Unilateral cerebral palsy (CP) is a condition that affects muscle control and function
on one side of the body. Children with unilateral CP experience difficulties using
their hands together secondary to disturbances that occur in the developing fetal
or infant brain. Often, the more affected limb is disregarded. Constraint‐induced
movement therapy (CIMT) aims to increase use of the more affected upper limb and improve
bimanual performance. CIMT is based on two principles: restraining the use of the
less affected limb (for example, using a splint, mitt or sling) and intensive therapeutic
practice of the more affected limb. To evaluate the effect of constraint‐induced movement
therapy (CIMT) in the treatment of the more affected upper limb in children with unilateral
CP. In March 2018 we searched CENTRAL, MEDLINE, Embase, CINAHL, PEDro, OTseeker, five
other databases and three trials registers. We also ran citation searches, checked
reference lists, contacted experts, handsearched key journals and searched using Google
Scholar. Randomised controlled trials (RCTs), cluster‐RCTs or clinically controlled
trials implemented with children with unilateral CP, aged between 0 and 19 years,
where CIMT was compared with a different form of CIMT, or a low dose, high‐dose or
dose‐matched alternative form of upper‐limb intervention such as bimanual intervention.
Primarily, outcomes were bimanual performance, unimanual capacity and manual ability.
Secondary outcomes included measures of self‐care, body function, participation and
quality of life. Two review authors independently screened titles and abstracts to
eliminate ineligible studies. Five review authors were paired to extract data and
assess risk of bias in each included study. GRADE assessments were undertaken by two
review authors. We included 36 trials (1264 participants), published between 2004
and 2018. Sample sizes ranged from 11 to 105 (mean 35). Mean age was 5.96 years (standard
deviation (SD) 1.82), range three months to 19.8 years; 53% male and 47% participants
had left hemiplegia. Fifty‐seven outcome measures were used across studies. Average
length of CIMT programs was four weeks (range one to 10 weeks). Frequency of sessions
ranged from twice weekly to seven days per week. Duration of intervention sessions
ranged from 0.5 to eight hours per day. The mean total number of hours of CIMT provided
was 137 hours (range 20 to 504 hours). The most common constraint devices were a mitt/glove
or a sling (11 studies each). We judged the risk of bias as moderate to high across
the studies. Key results: Primary outcomes at primary endpoint (immediately after
intervention) CIMT versus low‐dose comparison (e.g. occupational therapy) We found
low‐quality evidence that CIMT was more effective than a low‐dose comparison for improving
bimanual performance (mean difference (MD) 5.44 Assisting Hand Assessment (AHA) units,
95% confidence interval (CI) 2.37 to 8.51). CIMT was more effective than a low‐dose
comparison for improving unimanual capacity (Quality of upper extremity skills test
(QUEST) ‐ Dissociated movement MD 5.95, 95% CI 2.02 to 9.87; Grasps; MD 7.57, 95%
CI 2.10 to 13.05; Weight bearing MD 5.92, 95% CI 2.21 to 9.6; Protective extension
MD 12.54, 95% CI 8.60 to 16.47). Three studies reported adverse events, including
frustration, constraint refusal and reversible skin irritations from casting. CIMT
versus high‐dose comparison (e.g. individualised occupational therapy, bimanual therapy)
When compared with a high‐dose comparison, CIMT was not more effective for improving
bimanual performance (MD −0.39 AHA Units, 95% CI −3.14 to 2.36). There was no evidence
that CIMT was more effective than a high‐dose comparison for improving unimanual capacity
in a single study using QUEST (Dissociated movement MD 0.49, 95% CI −10.71 to 11.69;
Grasp MD −0.20, 95% CI −11.84 to 11.44). Two studies reported that some children experienced
frustration participating in CIMT. CIMT versus dose‐matched comparison (e.g. Hand
Arm Bimanual Intensive Therapy, bimanual therapy, occupational therapy) There was
no evidence of differences in bimanual performance between groups receiving CIMT or
a dose‐matched comparison (MD 0.80 AHA units, 95% CI −0.78 to 2.38). There was no
evidence that CIMT was more effective than a dose‐matched comparison for improving
unimanual capacity (Box and Blocks Test MD 1.11, 95% CI −0.06 to 2.28; Melbourne Assessment
MD 1.48, 95% CI −0.49 to 3.44; QUEST Dissociated movement MD 6.51, 95% CI −0.74 to
13.76; Grasp, MD 6.63, 95% CI −2.38 to 15.65; Weightbearing MD −2.31, 95% CI −8.02
to 3.40) except for the Protective extension domain (MD 6.86, 95% CI 0.14 to 13.58).
There was no evidence of differences in manual ability between groups receiving CIMT
or a dose‐matched comparison (ABILHAND‐Kids MD 0.74, 95% CI 0.31 to 1.18). From 15
studies, two children did not tolerate CIMT and three experienced difficulty. The
quality of evidence for all conclusions was low to very low. For children with unilateral
CP, there was some evidence that CIMT resulted in improved bimanual performance and
unimanual capacity when compared to a low‐dose comparison, but not when compared to
a high‐dose or dose‐matched comparison. Based on the evidence available, CIMT appears
to be safe for children with CP. Constraint‐induced movement therapy in the treatment
of the upper limb in children with unilateral cerebral palsy Review question Does
constraint‐induced movement therapy (CIMT) improve arm and hand use in children with
unilateral cerebral palsy (CP)? What is the aim of this review? To find out if CIMT
helps children with unilateral (hemiplegic) CP to use their hands more effectively.
Key messages CIMT may work better than another upper‐limb therapy carried out at low
intensity (low dose) for improving children’s ability to use both hands together.
CIMT appears no more effective than another upper‐limb therapy carried out at a high
dose or equal dose. CIMT appears to be safe. More well‐designed research is needed
for strong conclusions to be made. What was studied in the review? Children with unilateral
CP have difficulty using two hands together. Most daily activities need co‐ordinated
use of two hands together, so clinicians use CIMT to help children with unilateral
CP improve upper‐limb ability. There is no one type of CIMT, although it always involves
a constraint (e.g. mitt, sling, cast) on the less affected arm, accompanied by intensive
therapy with the more affected arm. What are the main results of the review? Thirty‐six
studies were found. Children were involved in CIMT from 20 to 504 hours. CIMT studies
were divided into three categories. CIMT compared with a low‐dose comparison group
(children had 0 to 25 hours of comparison therapy; and the amount of therapy was much
lower than the amount of CIMT) CIMT may improve bimanual ability (that is, using both
hands together; low‐quality evidence) and unilateral capacity (that is, one‐handed
ability using the more affected hand; very low‐quality evidence) more than low dose.
Three studies reported that a small number of children experienced frustration or
refused to wear the constraint, or had reversible skin irritations from casting. CIMT
compared with a high‐dose comparison group (children had more than 25 hours of bimanual
therapy or another form of intensive therapy and the amount was less than CIMT) CIMT
appeared no more effective than a high‐dose comparison therapy on bimanual ability
(low‐quality evidence) or unimanual capacity (very low‐quality evidence). Two studies
reported that some children experienced frustration from participating in CIMT. CIMT
compared with a dose‐matched comparison group ( children received the same amount
of bimanual therapy as the CIMT group). CIMT appeared no more effective than dose‐matched
therapy on bimanual ability, unimanual capacity (low‐quality evidence) or manual ability
(very low‐quality evidence). From 15 studies, two children did not tolerate CIMT and
three had difficulty getting used to CIMT. How up to date is this review? The review
includes studies published up to March 2018.