544982

research-article2014
CRE0010.1177/0269215514544982Clinical RehabilitationChen et al.

CLINICAL
Article REHABILITATION

Clinical Rehabilitation

Effectiveness of constraint-induced 2014, Vol. 28(10) 939953

The Author(s) 2014
Reprints and permissions:
movement therapy on upper- sagepub.co.uk/journalsPermissions.nav
DOI: 10.1177/0269215514544982

extremity function in children with cre.sagepub.com

cerebral palsy: a systematic review

and meta-analysis of randomized
controlled trials

Yu-ping Chen, Stephanie Pope, Dana Tyler and

Gordon L Warren

Abstract
Objective: To systematically examine the research literature on the effectiveness of constraint-induced
movement therapy on improving arm function in children with cerebral palsy, and to assess the association
between the study effect size and the characteristics of the patients and intervention protocol.
Data sources: A systematic literature search was conducted in PubMed, PsycINFO, Cochrane, CINAHL,
Web of Science, and TRIP Database up to May 2014.
Review methods: Studies employing randomized controlled trial design, children with cerebral palsy,
comparing constraint-induced movement therapy with another intervention with a focus on arm function,
and upper-extremity measures were included in this review. Methodological quality was evaluated using
the Physiotherapy Evidence-based Database (PEDro) scale.
Results: The literature search resulted in 27 randomized controlled trial studies with good methodological
quality that compared constraint-induced movement therapy with other intervention therapy. Overall,
constraint-induced movement therapy provided a medium beneficial effect (d=0.546; p<0.001)
when compared with conventional therapy. For the subgroup analyses, presence of a dose-equivalent
comparison group, intervention location, and time of follow-up were significant factors. Studies examining
constraint-induced movement therapy effect without a dose-equivalent comparison group showed a large
effect in children with cerebral palsy, but studies with a dose-equivalent group only showed a small effect.
Children who received home-based constraint-induced movement therapy had a better improvement in
arm function than those who received constraint-induced movement therapy elsewhere.
Conclusion: The research literature supports constraint-induced movement therapy as an effective
intervention to improve arm function in children with cerebral palsy.

Department of Physical Therapy, Georgia State University, Corresponding author:

Atlanta, GA, USA Yu-ping Chen, Department of Physical Therapy, Georgia State
University, PO Box 4019, Atlanta, GA 30302-4019, USA.
Email: ypchen@gsu.edu
940 Clinical Rehabilitation 28(10)
Keywords
Cerebral palsy, constraint-induced movement therapy, upper extremity (arm), meta-analysis, systematic
review
Received: 23 December 2013; accepted: 3 July 2014
Introduction
Constraint-induced movement therapy has recently
become a popular intervention for arm function
training in children with hemiplegic cerebral
palsy.13 There have been some attempts at reviewing
the efficacy of constraint-induced movement therapy
in improving arm function in children with hemiple-
gic cerebral palsy,46 but included very few rand-
omized controlled trials (RCTs) (37 RCTs only). To
the best of our knowledge, no systematic reviews
using a meta-analytic method to examine the effec-
tiveness of constraint-induced movement therapy in
children with cerebral palsy have been published. In
addition, 35 studies using RCT design have been
published since the databases were accessed for the
two most recently published systematic reviews.5,6
Thus, this review was designed to clarify the effects
of constraint-induced movement therapy on arm
function in children with cerebral palsy using a rigor-
ous systematic review and meta-analytic approach.
We expanded upon previous systematic reviews by:
(1) adding more studies; (2) quantifying effect sizes
(Cohens d) of constraint-induced movement ther-
apy; and (3) using the International Classification of
Functioning, Disability, and Health levels (ICF)
model to classify outcome variables and then com-
bine the outcome measures.7 We also attempted to
explain the between-study variance in effect size by
examining the effects of various factors, including
key characteristics of the children (e.g. age) and
aspects of the intervention protocol (e.g. constraint-
induced movement therapy setting, restraint type,
restraint duration, constraint-induced movement
therapy dosage).
Methods
Two of the authors independently conducted sys-
tematic literature searches in January 2012, January
2013, October 2013, and again in May 2014, using
the electronic databases: PubMed, PsycINFO,
Cochrane Central Register of Controlled Trials,
CINAHL, Web of Science and Trip Database, as
well as a manual search of the reference lists of
each article. The keywords or mesh terms (if appli-
cable) used for the search were: constraint-induced
movement therapy, constraint induced therapy,
forced use therapy, and cerebral palsy. References
found in publications such as review articles were
also considered for inclusion.
Studies meeting the following criteria were con-
sidered for review: (1) the study was conducted in
children with cerebral palsy (aged between birth
and 21years old); (2) the study compared con-
straint-induced movement therapy with another
therapy, such as bimanual intensive therapy, or
conventional rehabilitation, which emphasized
upper-extremity training; (3) the outcome meas-
ures used in the study were related to arm function;
(4) the study was an RCT; and (5) the study was
written in English. Studies were excluded if the
study did not compare constraint-induced move-
ment therapy with another therapy (e.g. only com-
pared three-week constraint-induced movement
therapy against six-week constraint-induced move-
ment therapy) or the study did not provide suffi-
cient data to compute the effect size (e.g. no
standard deviations).
A data extraction form was used to code the
demographic, methodological, medical, and mis-
cellaneous variables extracted from each RCT
included in the review. Demographic and medical
variables included childrens age, gender, diag-
nosis, severity, cognitive status, and lesion side.
Sample size, instruments used as outcome meas-
ures, restraint type, restraint duration, constraint-
induced movement therapy dosing (session
Chen et al. 941
intensity, duration, frequency, and total accumu-
lated constraint-induced movement therapy dura-
tion), comparison therapy type, dosing in
comparison therapy, and time of follow-up were
coded as methodological characteristics. Year
and type of publication, names of authors, and
country and affiliation of the authors were
included in the miscellaneous section.
The quality of RCTs was evaluated using the
Physiotherapy Evidence-Based Database Scale
(PEDro: www.pedro.fhs.usyd.edu.au). The PEDro
scale includes 11 items, in which the first item
assesses the external validity and the remaining 10
items assess the internal validity, examining ran-
dom allocation, concealment of allocation, baseline
equivalence, blinding procedure, intention to treat
analysis, adequacy of follow-up, between-group
statistical analysis, and measurement of data varia-
bility. This scale yields a total possible score of 10
points for the evaluation of internal validity, with a
score of 910 considered methodologically excel-
lent, 68 good, 45 fair, and less than 4 poor.8 week; (7) constraint-induced movement therapy
Data analysis
The outcome measures of each RCT were con-
verted to a standard format by calculating the
standardized mean difference (Cohens d), which is
referred to as effect size throughout this review.9,10
If the RCT reported Cohens d in the results, we
used that value and calculated the study variance
based on effect sizes and sample sizes. Because
correlations of pre- and postintervention measure-
ments were not reported in any study, we used the
postintervention mean and standard deviation data
to compute effect size using the equation: (mean of
constraint-induced movement therapy compari-
son mean) divided by the pooled standard devia-
tion. If more than one outcome measure was used
in an RCT, the effect size for each outcome meas-
ure was computed separately and then the multiple
effect sizes were averaged together to represent the
overall effect size of each RCT. In addition, the
outcome measures of each RCT were also classi-
fied based on the ICF model,7 and then the multiple
effect sizes of the same ICF level within a study
were averaged to represent the effect size of the
specific ICF level in each RCT.
Meta-analyses were run with a random-effects
model that accounted for true inter-study variation
in effects, as well as for random error within studies.
A random-effect model was chosen over a fixed-
effect model, because of the wide variation in exper-
imental factor levels (e.g. constraint-induced
movement therapy dosage, restraint duration, chil-
drens age) used in the included studies. We also
sought to determine the role of experimental factors
in explaining the considerable inter-study variation
observed in effect size. These experimental factors
can be treated as moderator variables in a meta-
analysis. Meta-regressions (using a method-of-
moments model) for continuous variables or sub-
group meta-analyses for categorical variables were
used to examine the following potential moderator
variables: (1) presence or not of a dose-equivalent
comparison group; (2) childrens age; (3) restraint
type; (4) restraint duration; (5) constraint-induced
movement therapy daily session intensity; (6) con-
straint-induced movement therapy frequency per
length in weeks; (8) total accumulated constraint-
induced movement therapy duration; (9) location of
training (e.g. laboratory or home); and (10) time of
follow-up.
Meta-analyses and meta-regressions were con-
ducted using the Comprehensive Meta-analysis
software (Version 2.2; Biostat Inc., Englewood,
NJ). An value of 0.05 was used for significance
in all analyses. Effect sizes were interpreted using
Cohens convention as small (0.2), medium (0.5),
or large (0.8). The effect of publication bias on the
primary meta-analyses was addressed by combin-
ing a funnel plot assessment with the Duval and
Tweedies trim and fill correction.11 This is a pre-
ferred method for assessing the extent of publica-
tion bias, as well as for making a correction to the
overall effect size.
Results
A total of 141 published studies were found from
the database searches. After reviewing abstracts
and titles, 40 RCTs,2,3,1249 16 reviews,46,5062 and
two clinical guidelines63,64 related to constraint-
induced movement therapy use in cerebral palsy
were selected for full-text review. One additional
942 Clinical Rehabilitation 28(10)
Pooled papers from search of
electronic databases using
keywords (n=141)
Titles or abstracts
not pertaining to the
research purpose.
Excluded (n=73)
40 RCTs, 16 reviews, and 2
clinical guideline related to
constraint-induced movement
therapy in cerebral palsy
1 additional RCT
article from the
reviews
Potentially relevant RCT articles for full text evaluation
(n=41)
Studies that did not
meet the inclusion
criteria (n=12)
Two studies reported
the same children in
4 articles (n=2)
Final included RCTs for meta-analysis computation (n=27)
Figure 1. A flow diagram of the number of studies
identified, the number excluded, and the final number
of studies included in this meta-analysis.
RCT study was added after reading previously
published reviews.65 Thus, a total of 41 RCT stud-
ies were retrieved for full evaluation (see Figure 1).
Among the 41 studies, 12 studies were excluded:
four studies3,43,47,48 reported the same participants
and outcome measures as in other articles;26,31,32
four studies40,41,45,46 did not include a comparison
group that received traditional therapy; and four
studies2,39,42,65 did not provide sufficient data to
compute an effect size, which did not meet our
inclusion criteria. Therefore, a total of 29 articles
were included for data extraction.1238,44,49 During
data extraction, two studies were found to report
their outcome measures in multiple articles;12,13,31,32
therefore, their outcome measures were merged
and treated as the same studies. The final number
of RCTs included in this review was 27, published
between 2004 and 2014.
Description of the studies
The characteristics of these studies are summarized
in Tables 1 and 2 and Supplementary Table 1,
available online. There were 894 participants in the
27 studies. The average age of participants ranged
from 2.4 to 10.7years. The restraint types used in
the studies included slings, glove, mitten, and cast.
The restraint duration over the entire study ranged
from 16 to 1008hours, whereas the daily dose
ranged from 0.5 to 6hours. Intervention length
ranged from 2 to 10weeks, with the majority of the
studies having an intervention length around two to
three weeks. Intervention frequency ranged from
two to seven days a week, with the majority of the
studies having a frequency of about five days a
week. The PEDro quality scores for the studies
ranged from 5 to 9 (with only one article with a
score of 5), indicating that the quality of the RCTs
included in this meta-analysis was good to excel-
lent. There were 15 studies that had a matched-
dose comparison group, while 12 studies did not.
Several measures of arm function were used in the
studies, including the Canadian Occupational
Performance Measure (COPM), the Quality of
Upper Extremity Skills Test (QUEST), the Jebsen-
Taylor Hand Function Test (JTHF), the Melbourne
Assessment of Unilateral Upper Limb Function
(Melbourne), the Bruininks-Oseretsky Test of
Motor Proficiency (BOTMP), the Assisting Hand
Assessment (AHA), range of motion, and reaching
kinematics (e.g. movement time, trajectory
smoothness).
We used the ICF model to group outcome vari-
ables (see Supplementary Table 1, available
online). For example, COPM was categorized at
ICFs participation level; QUEST, Melbourne,
AHA were at activity level; and reaching kinemat-
ics were at body structure and function level.
Among the studies used in this meta-analysis, the
majority (12 studies) included outcome variables
Table 1. Characteristics of the constraint-induced movement therapy and cerebral palsy studies that met the inclusion criteria of this meta-analysis.

Study Mean age (years) Number of Comparison group therapy Equivalent dose Country of authors
subjects content between CIMT and
Chen et al.

comparison group
Aarts et al., 2010, 201112,13 4.93 28 CIMT Usual care + home programme Yes Netherlands
22 comparison
Al-Oraibi et al., 201114 4.72 7 CIMT NDT No Jordan
7 comparison
Charles et al., 200615 6.67 11 CIMT Ordinary therapy No USA
11 comparison
Chen et al., 201216 8.75 24 CIMT Traditional rehabilitation Yes Taiwan
23 comparison
Choudhary et al., 201217 5.04 16 CIMT Conventional therapy No India
15 comparison
de Brito Brandao et al., 201019 5.82 8 CIMT Regular OT No Brazil
7 comparison
de Brito Brandao et al., 201218 6.24 8 CIMT Bimanual HABIT Yes USA
8 comparison
Deppe et al., 201320 6.33 16 CIMT Intensive bimanual therapy Yes Germany
13 comparison
El-Kafy et al., 201449 6.10 14 CIMT Non-structured movement therapy Yes Egypt
13 comparison
Eliasson et al., 201121 2.39 12 CIMT Ordinary therapy No Sweden
13 comparison
Eugster-Buesch et al., 201222 10.68 12 CIMT Regular therapy No Switzerland
11 comparison
Facchin et al., 201123 7.92 39 CIMT Traditional therapy No Italy
33 comparison
Fedrizzi et al., 201224 7.92 39 CIMT Traditional therapy No Italy
33 comparison
Geerdink et al., 201325 4.93 28 CIMT Usual care + home programme Yes Netherlands
22 comparison
Gordon et al., 201126 6.35 21 CIMT Bimanual HABIT Yes USA
21 comparison
Hoare et al., 201344 2.98 17 CIMT Bimanual occupational therapy Yes Australia
17 comparison
943

(Continued)
 944

Table 1. (Continued)
Study Mean age (years) Number of Comparison group therapy Equivalent dose Country of authors
subjects content between CIMT and
comparison group
Hsin et al., 201227 6.9 11 CIMT Traditional rehabilitation Yes Taiwan
11 comparison
Hung et al., 201128 6.9 10 CIMT Bimanual HABIT Yes USA
10 comparison
Lin et al., 201129 6.63 10 CIMT Control Yes Taiwan
11 comparison
Rostami et al., 201230 8.17 8 CIMT Regular therapy No Iran
8 comparison
Sakzewski et al. 2011, 201231,32 10.12 32 CIMT Bimanual Yes Australia
30 comparison
Smania et al., 200933 3.33 10 CIMT Conventional therapy Yes Italy
10 comparison
Sung et al., 200534 3.12 18 CIMT Control No Korea
13 comparison
Taub et al., 200436 3.44 9 CIMT Conventional therapy No USA
9 comparison
Taub et al., 201135 3.65 10 CIMT Usual care No USA
10 comparison
Wallen et al., 201137 4.05 25 CIMT Intensive occupational therapy Yes Australia
25 comparison

Xu et al., 201238 4.55 22 CIMT Occupational therapy Yes China

23 comparison

CIMT: constraint-induced movement therapy; NDT: neurodevelopmental therapy; HABIT: Hand-Arm Bimanual Intensive Therapy; OT: Occupational Therapy.
Clinical Rehabilitation 28(10)
Chen et al. 945
in activity level, five studies contained activity and
participation levels, five contained body structure
and activity levels, one contained participation
level only, one contained body structure level, and
three included all three levels.
Overall effect of constraint-induced
movement therapy
Across all studies, there was a medium effect
(d=0.546; p<0.001) of constraint-induced move- Discussion
ment therapy on arm function in children with cer-
ebral palsy. The individual study and overall effect
sizes are illustrated in the forest plot in Figure 2.
We found moderate heterogeneity among the stud-
ies as the value of I2 was 53% (Q =55.74,
p=0.0006).
When effect sizes were broken down based on
the classification of outcomes using the ICF model,
a medium effect (d=0.641) was found at posttest
for activity level, and small effects were found for
participation, and body structure and function lev-
els (d=0.306 for participation and d=0.486 for ticipation) immediately after the intervention; a
body structure and function). During follow-up, a
medium effect (d=0.600) was found for participa-
tion level, and small effects were found for activity,
and body structure and function levels (d=0.394
for activity and d=0.279 for body structure and
function) (see Table 3 for details).
Publication bias was assessed by examining a
funnel plot of standard error vs. effect size. Minor
asymmetry was noted in the plot, and thus a Duval
and Tweedies trim and fill correction to the overall
effect size was calculated. This correction shifted
from 0.546 to 0.365.
Subgroup meta-analyses and meta-
regression analyses
Presence or absence of a dose-equivalent compari-
son group, constraint-induced movement therapy
location, and time of follow-up were significant
factors (p<0.05) (see Supplementary Table 2,
available online). Studies with a dose-equivalent
comparison group had a smaller effect size than
studies without a dose-equivalent comparison group
(See Figure 3). Home-based constraint-induced
movement therapy and clinic-based constraint-
induced movement therapy had a larger effect size
than camp-based constraint-induced movement
therapy. Meta-regression analysis also showed a
statistically significant negative linear relationship
between time of follow-up and study effect size
(p<0.05): the longer the follow-up time, the
smaller the effect size.
In general, when combining all outcome measures
and evaluation time points of all studies, constraint-
induced movement therapy had a medium effect in
improving arm function in children with cerebral
palsy (d=0.546). The effect was similar to the
effect of constraint-induced movement therapy
when used in adults with stroke (d=0.44).66,67
When outcome measures were examined based on
the ICF model, a medium effect size was found for
activity level and a small effect size for the other
two levels (body structure and function, and par-
medium effect size for participation level and a
small effect size for the other two levels (body
structure and function, and activity) were found
during follow-up. This suggests that improvements
in activity level may be prominent in a short period
of time but may disappear without continuous
practice, while improvement in participation level
may require extended time, and therefore showed
up only during the follow-up period. This finding is
similar to findings on the use of constraint-induced
movement therapy in adults with stroke.66,67
Previous systematic reviews of the effectiveness
of constraint-induced movement therapy on chil-
dren with cerebral palsy were unable to identify
associations among study effect size, childrens
characteristics, and intervention protocol (e.g.
Huang et al.,;5 Sakzewski et al.,;55 Hoare et al.,4).
Because a greater number of RCTs was included in
this meta-analysis, we found that intervention loca-
tion, time of follow-up, and presence of a dose-
equivalent comparison group had significant
associations with study effect size.
In terms of intervention setting, home-based
constraint-induced movement therapy had a larger
Table 2. Restraint type, restraint duration, constraint-induced movement therapy intervention protocol (i.e. duration, intensity), and intervention
946

location for individual studies.

Study Restraint type Restraint duration CIMT protocol Total CIMT Location
duration in
hours
Aarts et al., 2010, 201112,13 Slings 3 hours/day 3 days/week 8 3 hours/day 3 days/week 8 72 Clinic
weeks weeks
Al-Oraibi et al., 201114 Glove 2 hours/day 6 days 8 weeks 2 hours/day 8 weeks 96 Home
(actual 92.2 hours)
Charles et al., 200615 Slings 6 hours/day 5 days 2 weeks 6 hours/day 5 days 2 weeks 60 Camp
Chen et al., 201216 Mitten 3.54 hours/day 7 days/week 3.54 hours/day 2 days/week 105 Home
4weeks 4 weeks
Choudhary et al., 201217 Slings 2 hours/day 10 days 2 hours/day 10 days 20 Clinic
de Brito Brandao et al., 201019 Splint 10 hours/day 10 days 3 hours/day 5 days/week 2 30 Clinic
weeks
de Brito Brandao et al., 201218 Slings 6 hours/day 5 days 3 weeks 6 hours/day 5 days 3 weeks 90 Camp
Deppe et al., 201320 Elastic bandage 4 hours/day 5 days 3 weeks 4 hours/day 5 days 4 weeks 80 Clinic
El-Kafy et al., 201449 Slings 6 hours/day 5 days 4 weeks 6 hours/day 5 days 4 weeks 120 Clinic &
home
Eliasson et al., 201121 Glove+splint 2 hours/day 2 months 2 hours/day 2 months 120 Home
Eugster-Buesch et al., 201222 Removable velcro cast 6 hours/day 14 days 6 hours/day 14 days 84 Home
Facchin et al., 201123 Glove+splint 3 hours/day 7 days/week 10 3 hours/day 7 days/week 10 210 Clinic
weeks weeks
Fedrizzi et al., 201224 Glove+splint 3 hours/day 7 days/week 10 3 hours/day 7 days/week 10 210 Clinic
weeks weeks
Geerdink et al., 201325 Slings 3 hours/day 3 days/week 8 3 hours/day 3 days/week 8 72 Clinic
weeks weeks
Gordon et al., 201126 Slings 6 hours/day 5 days 3 weeks 6 hours/day 5 days 3 weeks 90 Camp
Hoare et al., 201344 Glove 3 hours/day 7 days 8 weeks 1 hour/day 2 days 8 weeks 16 Clinic
Hsin et al., 201227 Glove 3.5 hours/day 4 weeks 3.54 hours/day 2 days/week 105 Home
4 weeks
Hung et al., 201128 Slings 6 hours/day 5 days 3 weeks 6 hours/day 5 days 3 weeks 90 Camp
Lin et al., 201129 Elastic bandage 3.54 hours/day 7 days/week 3.54 hours/day 2 days/week 105 Home
4 weeks for both groups + 4 weeks
CIMT training time
Clinical Rehabilitation 28(10)
 Chen et al.

Table 2. (Continued)

Study Restraint type Restraint duration CIMT protocol Total CIMT Location
duration in
hours
Rostami et al., 201230 Splint 5 hours/day 4 weeks 1.5 hours/day 3 days/week 18 Clinic
4 weeks
Sakzewski et al., 2011, 201231,32 Glove+splint 6 hours/day 10 days 6 hours/day 5 days/week 2 60 Camp
weeks
Smania et al., 200933 Mitten 8 hours/day 5 weeks 1 hour/day 2 days/week 5 10 Clinic
weeks
Sung et al., 200534 Cast 24 hours/day 7 days 6 0.5 hour/day 2 days/week 6 Clinic
weeks 6 weeks
Taub et al., 200436 Cast 24 hours/day 21 days 6 hours/day 21 days 126 Clinic
Taub et al., 201135 Cast 24 hours/day 13 days 6 hours/day 5 days/week 3 90 Home
weeks
Wallen et al., 201137 Mitten 2 hours/day 7 days/week 8 2 hours/day 7 days 8 weeks 112 Clinic
weeks
Xu et al., 201238 Splint 4 hours/day 5 days/week 2 3 hours/day 5 days/week 2 30 Clinic
weeks weeks

CIMT: constraint-induced movement therapy.

947
948 Clinical Rehabilitation 28(10)

Study name Statistics for each study Std diff in means and 95% CI

Std diff Standard

in means error p-Value
de Brito Brandao et al 2012 -0.585 0.511 0.252
Gordon et al 2011 -0.061 0.309 0.843
Sakzewski et al 2011, 2012 -0.041 0.260 0.875
Hoare et al 2013 0.069 0.343 0.841
Fedrizzi et al 2012 0.117 0.237 0.621
Hung et al 2011 0.157 0.448 0.727
Wallen et al 2011 0.167 0.283 0.557
Sung et al 2005 0.179 0.365 0.623
Xu et al 2012 0.237 0.299 0.428
Deppe et al 2013 0.321 0.376 0.393
Eugster-Buesch et al 2012 0.347 0.421 0.410
Facchin et al 2011 0.355 0.238 0.136
Lin et al 2011 0.466 0.443 0.293
Choudhary et al 2012 0.603 0.367 0.101
Charles et al 2006 0.616 0.436 0.158
Hsin et al 2012 0.710 0.440 0.106
Aarts et al 2010,2011 0.735 0.294 0.012
Geerdink et al 2013 0.761 0.295 0.010
El-Kafy et al 2014 0.815 0.401 0.042
de Brito Brandao et al 2010 0.935 0.545 0.086
Chen et al 2012 0.984 0.309 0.001
Taub et al 2004 1.124 0.507 0.027
Smania et al 2009 1.132 0.482 0.019
Eliasson et al 2011 1.260 0.438 0.004
Al-Oraibi et al 2011 1.500 0.605 0.013
Taub et al 2011 1.775 0.528 0.001
Rostami et al 2012 3.729 0.827 0.000
0.546 0.106 0.000
-4.00 -2.00 0.00 2.00 4.00

Favors Comparison Favors CIMT

Figure 2. Forest plot of effect sizes from the 27 studies that assessed the effect of constraint-induced movement
therapy on arm function in children with cerebral palsy. A square represents the effect size for a given study, with
the size of the square proportional to the weighting of that study in the meta-analysis. A horizontal line indicates
the 95% confidence interval for an effect. The diamond at the bottom represents the overall effect size calculated
using a random-effects model.

effect size than other settings (clinic-based and
camp-based). This finding was consistent with the
proposed benefits of using a natural environment
(home) as the intervention location.68,69 The natural
environment (home) offered less distress during
constraint-induced movement therapy practice for
both children with cerebral palsy and their parents.
Further, the training schedule can be tailored to fit
into the familys daily routine. A home-based inter-
vention can also save the family time and money
for commuting and parents can be more involved
throughout the process, increasing opportunities
for parentchild interaction.
The time of follow-up was negatively associated
with study effect size: the longer the follow-up
time, the smaller the study effect size. This finding
is also consistent with the logical assumption that
the constraint-induced movement therapy effect
could not be maintained over time. After constraint-
induced movement therapy ended, children with
cerebral palsy might not practice with their affected
arm as much as they did previously during
constraint-induced movement therapy. From the
motor learning perspective, repetitive practice
advances motor skills. Research on patients with
stroke suggested the patients with proper transfer
training from constraint-induced movement therapy
to real-life functional tasks had a better follow-up
performance than patients without transfer train-
ing.70 The majority of the studies reviewed here
Chen et al. 949

Group by Study name Statistics for each study Std diff in means and 95% CI
Dose equvalence Std diff Standard
in means error p-Value
No Fedrizzi et al 2012 0.117 0.237 0.621
No Sung et al 2005 0.179 0.365 0.623
No Eugster-Buesch et al 2012 0.347 0.421 0.410
No Facchin et al 2011 0.355 0.238 0.136
No Choudhary et al 2012 0.603 0.367 0.101
No Charles et al 2006 0.616 0.436 0.158
No de Brito Brandao et al 2010 0.935 0.545 0.086
No Taub et al 2004 1.124 0.507 0.027
No Eliasson et al 2011 1.260 0.438 0.004
No Al-Oraibi et al 2011 1.500 0.605 0.013
No Taub et al 2011 1.775 0.528 0.001
No Rostami et al 2012 3.729 0.827 0.000
No 0.844 0.203 0.000
Yes de Brito Brandao et al 2012 -0.585 0.511 0.252
Yes Gordon et al 2011 -0.061 0.309 0.843
Yes Sakzewski et al 2011, 2012 -0.041 0.260 0.875
Yes Hoare et al 2013 0.069 0.343 0.841
Yes Hung et al 2011 0.157 0.448 0.727
Yes Wallen et al 2011 0.167 0.283 0.557
Yes Xu et al 2012 0.237 0.299 0.428
Yes Deppe et al 2013 0.321 0.376 0.393
Yes Lin et al 2011 0.466 0.443 0.293
Yes Hsin et al 2012 0.710 0.440 0.106
Yes Aarts et al 2010,2011 0.735 0.294 0.012
Yes Geerdink et al 2013 0.761 0.295 0.010
Yes El-Kafy et al 2014 0.815 0.401 0.042
Yes Chen et al 2012 0.984 0.309 0.001
Yes Smania et al 2009 1.132 0.482 0.019
Yes 0.387 0.111 0.001
-4.00 -2.00 0.00 2.00 4.00

Favors Comparison Favors CIMT

Figure 3. Subgroup analysis of whether the comparison group received a dose-equivalent treatment.

Table 3. Average effect size when breaking down outcomes based on the classification by the ICF model. The
numbers in parentheses are the lower and upper limit of 95% confidence interval for the effect size.

Variables N Post N Follow-up

Body structure and function 8 0.486 (0.122, 0.849) 5 0.279 (0.009, 0.550)
Activity 23 0.641 (0.396, 0.885) 18 0.394 (0.172, 0.617)
Participation 9 0.306 (0.069, 0.680) 8 0.600 (0.148, 1.051)

either did not include a transfer training in their
intervention or included a relatively short transfer
training to help these children apply to their daily
living the new functional skill they learned using
their affected hand. Consequently, the effect of this
newly learned function could fade away without
proper practice and reminding over time.
As expected, once we compared studies with and
without a dose-equivalent comparison group, the
overall effect size changed from large (d=0.844
without a dose-equivalent comparison group) to
small-to-moderate (d=0.370 with a dose-equivalent
group). The finding that constraint-induced move-
ment therapy showed a large effect size when com-
pared with a non-equivalent dose comparison group
suggests the importance of intensive intervention
regardless of the intervention type. Children in this
meta-analysis received constraint-induced move-
ment therapy intensively (a few hours per day, two
to seven days per week), whereas children in the
950 Clinical Rehabilitation 28(10)
non-equivalent comparison group received conven-
tional therapy only once per week or once every
other week. Thus, the large effect was expected. In a
meta-analysis done by Arpino et al.,71 intensive
interventions, regardless of the treatment content,
were compared with non-intensive rehabilitation
treatment for children with cerebral palsy using the
Gross Motor Function Measure score as the out-
come measure. The authors found a large effect size
with intensive intervention (d=1.32) compared with
the non-intensive therapy. Our finding is consistent
with theirs.
When constraint-induced movement therapy
was compared with a dose-equivalent comparison
group, constraint-induced movement therapy was
slightly better than the comparison group with a
small-to-moderate effect size. That is, although
small, constraint-induced movement therapy still
showed an advantage in improving arm function in
children with cerebral palsy.
We did not find any association between con-
straint-induced movement therapy dosage with
study effect size. We believe this finding might
come from a complex interaction from the study
heterogeneity included in this review, especially if
the intervention-related dosage in the comparison
group was not equivalent with that of the constraint-
induced movement therapy group. The effect of dif-
ferent constraint-induced movement therapy dosage
remains inconclusive. Further investigations with
vigorous research design are needed before a con-
clusion can be made.
Potential limitations of our study include: (1)
inclusion of only published RCT studies; (2) publi-
cation bias; (3) exclusion of few studies because
the information needed to compute effect size was
unavailable; and (4) the varied outcome measures,
intervention protocols, and childrens characteris-
tics made the analysis and conclusions compli-
cated, even though we used the ICF model as our
theoretical framework.
In conclusion, our systematic review and meta-
analysis found that constraint-induced movement
therapy overall is an effective intervention to improve
arm function in children with cerebral palsy. In con-
trast, when constraint-induced movement therapy is
compared with a non-dose-equivalent comparison
group, the overall effect of constraint-induced move-
ment therapy appears smaller when compared with a
dose-equivalent comparison group.
Clinical messages
Constraint-induced movement therapy
provides a medium effect (d=0.546) in
improving arm function in children with
cerebral palsy.
Studies examining constraint-induced
movement therapy effect without a dose-
equivalent comparison group showed a
large effect in children with cerebral palsy;
however, studies with a dose-equivalent
comparison group only showed a small
effect.
Constraint-induced movement therapy
intervention settings were significantly
associated with study effect size.
Conflict of interest
The authors declare that there is no conflict of interest.
Funding
This research received no specific grant from any fund-
ing agency in the public, commercial, or not-for-profit
sectors.
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