Constraint-induced movement therapy in stroke patients: systematic review and meta-analysis

Aim. Upper extremity paresis is a leading cause of disability after stroke. A Cochrane review found an impact on disability of Constraint-Induced Movement Therapy (CIMT), its modified forms (mCIMT) and Forced Use (FU), with a moderate significant effect and a large significant effect on arm motor function. This article aims to present an update of the Cochrane review and assess the effects of CIMT, mCIMT and FU on disability and arm motor function. Methods. Electronic databases were searched for Randomised Controlled Trials (RCT) and quasi-RCTs comparing CIMT, mCIMT or FU with other rehabilitative techniques, or none, in adult stroke patients. The primary and secondary outcomes were disability and arm motor function. Two reviewers independently screened search results, documented the methodological quality and extracted data. Results. Four new studies were added to the previous review, for a total of 18 studies. The updated meta-analyses no longer indicate a benefit of CIMT mCIMT and FU on disability (eight studies, 276 participants, Standardised Mean Difference (SMD) 0.21, 95% CI -0.08 to 0.50), and a moderate benefit on arm motor function (14 studies, 479 participants, SMD 0.44, 95% CI 0.03 to 0.93). Conclusion. New evidence pushes the overall estimate of benefit toward the null effect. The majority of studies were underpowered and imprecise, exposing these analyses to small-study bias. This may explain why accumulation of evidence makes overall estimates inconsistent. Larger randomised trials to resolve these uncertainties are needed.