapy was
-*! (Tabs. 2, 3, 4, 5, and 6).
used for intervention, and (3) out- The results from the study by
come measures related to the effects Juenger et al''^ were not included in
of CIMT or forced-use therapy.
the tables of this review due to the
age of the subjects (range=10-30
Twenty-one intervention studies and years).
2 systematic reviews met the inclusion criteria (Tab. I).'''' The level of Assessing validity of studies. The
evidence ranged from la to 5 validity of RCTs and nonequivalent
(Tab. l).2o Of the 21 intervention pretest-posttest control group de-

Number 11

November 2009

CIMT in Children With Cerebral Palsy

mediui

No or
Mediu
Small 1 large
Activity
Mediu
Mediu
Large

>.
T3

E E

1 + ++

Activity
EBS
PMAL
TAUT
oo

Activity
BBT
EDPA
WeeFIM

Activity
PDMS
00

Ulili
Ul

Activity
QUEST
PMAL
EBS

iCF Lev eis:

Outcoi
Measui
ength

Body struct ure

Grasp str engt
TPD
MAS
Activity
)-T Test
BOTMP
CFUS

Contre)lled

ndomi;2ed

3U1

S3J

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i
2 S y "

6wk

'1
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so

rsi

hr)

Total
lount
entio

a>

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126

bral

so

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so

126

nj

a.

ro

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Activity
Noeff
Small
Small

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Large
Large

.c

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hil

Q.

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I o 2

rsl

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Cast

VI

VI

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Os

CO

2006

>s
00

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16)
| o

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ra w^

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Tab

H"
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Mov

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Con:

*-0 tii

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(N -

r/d for 1

hr/wk f

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3n abou ime)

r/d for 2
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so

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96 mo

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tz

c
f

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>

Type of
onstraint

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tz

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ubjects

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'id

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Because the scoring protocol was designed for RCTs and nonequivalent
pretest-posttest control group designs, we modified the validity scoring for the studies with one-group
pretest-posttest designs by deleting
categories (D) and (G) (Appendix 2).
These studies were scored 0/1 on an
11-point scale that measLired aspects
of: (A) study population, (B) design,
(C) blinding procedLire, (D) measurement instruments, (E) control of
cointerventions, (F) control for dose
of therapy, and (G) appropriate statistical analysis. The kappa coefficient was used to measure scoring
agreement between raters. Kappa
values for agreement between 2 raters have been categorized as poor
(.00), slight (.01-.20), fair (.21-.40),
moderate (.41-.60), substantial (.61.80), and almost perfect (.81-1.00).''
Nine of these 21 studies were scored
for internal validity (Tabs. 2, 3, and
4) using the scoring protocol for
group designs and included 173 subjects.2i-2:^|> Seven of the 9 studies
were scored out of l6 points,^'-^^
and 2 studies were scored out of 11

*"

Effect
Effect/
of Chai

ial Desi

irectio
e(+/-

e T

;ure

signs (ie, the subjects are not assigned to groups randomly)''-'* using
a between-group comparison was
evaluated by 2 reviewers not blinded
to authors or journals. We used the
scoring protocol developed by
Kwakkel et al'''' and Cambach et al'''
containing l6 items, each scored
0/1, which measured study validity
for the following methodological
categories: (A) randomization, (B)
matching, (C) blinding procedure,
(D) dropouts and intention-to-treat
analysis, (E) characteristics of measurement instruments, (F) control of
cointerventions, (G) comparability
of group characteristics, and (H)
control for dose of therapy (Appendix 1). The protocol was recommended by the Potsdam standards'"^
and other investigators''^''" to identif)' the potential confounders for the
ES of individual studies.

> -

D
CM

.Q

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= . C II

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Volume 89

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Number 1-1

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1129

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for 8 wk)

< .i >
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Body structure
Tardieu Scale
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MAUULF
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COPM
CAS

Activity
I-T Test
BOTMP
CFUS

Body structure
Crip strength
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BOTMP
AMPS
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Effect Size

Body structure
No or small''
No or small''
No or small''
Activity
Large''
Large''
Large''

Activity
Large

Activity

Body Structure

(+/-)

Effect/Direction
of Ciiange

-1-

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'tl + + +
<

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(N=8)

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Splint

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c

ICF Levels:
Outcome Measures

o
a.

Length of
Study

"c

Totai
Amount of
Intervention (iir)

'
Q.

ide

Body structure:
Crasp strength
TPD
MAS
Activity
J-T Test
BOTMP
CFUS

Activity
AHA

ICF Levis:
Outcome Measures

Frequency and
Duration of
intervention Sessions

Lengtii of
Study

.^

Hours/Day
of
Constraint

PT, OT(6hr/dfor lOd)

Functional activities
(2 hr/d for 2 mo)

120

Totai
Amount of
Intervention (hr)

(U

13-18 y

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Constraint

Age of
Subjects

6
S

T3
O

Vaiidity
Score
(Out of 11)

Q.

Sling

y
o

4-13 y

Si

Frequency and
Duration of
intervention Sessions

Hours/Day
of
Constraint

Splint

Type of
Constraint

e
u

18-48 mo

Age of
Subjects

-Pos

Q
Q.

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Evidence

Study

Vaiidity
Score
(Out of 16)

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Evidence

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Behavioral Observation
(eg, reach, grasp)
126
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21 d)

Activity
Activity
QUEST
Functional and
piay activities
(1 hr/d for
4 wk)

12 wk

Spiint

Activity
PDMS-F
4.5
OT, ST, PT (1.5
hr/wk for 3
wk)

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Moreover, when sufficient data (ie,

number or percentage improved in
each group) were provided in the
study, treatment effects were calculated and presented, including the
control event rate, experimental
event rate, number needed to treat,
absolute benefit increase, and relative benefit increase.2"

Activity

Type of
Constraint

c
a>

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Subjects

re

Study
Design

"a
c

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"^ c
J.

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'o

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Levei of
Evidence

where X-,- is the mean result for the

treatment group, X(^ is the mean result in the control group, and sd^,^^i^^,
is the pooled standard deviation.

A-B-A

If means

Hours/Day
of
Constraint

Evidence-based statistics.

and standard deviations were included in the published studies, ES

was calculated using the Cohen d
statistic.5" This ES formula is readily
accepted in the meta-analysis literature and calculated to determine the
overall effect of treatment. It is expressed by the following equation:

Crocker et al,
199731
(N=1)

(U

OO

Splint

ICF Levels:
Outcome Measures
Length
of
Study

-Su
g.
E

Total Amount of
Intervention (hr)

U
u
ai

Frequency and
Duration of
intervention
Sessions

J2
V

Vaiidity
Scores
(Out of
16 or 11)

Of note is that 3 of the RCTs were

assigned level 2b due to the loss of
participants (ie, less than 80% in the
follow-up phase),^' lack of statistical
control at baseline.^' or no reports
regarding the dropouts in the trial or
the lack of blinding of outcome assessors^s (Tabs. 1 and 2).

Effect/Direction
of Change

points.2**-^" This was a sufficient

number of studies to achieve substantial interrater reliability. The remaining 11 studies"-'" were not
scored for internal validity because
the items from the scoring protocol
did not apply to the study designs
(SSRD and case report) (Tabs. 5 and
6). Case reports were systematically
reported as the results of clinical
practice without the application of
inferential statistics. To our knowledge, there is no available validity
scoring for this design.

CIMT in Children With Cerebral Palsy

Volume 89 Number 11

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Physical Therapy

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November 2009

CIMT in Children With Cerebral Palsy

Objective 2: Identify Key
Characteristics of the Child and
Intervention Protocol Associated
With Effects of CIMT
In addition to assessing the validity
of the studies, we recorded: (1) inclusion and exclusion criteria, (2) type
of constraint, (3) duration of constraint, (4) intervention duration,
(5) study duration, and (6) outcomes
measures at the ICF levels. We included the definitions of these features for each study and the rationale
for choosing the definitions. We believe that examining the rationale for
the choices for each component of
CIMT will give the reader insight into which choices might warrant inclusion in future studies and how
the specific children in their clinical
caseloads compare with research
participants.

scores between 5 and 7 of the maximum 11 points28so (Tab. 4).

Effect size. Only 4 studies provided means and standard deviations
to enable computation of Cohen d
and the 95% confidence interval (CI),
for a total of 12 outcome measures22.25,26.5i (Tab. 7). Cohen"'-' defined ES as no effect (d<0.2), small
(0.2<d<0.5), medium (0.5^d<0.8),
and large (d>0.8). We also included
in Table 7 the ES (eta values) published in the studies by Charles
et aPs and Gordon et al.^?

There were 5 ES values at the body

fonctions and structure level, but
only 1 was significant (ie, the CI did
not include zero), and there were 14
ES values at the activity level, with 4
being significant (Tab. 7). All significant ES values were medium to large
Results
(ie, d=0.6-1.6l). Of particular note
Reliability of Scoring
is the significant treatment effect reEach RCT and nonequivalent pretest- ported by Eliasson et aF*- favoring
posttest control group study was the CIMT on the Assisting Hand Asscored by 2 reviewers on the 16 va- sessment (AHA) immediately postlidity items, totaling 112 items treatment (large ES) and sustained at
scored across 7 studies.21-27 Review- 6 months (medium ES).
ers agreed on 82 of the 112 items
scored, for a kappa coefficient of .66. Tlie AHA is currently the only reliable
Reviewers' disagreements were re- and viilid measure used in pdiatrie
solved easily with discussion.
CIMT studies that measures ftinctional
use of the iffected UE in bimanual
There were 22 items scored for the tasks.** Tlie norm-referenced tests
2 studies that used a one-group, evaluating fine motor development
pretest-posttest design.2.3'> Review- (eg, Peabody Developmental Motor
ers agreed on 20 of the 22 items Scale) were used in several studscored, for a kappa coefficient of .76. ies 28,31.38 However, these tests do
not measure the functional use of the
Objective 1: Investigate Whether affected hand in bimanual tasks.
CIMT Is Supported With Valid
Some tests (eg, Pdiatrie Motor AcResearch of Its Effectiveness
tivity Log [PMAL], Emerging BehavValidity scores and study characteris- ior Scale [EBS]) were developed spetics are shown in Tables 2 tlirougli 6. cifically to examine the effects of
CIMT, but the psychometric properValidity scoring. The 7 RCTs and ties of these tests have not been
nonequivalent pretest-posttest con- established.
trol group designs had validity scores
between 7 and U of the maximum A significant treatment effect favor16 points2i-27 (Tabs. 2 and 3). The 2 ing CIMT with a large ES was reone-group designs had validity ported by Charles et aps on the
frequency of use portion of the CareNovember 2009

Volume 89

giver Functional Use Survey. Taub

et aF2 also found significant and
large ES values for amount of use on
the PMAL immediately posttreatment and 3 weeks posttreatment and
for the EBS.
Only the study by Eliasson et aF<^
provided sufficient data for calculating control event rate (0.78), experimental event rate (1), number
needed to treat (5), absolute benefit
increase (0.22), and relative benefit
increase (0.28). The control event
rate and experimental event rate are
determined in order to compute
nimiber needed to treat, which is the
number of children who would need
to be treated to achieve one additional favorable outcome.2" To increase the score on the AHA for children with hmiplgie CP, 5 children
with hmiplgie CP must be treated
with CIMT (2 hours of constraint per
day and 2 hours of intervention per
day for 2 months). The absolute benefit increase is the difference in rates
of positive outcomes between experimental and control subjects in
the same trial,-" and it was 22% in
the study by Eliasson et al.^ The absolute benefit increase is divided by
the control event rate to give the
relative benefit increase, which is
the proportional increase in rates of
positive outcomes between experimental and control subjects in the
same trial (28%).2"
Direction of change results. For
the 16 studies for which ES could not
be calculated, outcome measures
were primarily at the activit)' level
and supported positive change immediately and up to 12 months
postintervention in fine motor and
functional activities (Tabs. 2, 3, 4, 5,
and 6). Change at the body structures and function level was mostly
positive. Three studies measured
changes at the participation level,
with positive changes reported.^y-^^'"

Number 11

Physical Therapy

1133

CIMT in Children With Cerebral Palsy

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LU

1134

Physical Therapy

Volume 89 Number 11

November 2009

CIMT in Children With Cerebral Palsy

Objective 2: Identify Key
Characteristics of the Child and
Intervention Protocol Associated
With Effects of CIMT
Common features of studies.
The following features are summarized by study in Tables 2 through 6:
(1) inclusion and exclusion criteria,
(2) type of constraint, (3) duration of
constraint, (4) intervention duration,
(5) study duration, and (6) outcome
measures at the ICF levels.
Inclusion and exclusion criteria.
Hmiplgie CP was the only consistent criterion across all studies.
There was heterogeneity across the
studies regarding the inclusion criteria (ie, the required minimal wrist
range of motion and UE movement
abilities). Four studies required subjects to have at least 20 degrees of
active extension at the wrist and 10
degrees of active extension at the
metacarpophalangeal joints.23-27,3o,'i i
These were the same criteria for inclusion used in the studies of adults
with stroke, specifically in the EXCITE trial.s"'-52-5'i One study recruited children who were able to
actively extend the affected wrist at
least 10 degrees with finger extension and lift the arm from resting on
a table and place it on a 13-cm-high
box,-'*5 and 2 studies required that
subjects be able to use the affected
extremity only as a gross ftmctional
assist in tasks (eg, reaching) or have
some active wrist or finger extension
of the affected UE.^y.^' Movement
ability was not an inclusion criterion
in the other 14 studies. Three studies
excluded children with severe paralysis of the UE.23.25.27
Only 4 studies addressed the issue of
sensor)' impairments and excluded
children with major sensor)' disorders or vision problems.23'27.3()..si positive outcomes were reported in all 4
studies following implementation of
CIMT. No specific criteria for sensor)' abilities were included in the
other studies.
November 2009

Age and CP severit)' varied across

studies. The association between
subject characteristics and the effects of CIMT has not been systematically evaluated through research.
Type of constraint. There was wide
variability in the t)'pe of constraint,
ranging from a full-arm cast to gentle
parental restraint (Tabs. 2, 3, 4, 5, and
6). Nine studies included a cast as tlie
constraint,^ 1.22.24.25,3'i.3fi,38.39,41 referencing the literature on adults with
stroke in justifying their selection.
Five of the studies used bivalved
casts,22.24.25.3,4i ^nd Cope et aP-*
used a nonremovable cast and determined it was the best method of restraint for the particular child in their
study. Willis et aP' did not bivalve
the cast and reported that several
subjects dropped out of the study
due to the irritability from casting.
Two studies did not provide information regarding the
Wallen et aPy and Pierce et aP^ selected a fabric mitt, with no specified
reason provided. Fergus et al'"' reported that using a soft, removable
mitt provided a simple, easily manipulated constraint. Researchers in 5
studies chose a splint,^''^..? 1,33.36 citing
previous literature. Glover et al^^^ used
2 types of restraint: cast and splint.
Eliasson et al^*"' reported that the splint
restricted use of the unaffected hand
but iillowed for necessary balance reactions. Four studies used a sling
strapped to the child's trunk to prevent bimanual tasks.2327.30,35 Gordon
and colleagues' choice^''' was derived
from positive results of their pilot
studies. The parent gently restrained
the child's unaffected extremit)' in
the study by Naylor and Bower. ^2
Duration of constraint. Constraint
duration ranged from 1 to 24 hours
per day (Tabs. 2, 3, 4, 5, and 6). The
unaffected UE was constrained for at
least 10 hours per day in 11 studies.2i.22,24.25,3i.33,3'f,36-.39 n 9 of tliese

studies, the subjects wore the reVolume 89

straint for 24 hours.2''22,2..25.3-.36-3y

Two studies used a splint continuously except for bathing, sleeping,

and short rests."-'^
The remaining 10 studies used a
constraint
only
during
treatment.2<''-3O32.35,.io,4i,5i Treatment duration in these studies varied from 1
to 7.5 hours per day. The authors
justified the duration of constraint
based on previous studies of adult
and pdiatrie CIMT literature and in
order to create a "child-friendly" intervention. Martin et al'" casted children's affected UE for 4 hours during
therapy and for an additional 3 to 5
hours per day without providing a
rationale. Eliasson et aF^ had children wear a glove for 7 hours,2 and
Eliasson and collegues2f' and Wallen
et al2y had children wear a glove for
2 hours per day.
Intervention duration. Intervention
duration ranged from 1 hour per week
to 7 hours per day (Tabs. 2, 3, 4, 5, :md
6). Ten studies included 6 to 7 hours
of t h e r a p y p e r day.22-2'.27.2H.3.33.35.38.'o

This liigli-intensity intervention was

based on the interventions used in
studies of adult subjects.255-58 DeLuca
et aP' chose tliis intensit)', stating that
the prior pdiatrie literature on CIMT
had yet to match the intensit)' of tlie
studies of adults with stroke. Furthermore, the autliors noted that die intensity used for adults with stroke was
exceeded in order to maximize cortical reorganization, although no su|>
porting data in a pdiatrie population
were provided.
Treatment in the studies by Eliasson
et al2fi and Wallen et aF consisted of
2 hours of therapy per day within the
child's usual environment (ie, at
home or in the preschool setting).
The authors noted that a rich natural
environment was important to facilitate the learning process. Glover et
aP6 applied 2-hour sessions of occupational therapy or physical therapy
as weekday treatment without proNumber 11

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1135

CIMT in Children With Cerebral Palsy

studies measured change at the activity Ievel.2'-537-4i There was little consistency in these 20 studies as to
which activities were assessed. Only 3
studies26.29,39 used the AHA. In addition, 3 saidies measured outcomes at
the participation level by using the Canadian Occupational Performance
Measures (COPM).2'''39,4i A systematic
evaluation of shared and valid outcome measures is critical to understanding the impact of CIMT.

viding a rationale for intervention duration. Nayior and Bower^^ also provided therapy within the home
setting for 1 hour per day, stating
that treatment in the child's natural
environment increased adherence
among parents and teachers, thus decreasing the need for an intense
training schedule in clinical settings.
Pierce et al-^^ included two 1-hour
sessions of physical therapy and two
1-hour sessions of occupational therapy per week (ie, a total of 4 hours of
treatment per week), noting that the
high intensity of treatment in studies
by Taub and colleagues^"" was not
feasible in a managed care environment. Similarly, Cope et al^' applied
a total of 8 hours of treatment per
week. Four studies provided little intervention (eg, 1 hour of physical
therapy or occupational therapy per
week) and assessed the effectiveness
of constraint alone.^c^'i.so.ss The optimal durations of constraint and intervention have not been systematically evaluated.

Discussion

Study duration. Study durations in

19 of the suidies ranged from 6 weeks
to 18 months (Tabs. 2, 3, 4, 5, and
(5)^21-24,26-3537-41 ^jth 2 studies without a follow-up period, only evaluation
immediately after intervention.^5.36
Eight of the 19 suidies used a 6-month
intervention,.26.27,29,31,34,35.39 and the

intervention was of 8 months' duration in 4 studies.2'.22.30,37 Positive effects were demonstrated in most studies up to 6 to 8 months after
Intervention.
Outcome measures. Eight studies
used outcome measures with multiple ICF levels (Tabs. 2, 3, 4, 5, and
6) 23,27-29.35,37,39,41 Eight studies had
o u t c o m e measures at the body functions and structure ievel,23 27-29,35,37,39.41

including functional magnetic resonance imaging (fMRI), muscle tone

(velocity-dependent resistance to
stretch), sensation, grip strength (forcegenerating capacity), 2-point discrimination, and pinch gauge, and 20
11 36

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Volume 89

The Cochrane review,'' which represents the highest level of research

evidence (ie, la), determined that
there was insufficient evidence to
either support or refute the use of
CIMT for children with hmiplgie
CP and that more-rigorous research
was needed and specifically research
with valid outcome measures. However, if we consider studies at all
levels of evidence, as we did in this
systematic review, there is positive
support for the use of CIMT to improve the frequency of use of the
UE for children with hmiplgie
CP. The strongest evidence for this
improvement comes from the 3
RCrs22-2'f aj, I nonequivalent pretestposttest study,2'7 but an increased frequency of use of the UE following
CIMT also was supported in studies
with less-rigorous designs.-^""* Taub
et al22 and Charles et aF demonstrated large ES values for the frequency of use, with the findings
from the study by Charles et aF^ extended to 6 months posttherapy. Of
particular note is that both Charles
et al23 and Gordon et aF^ had only
half of the total time for intervention
(60 hours) and a fourth of the time
wearing the restraint (6 hours per
day) in comparison with the study by
Taub et al22 (total intervention
time=120 hours; restraint time=24
hours per day). It is not apparent
from the available literature whether
even less intervention time and less
time in restraint also could have a
positive and large impact on the fre-

Number 11

quency of use of the UE. This remains an empirical question.

Although improving the frequency
of use of the affected extremity is an
excellent starting point, improving
the quality' of use, particularly for
ftmctional activities, also is an important goal. Charles et aF-^ reported
a large and significant ES for the
quality' of use of the UE on the Caregiver Functional Use Survey (CFUS),
a caregiver questionnaire of UE skills,
although subjects in this study
showed these effects only at 1
month posttreatment and not at 1
week or 6 months posttreatment.
Subjects in the study by Gordon
et aF^ showed a large ES on the CFUS
1 week posttreatment. Taub et al^^
showed a significant and large ES following CIMT on the EBS, which is a
scale that quantifies the number of
different movement patterns that are
observed. This same trend, but without available ES, was demonstrated
by DeLuca et aF* on the EBS.
The most compelling data on the
positive impact of CIMT comes from
the study by Eliasson et aF"' with a
large and sustained ES for the
AHA.'^<''<^2 The AHA measures the
frequency of use of the affected UE
but also captures aspects of quality
of use.''^ This study,^''' however, had
a rather low validity' score (7 of I6)
because it was not an RCT and the
control of cointervention was not adequate. Of importance is that the
constraint was worn for only 2 hours
per day and intervention was 2 hours
per day during the constraint period,
but the treatment was implemented
over a 60-day period. This again
raises the question of what is the
appropriate dose for intervention
and constraint. The critical threshold
for intensity in terms of both number
of hours per day and number of
weeks that constitute an adequate
dose cannot be determined from the
available research.

November 2009

CIMT in Children With Cerebral Palsy

We cannot identify key characteristics of the cliild and intervention protocol associated with effects of
CIMT. The reviewed studies have
few common features regarding the
method. However, based on the current findings, all future CIMT studies
could calculate power a priori in
order to have a sufficient sample
size. Although no a priori power calculations were reported or provided
in the reviewed studies,22,23,25.2rt ji^g
actual statistical power can be computed from the numbers of subjects
and the reported means and standard
deviations in the studies. The results
show that outcomes at the body
functions and structure and activity
levels have power between 50% and
70% and 80% and 95%, respectively.
Thus, for example, to provide 80%
statistical power and a medium to
large ES (d=0.8) at the activity' level,
a CIMT RCT design study would require at least 20 subjects in the treatment group and 20 subjects in the
control group.

Impact on the Developing Brain

As mentioned in the introduction to
this review, Krakauer'"' described
true recovery in contrast to compensation in motor learning. True recover)' involves recruiting the undamaged brain regions to control the
muscles previously used for a movement. Compensation, in contrast, involves the use of different muscle
groups to achieve the same movement goal.'7 The use of inappropriate compensatory strategies may
limit development or recovery in
children or adults after neurological
impairments.''-^'^'' The effects of
CIMT on the brain that result in either true recovery or compensation
require more-detailed analysis, particularly for the developing brain.
The impact of CIMT on undamaged
brain regions during development
remains largely unknown, and the
potential impact may differ with the
stage of development during which
CIMT is applied.5
November 2009

To our knowledge, only 2 studies

have investigated the potential cortical changes from CIMT in children.:^y''2 Sutcliffe et ais reported
the effects of cortical reorganization
in an 8-year-old child with hemiplegic CP following a 3-week CIMT intervention (24 hours of constraint
per day, 1 hour of therapy per
week). The results of fMRI indicated
increased bilateral cortical activation
in the sensorimotor cortex of the affected UE after therapy and a shift in
laterality from the ipsilateral hemisphere to the contralateral hemisphere. Modified CIMT led to increased activity of the contralateral
somatosensor>' cortex. Sutcliffe and
colleagues-^5 also found increased
cortical activation in the ipsilateral
motor cortex and contralateral somatosensory cortex after therapy.
These cortical changes were associated with improvements in clinical
measures and persisted at 6 months.
Juenger et al'''2 also reported increased fMRI activations in the primary sensorimotor cortex of the lesioned hemisphere in 3 children
with congenital hemiparesis (age
range =12-16 years) after a 12-day
CIMT intervention (10 hours of constraint per day, 2 hours of therapy
per day), suggesting that these results supported the mechanism of
cortical reorganization for improvements of UE ftinction after modified
CIMT.

ticospinal projection from the Iesioned hemisphere after transcranial

magnetic stimulation. The organization of the corticospinal system in
children with hmiplgie CP is characterized by the loss of motor responses of the lesioned side and
emergenee of bilateral responses
from the unlesioned side. However,
the authors did not specify whether
the unlesioned hemisphere was the
dominant hemisphere.
Preliminar}' work by Kuhnke and
colleagues'^^' with adolescents with
congenital hemiparesis suggests that
individuals with preserved crossed
eortical projections versus ipsilatenil
projections may have different outcomes from CIMT. Although both
groups of subjects had significant improvements of UE function, subjects
witli preserved crossed cortical projections perfomied the relatively short
tasks of the Wolf Motor Function Test
more rapidly compared with tliose
with ipsilatenil projections. Constniintinduced movement therapy might influence interhemispheric iiihibition by
reducing cortic;il activity in the unlesioned hemisphere O^y constniining
tlie un:iffected UE), while increasing
cortical activify in tlie lesioned hemisphere (by implementing the intensive
intervention).''''^ Nevertheless, it is still
unclear whether similar results will
be found in children witli congenital
hemip:iresis. Thus, Hoare''' recommends stratification on cortical-spinal
organization for ftiture studies of congenital hemiplegia.

Eyre et aK'5 suggested that due to the

loss of competition from the lesioned hemisphere in children with
hmiplgie CP, the unlesioned hemi- Future Research
sphere might have acquired bilateral There have been insufficient studies
organization. They found that trans- systematically comparing the critical
cranial magnetic stimulation of the variables of duration and type of conunlesioned hemisphere evoked bi- straint and the duration and type of
lateral motor responses in 10 chil- intervention using valid and reliable
dren with hmiplgie CP (median outcome measures. The future direcage=11.5 years), demonstrating per- tion for CIMT studies is to develop
sistence of ipsilateral and contralat- further good-quality research with a
eral corticospinal projections from priori power calculations to examthe unlesioned hemisphere. There ine the different features of CIMT,
was only a sparse contralateral cor- including the effectiveness of the reVolume 89

Number 11

Physical Therapy

1137

CIMT in Children With Cerebral Palsy

7 Hoare BJ, Wasiak J, Imms C, Carey L.
Constraint-induced movement therapy in
the treatment of the upper limb in children with hmiplgie cerebral palsy. Cochrane Database SystRev. 2007;2:CD004l49.

straint and the frequency and duration of the intervention sessions.

Measures at the participation level of
the ICF also should be included in
future studies, as well as an elucidation of the relationships among ICF
levels. Finally, there has been insufficient investigation of the potential
central nervous system changes that
may ensue from constraining the extremity of a developing child to support the use of prolonged constraint
of an unaffected extremity. Research
using CIMT should incorporate outcome measures of the effects on the
developing brain to guide best physical therapist practice.

8 Taub E, Griffin A, Nick J, et al. Pdiatrie CI

therapy for stroke-induced hemiparesis in
young children. Dev Neurorehabil. 2007;
10:3-18.
9 Taub E. Movement in nonhuman primates
deprived of somatosensory feedback. Exerc
Sports Sei Rev. 1976;4:335-374.
10 Taub E. Somatosensory deafferentation research with monkeys: implications for rehabilitation medicine. In: Ince LP, ed. Behavioral Psychology in Rehabilitation
Medicine: Clinical Applications. Baltimore,
MD: WiUiams & Wilkins; 1980:371-401.
11 Wolf SL, Lecraw DE, Barton LA, Jann BB.
Forced use of hmiplgie upper extremities to reverse the effect of learned nonuse
among chronic stroke and head-injured
patients. Exp Neurol. 1989;104:125-132.

Ms Huang and Dr Fetters provided concept/

idea/research design and project management. All authors provided writing, data collection and analysis, and consultation
(including review of manuscript before
submission).
Tliis articie was received Aprii 14, 2008, and
was accepted juiy IS, 2009.

DOI: 10.2522/ptj.20080m
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31 Crocker MD, MacKay-Lyons M, McDonnell
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32 Naylor CE, Bower E. Modified constraintinduced movement therapy for young
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33 Dickerson AE, Brown LE. Pdiatrie
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36 Glover JE, Mateer CA, Yoell C, Speed S.
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37 Fierce SR, Only K, Gallagher KG, et al.
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Ineorporating variations in the quality of
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48 Jenicek M. Meta-analysis in medicine:

where we are and where we want to go.
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59 Taub E, Morris DM. Constraint-induced

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3:279-286.

39 Sutcliffe TL, Gaetz WC, Logan WJ, et al.

Cortical reorganization after modified
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Pediatr Phys Wer. 2008;20:271-283.
41 Martin A, Burtner PA. Poole J, Phillips J.
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42 Juenger H, Linder-Lucht M, Walther M,
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Clinical Research: Applications to Practice. 2nd ed. Englewood Cliffs, NJ: Prentice Hall; 2000:196-197.
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45 Cambach W, Wagenaar RC, Koelman TW,
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49 Landis JR, Koeh GG. The measurement of

observer agreement for categorical data.
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52 Taub E, Uswatte G. Constraint-induced
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53 Winstein CJ, Miller EA, Blanton S, et al.
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investigate the effect of constraintinduced movement therapy in improving
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Effects of eonstraint-induced movement
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60 Taub E, Crago JE, Uswatte G. Constraint

induced movement therapy: a new ap.
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Appendix 1.
Scoring Protocol'"'-''^."
Criteria for operationalization:

Methodological aspect:

Operationalization
(yes=1/no=0)

1. concealed allocation is applied (ie, sealed envelopes)

1. D = 1 D = 0

2. random sequence generation is applied (Ie, random

numbers table, coin tossing, computer random
numbers or shuffling)

2. D = 1 D = 0

B. Matching procedure is adequate if:

3. patients are matched according to relevant patient

characteristics (ie, age, type of stroke, initial activities
of daily living score, and time since stroke onset)

3. a = 1 D = 0

C. Bunding procedure is adequate if:

4. observer(s) are kept unav\/are of the groups to which

patients have been assigned

4. D = 1 D = 0

5. those performing statistical analysis are kept unaware

of the groups to which patients have been assigned

5. D = 1 D = 0

6. patients are kept unaware with respect to the

condition to which they have been assigned

6. D = 1 D = 0

7. the number of dropouts is described for each group

separately

7. D = 1 D = 0

8. the number of intercurrent dropouts is described for

each group separately

8. D = 1 D = 0

A. Randomization procedure is adequate if:

D. Dropouts and intention-to-treat analysis are adequate if:

9. intention-to-treat analysis has been applied

9. D = 1 D = 0

10. statistically significant test-retest correlation coefficients

and/or intraobserver/interobserver reliability of relevant
measurement instruments have been reported by the
authors or have been established in studies that are
cited by the authors

10. D = 1 D = 0

11. the relevant measurement instruments are compared

statistically with other instruments measuring the same
modality by the authors or in studies reported by the
authors

11. D = 1 0 = 0

12. other cointerventions leading to systematic differences

in results are avoided

12. 0 = 1 0 = 0

13. adjunctive (medical) interventions are reported for

each individual separately

13. D = 1 0 = 0

C. Comparability of patients characteristics is adequate if:

14. relevant patient characteristics (ie, initial activities of

daily living score, type of stroke, age, and time since
stroke onset) are not statistically significantly different
between experimental and control groups

14. O = 1 0 = 0

H. Control for dose of therapy is adequate if:

15. predetermined rehabilitation time (in minutes or

hours) and/or number of exercises and/or dosage of
applied exercises have been reported in experimental
and control groups

15. o = 1 0 = 0

16. actual rehabilitation time spent (in minutes or hours)

and/or number of exercises and/or dosage of applied
exercises have been reported in experimental and
control groups

16. O = 1 0 = 0

E. Measurement instruments are adequate if:

F. Controi of cointervention(s) is adequate if:

E Control for measurement error: A test was considered to be reliable if test-retest correlation coefficient and/or interobserver reliability and/or
intraobserver reliability was significant according to the authors or according to the studies that were cited by the authors. The (construct) validity of a
measurement instrument was considered to be demonstrated if a significant relationship between this instrument and a "gold standard" had been
established according to the authors or according to the studies that were cited by the authors. F. Control for cointervention: Control for adjunctive
(medical) cointervention was judged to be adequate (score 1) if: (1) trials in which other interventions were avoided or (2) trials in which data on
cointervention were presented were not significantly different between groups (P<.05). H. Control for dose therapy: Dose of therapy was judged to be
monitored adequately if predetermined (15) and actual rehabilitation time spent (16) were reported in experimental and control groups. Repnnted with
permission from: Kwakkel C, Wagenaar RC, Koelman TW, et al. Effects of intensity of rehabilitation after stroke: a research synthesis. Stroke. 1997;28:15501556.

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Appendix 2.
Modified Scoring Protocol"
Methodological aspect:
A. Study population is adequate if:

Criteria for operationaiization:

Operationaiization

1. a representative sample is selected from a relevant

population

1. G = l

2. description of inclusion and exclusion criteria, baseline

characteristics, and/or pretest are applied

2. G = 1 G = 0

G=0

B. Design procedure is adequate if:

3. the follow-up is long enough for important events to occur

3. G = 1 G = 0

C. Blinding procedure is adequate if:

4. observers are kept unaware of the objective of the study

4. G = 1 G = 0

D. Measurement instruments are adequate if:

5. statistically significant test-retest correlation coefficients

and/or intraobserver/interobserver reliability of relevant
measurement instruments have been reported by the
authors or have been established in studies that are cited
by the authors

S. G = l

6. the relevant measurement instruments are compared

statistically with other instruments measuring the same
modality by the authors or in studies reported by the
authors

6. G = 1 G = 0

E. Control of co-intervention(s) is adequate if:

7. other cointerventions leading to systematic differences in

results are avoided

7. G = 1 G = 0

F. Control for dose of therapy is adequate if:

8. adjunctive (medical) interventions are reported for each

individual separately

8. G = 1 G = 0

9. predetermined rehabilitation time (in minutes or hours)

and/or number of exercises and/or dosage of applied
exercises have been reported

9. G = 1 G = 0

C. Statistical analysis is appropriate if:

G=0

10. actual rehabilitation time spent (in minutes or hours) and/or

number of exercises and/or dosage of applied exercises
have been reported for each individual

10. G = 1 G = 0

11. parametric or nonparametric, single-subject statistics are

applied

11. G = 1 G = 0

" Modification from Kwakkel et al.'"'

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