This review assessed the effectiveness of constraint-induced movement therapy (CIMT) to improve upper limb function and quality of life following stroke. The authors concluded that, compared with an alternative or no treatment, CIMT may improve upper limb function for some patients. The conclusion is suitably cautious given the very weak evidence identified.

To assess the effects of constraint-induced movement therapy (CIMT) for upper limb hemiparesis following stroke on function, costs, patient and carer satisfaction, and quality of life.

MEDLINE (from 1966), EMBASE (from 1988), CINAHL (from 1982), the Cochrane Library (to 2005), PEDro and OTseeker (to March 2005) were searched for papers published in the English language; the search terms were provided online. In addition, the references of included studies were screened.

Study designs of evaluations included in the review

Randomised controlled trials (RCTs) and quasi-RCTs (including crossover trials) and systematic reviews of RCTs were eligible for inclusion.

Specific interventions included in the review

Studies comparing CIMT with no intervention or with an alternative treatment were eligible for inclusion. Studies comparing CIMT alongside other treatments were eligible if all comparison groups received the same treatments. The included studies used traditional CIMT or a modified version of CIMT. The type of restraint used in the included studies was in the form of a mitten or glove, or a hand splint and sling. One trial carried out movement therapy as clinically indicated, while the intensity of the therapy for the other trials ranged between 0.5 hours three times per week to 6 hours five times a week.

Participants included in the review

Studies of participants aged over 18 years with reduced upper extremity function following stroke were eligible for inclusion. All of the included participants had a diagnosis of upper limb hemiparesis. Half of the studies excluded participants with excessive spasticity.

Outcomes assessed in the review

The included studies needed to report at least one measure of upper limb function.

How were decisions on the relevance of primary studies made?

Two authors independently identified trials. Full papers were obtained in instances of uncertainty and any disagreements were resolved through discussion.

Two authors independently conducted the quality assessment using a published scale. Any disagreements were resolved through discussion. The quality assessment encompassed randomisation, allocation concealment, comparability at baseline, blinding of the participants and assessors, drop-outs, intention-to-treat analysis, between-group comparisons, and the reporting of point measures and measures of variability for outcomes.

Two authors independently extracted the data using a standardised form. Any discrepancies were resolved by discussion. Hedges g was used to calculate the effect size of the intervention, which was reported together with its 95% confidence interval (CI). Authors were approached for any data required that had not been reported.

How were the studies combined?

The overall results were pooled statistically using fixed-effect and random-effects models, depending on evidence of heterogeneity.

How were differences between studies investigated?

The authors assessed statistical heterogeneity but the method used was not specified.

Fourteen RCTs (n=292) were included.

The average quality score across the trials was 5 out of 10 (range: 3 to 7). Random allocation was reported for 13 of the 14 trials. None of the studies reported blinding of the participants. All trials defined the eligibility of the participants and the interventions well.

Participants in the CIMT (traditional and modified) group performed significantly better in the Action Research Arm Test compared with the control group receiving either no therapy or an alternative therapy (g 1.51, 95% CI: 0.27, 2.74; 4 trials); there appeared to have been evidence of statistical heterogeneity. There was no statistically significant difference in performance between the two groups for the Fugl-Meyer Assessment, Motor Activity Log amount of use, Motor Activity Log quality of movement and the Wolf Motor Function Test.

Adverse events were reported in two trials: burns were reported for both treatment groups, minor skin lesions occurred in a control group and muscle soreness in a treatment group. Three trials reported no adverse events and one trial reported no adverse events requiring acute care.

The authors stated that the potential costs could be high. However, no further information was provided.

Compared with an alternative or no treatment, CIMT may improve upper limb function following stroke for some patients.

The research question was clear and the review contained well-defined inclusion criteria. The search strategy used to identify published studies was reasonable but only English language papers were included, thus raising the possibility of language bias having been introduced into the review. There was also little attempt to identify unpublished studies, thereby introducing the possibility of publication bias, and publication bias was not assessed. The method used to select studies seemed appropriate, reducing the likelihood of bias. The assessment of study quality was thorough but might have been explored further in the synthesis. Measures were taken to minimise errors and bias in the data extraction process, and the authors appear to have made attempts to obtain additional data from the trials.

The review contained a good description of the studies and a detailed presentation of individual study results. Several results appeared to show evidence of statistical heterogeneity but, as the method and extent was not reported, it was difficult to assess the appropriateness of the pooled results. Some limitations of the review were discussed, e.g. the variation in design and quality of the trials, and the different outcome measures used. The number of participants was very small in most trials. The results showed only weak and inconsistent evidence supporting the use of CIMT following stroke to improve function. The authors' conclusion is suitably cautious given the very weak identified evidence.

Practice: The authors did not state any implications for practice.

Research: The authors stated that rigorous evaluations of CIMT using well-designed and adequately powered trials are needed to evaluate the efficacy of different protocols on different stroke populations and to assess the impact on quality of life, cost, and patient and carer satisfaction. Furthermore, studies investigating the optimal time after the stroke of when to implement CIMT should consider the required inclusion criteria to maximise results and participant eligibility. Future research should also focus on compliance.

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.