Enhancing activities of daily living of chronic stroke patients in primary health care by modified constraint-induced movement therapy (HOMECIMT): study protocol for a cluster randomized controlled trial

Dysphagia screening post-stroke: systematic review

BACKGROUND/SCOPE

Stroke is one of the main causes of death, especially when associated with dysphagia. Hence, the assessment of nutritional status and aspiration risk is important to improve clinical outcomes. The aim of this systematic review is to identify which are the most suitable dysphagia screening tools in chronic post-stroke patients.

METHODOLOGY

A systematic literature search was conducted for articles published from 1 January 2000 to 30 November 2022 in the Cochrane Library, PubMed, Embase, CINAHL, Scopus and Web of Science databases, including primary studies providing quantitative or qualitative data. Additionally, a manual search was conducted scanning the reference lists of relevant articles and Google Scholar was searched to retrieve additional records. The process of screening, selection and inclusion of the articles, as well as the assessment of risk of bias and methodological quality, were conducted by two reviewers.

RESULTS

Out of the 3672 records identified, we included 10 studies, mostly (n=9) cross-sectional, evaluating screening for dysphagia in 1653 chronic post-stroke patients. Volume-Viscosity Swallow Test was the only test applied in multiple studies with adequate sample size, demonstrating high diagnostic accuracy (sensitivity=96.6%-88.2%; specificity=83.3%-71.4%) compared with the videofluoroscopic swallowing study.

CONCLUSIONS

Dysphagia is an important complication in chronic post-stroke patients. Early identification of this condition through screening tools with adequate diagnostic accuracy is of paramount importance. The limited number of studies available and their small sample sizes may be a limitation to this study.

PROSPERO REGISTRATION NUMBER

CRD42022372303.

Data mining versus manual screening to select papers for inclusion in systematic reviews: a novel method to increase efficiency

Systematic reviews rely on identification of studies, initially through electronic searches yielding potentially thousands of studies, and then reviewer-led screening studies for inclusion. This standard method is time- and resource-intensive. We designed and applied an algorithm written in Python involving computer-aided identification of keywords within each paper for an exemplar systematic review of arm impairment after stroke. The standard method involved reading each abstract searching for these keywords. We compared the methods in terms of accuracy in identification of keywords, abstracts' eligibility, and time taken to make a decision about eligibility. For external validation, we adapted the algorithm for a different systematic review, and compared eligible studies using the algorithm with those included in that review. For the exemplar systematic review, the algorithm failed on 72 out of 2,789 documents retrieved (2.6%). Both methods identified the same 610 studies for inclusion. Based on a sample of 21 randomly selected abstracts, the standard screening took 1.58 ± 0.26 min per abstract. Computer output screening took 0.43 ± 0.14 min per abstract. The mean difference between the two methods was 1.15 min ( P  < 0.0001), saving 73% per abstract. For the other systematic review, use of the algorithm resulted in the same studies being identified. One study was excluded based on the interpretation of the comparison intervention. Our purpose-built software was an accurate and significantly time-saving method for identifying eligible abstracts for inclusion in systematic reviews. This novel method could be adapted for other systematic reviews in future for the benefit of authors, reviewers and editors.

Remote constraint induced therapy of the upper extremity (ReCITE): A feasibility study protocol

Background

Difficulty using the upper extremity in everyday activities is common after stroke. Constraint-induced movement therapy (CIMT) has been shown to be effective in both sub-acute and chronic phases of stroke recovery and is recommended in clinical practice guidelines for stroke internationally. Despite reports of equivalence of outcome when stroke rehabilitation interventions are delivered using telehealth, there has been limited evaluation of CIMT when using this mode of delivery. ReCITE will (a) evaluate the feasibility and acceptability of CIMT when delivered via telehealth to stroke survivors (TeleCIMT) and (b) explore therapists' experiences and use of an online support package inclusive of training, mentoring and resources to support TeleCIMT delivery in clinical practice.

Methods

A prospective single-group, single blinded, study design with embedded process evaluation will be conducted. The study will be conducted at three outpatient services in Sydney, Australia. A multi-faceted therapist support package, informed by the Capabilities, Opportunity, Motivation- Behaviour model (COM-B), will be used to support occupational therapists to implement TeleCIMT as part of routine care to stroke survivors. Each service will recruit 10 stroke survivor participants (n = 30) with mild to moderate upper extremity impairment. Upper extremity and quality of life outcomes of stroke survivor participants will be collected at baseline, post-intervention and at a 4 week follow-up appointment. Feasibility of TeleCIMT will be evaluated by assessing the number of stroke participants who complete 80% of intensive arm practice prescribed during their 3 week program (i.e., at least 24 h of intensive arm practice). Acceptability will be investigated through qualitative interviews and surveys with stroke survivors, supporter surveys and therapist focus groups. Qualitative interviews with therapists will provide additional data to explore their experiences and use of the online support package.

Discussion

The COVID-19 pandemic resulted in a rapid transition to delivering telehealth. The proposed study will investigate the feasibility and acceptability of delivering a complex intervention via telehealth to stroke survivors at home, and the support that therapists and patients require for delivery. The findings of the study will be used to inform whether a larger, randomized controlled trial is feasible.

Family-Centered Care During Constraint-Induced Therapy After Chronic Stroke: A Feasibility Study

PURPOSE

This feasibility study evaluated a theory-based intervention (CARE-CITE) designed to engage carepartners (CPs) in supporting stroke survivor upper extremity rehabilitation.

DESIGN

The study was a one-group design with pre- and posttest and 1 month follow-up (N = 7 dyads).

METHODS

Feasibility was determined by participant retention, CP and stroke survivor intervention adherence, and CP acceptability of the intervention (exit interview). Measures of CP depressive symptoms, fatigue, and family conflict around stroke recovery and stroke survivor upper extremity function are reported. Data were analyzed using descriptive statistics.

FINDINGS

All participants completed the study and adhered to the intervention, and CPs found CARE-CITE helpful. Descriptively, better scores were observed for CP's mental health, family conflict, stroke survivor confidence, and upper extremity tasks performed.

CONCLUSION

These results provide initial evidence that CARE-CITE is feasible after chronic stroke and that CPs and stroke survivors may benefit from family-centered care.

CLINICAL RELEVANCE

Improving CP skills in supporting rehabilitation activities may improve stroke survivor upper extremity function.

Feasibility of Wearable Sensing for In-Home Finger Rehabilitation Early After Stroke

Wearable grip sensing shows potential for hand rehabilitation, but few studies have studied feasibility early after stroke. Here, we studied a wearable grip sensor integrated with a musical computer game (MusicGlove). Among the stroke patients admitted to a hospital without limiting complications, 13% had adequate hand function for system use. Eleven subjects used MusicGlove at home over three weeks with a goal of nine hours of use. On average they achieved 4.1 ± 3.2 (SD) hours of use and completed 8627 ± 7500 grips, an amount comparable to users in the chronic phase of stroke measured in a previous study. The rank-order usage data were well fit by distributions that arise in machine failure theory. Users operated the game at high success levels, achieving note-hitting success >75% for 84% of the 1061 songs played. They changed game parameters infrequently (31% of songs), but in a way that logically modulated challenge, consistent with the Challenge Point Hypothesis from motor learning. Thus, a therapy based on wearable grip sensing was feasible for home rehabilitation, but only for a fraction of subacute stroke subjects. Subjects made usage decisions consistent with theoretical models of machine failure and motor learning.

Stroke patients' and non-professional coaches' experiences with home-based constraint-induced movement therapy: a qualitative study

Objective:

To investigate the experiences of chronic stroke patients and non-professional coaches with home-based constraint-induced movement therapy (homeCIMT).

Design:

Qualitative study embedded within a cluster randomized controlled trial investigating the efficacy of homeCIMT to improve the use of the affected arm in daily activities.

Setting:

Patients’ home environment.

Participants:

13 stroke patients and 9 non-professional coaches’ alias family members who had completed the four-week homeCIMT programme in the context of the HOMECIMT trial.

Interventions:

Semi-structured interviews; qualitative data were analysed using the methodology of the hermeneutic phenomenological data analysis.

Results:

We identified six themes in the qualitative analysis describing the experiences of patients and non-professional coaches with homeCIMT: (1) homeCIMT can be integrated into everyday life with varying degrees of success; (2) training together may produce positive experiences as well as strain; (3) self-perceived improvements during and following homeCIMT; (4) using the affected arm in everyday life is challenging; (5) subjective evaluation of and experiences with homeCIMT-specific exercises; and (6) impact of professional therapists’ guidance and motivation during homeCIMT. Statements regarding theme five and six were only provided by patients, whereas the other themes contain both, the experiences of stroke patients and non-professional coaches.

Conclusion:

Patients’ and non-professional coaches’ narratives offer a detailed insight into the manifold experiences with the practical implementation of homeCIMT that may help improve implementing the homeCIMT programme and similar approaches involving increased training duration and intensity and/or involvement of family members.

Effects of Home-Based Robotic Therapy Involving the Single-Joint Hybrid Assistive Limb Robotic Suit in the Chronic Phase of Stroke: A Pilot Study

Introduction

Robotic therapy has drawn attention in the rehabilitation field including home-based rehabilitation. A previous study has reported that home-based therapy could be more effective for increasing upper limb activity than facility-based therapy. The single-joint hybrid assistive limb (HAL-SJ) is an exoskeleton robot developed according to the interactive biofeedback theory, and several studies have shown its effectiveness for upper limb function in stroke patients. A study of home-based robotic therapy has shown to enhance rehabilitation effectiveness for stroke patient with a paretic upper limb. However, home-based therapy involving a HAL-SJ in stroke patients with paretic upper limbs has not been investigated. The present study aimed to investigate paretic upper limb activity and function with home-based robotic therapy involving a HAL-SJ in stroke patients.

Materials and Methods

A home-based robotic therapy program involving a HAL-SJ was performed for 30 min per session followed by standard therapy for 30 min per session, 2 times a week, for 4 weeks (i.e., completion of all 8 sessions involved 8 h of rehabilitation), at home. After the intervention, patients were followed up by telephone and home visits for 8 weeks. The paretic upper limb activity and function were assessed using the Motor Activity Log (MAL; amount of use (AOU)), arm triaxial accelerometry (laterality index (LI)), the Fugl–Meyer assessment (FMA), and the action research arm test (ARAT), at baseline and week 4 and week 12 after the start of training.

Results

The study included 10 stroke patients (5 men; mean age, 61.1 ± 7.1 years). The AOU scores and LI significantly improved at week 4 after the start of training (p<0.05). However, no significant changes were observed in the LI at week 12 (p=0.161) and the FMA scores at both week 4 and week 12 (p=0.059 and p=0.083, respectively). The ARAT scores significantly improved at both week 4 and week 12 (p<0.05).

Conclusion

Home-based robotic therapy combined with conventional therapy could be a valuable approach for increasing paretic upper limb activity and maintaining paretic upper limb function in the chronic phase of stroke.

Effects of modified constraint-induced movement therapy in the recovery of upper extremity function affected by a stroke: a single-blind randomized parallel trial-comparing group versus individual intervention

An extensive corpus of literature supports the positive impact of constraint-induced movement therapy (CIMT) on neuroplasticity and the recovery of function. However, its clinical applicability is limited by the time of intervention and individual modality. We propose to assess the efficacy of modified CIMT protocols through a group therapy intervention. To determine the effectiveness of a group therapy, compared with individual modified CIMT, in increasing the use and functionality of movement of a paretic upper limb. The study was a single-blind, randomized parallel trial. Thirty-six patients who had had a stroke more than 6 months previously were divided randomly into two intervention groups. The independent variable was the implementation of group or individual modalities for 3 h for 10 consecutive days and the dependent variables were evaluated by the Motor Activity Log and Action Research Arm Test, at baseline (preintervention evaluation), end (postintervention evaluation), and 6 months after intervention (follow-up). By controlling the preintervention evaluations, analyses of covariance indicated that both dependent variables presented significant differences in favor of the group therapy at both the postintervention evaluation and the follow-up evaluations. Both types of intervention generated increases in the function and use of the upper extremity, with these increases being higher in the group therapy. The effects of the group therapy modality were maintained 6 months after the intervention ended.

Home-based hand rehabilitation after chronic stroke: Randomized, controlled single-blind trial comparing the MusicGlove with a conventional exercise program

Individuals with chronic stroke have limited options for hand rehabilitation at home. Here, we sought to determine the feasibility and efficacy of home-based MusicGlove therapy. Seventeen participants with moderate hand impairment in the chronic phase of stroke were randomized to 3 wk of home-based exercise with either the MusicGlove or conventional tabletop exercises. The primary outcome measure was the change in the Box and Blocks test score from baseline to 1 mo posttreatment. Both groups significantly improved their Box and Blocks test score, but no significant difference was found between groups. The MusicGlove group did exhibit significantly greater improvements than the conventional exercise group in motor activity log quality of movement and amount of use scores 1 mo posttherapy (p = 0.007 and p = 0.04, respectively). Participants significantly increased their use of MusicGlove over time, completing 466 gripping movements per day on average at study end. MusicGlove therapy was not superior to conventional tabletop exercises for the primary end point but was nevertheless feasible and led to a significantly greater increase in self-reported functional use and quality of movement of the impaired hand than conventional home exercises.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov; "Influence of Timing on Motor Learning"; NCT01769326; https://clinicaltrials.gov/ct2/show/NCT01769326.

Caregiver-mediated exercises for improving outcomes after stroke

BACKGROUND

Stroke is a major cause of long-term disability in adults. Several systematic reviews have shown that a higher intensity of training can lead to better functional outcomes after stroke. Currently, the resources in inpatient settings are not always sufficient and innovative methods are necessary to meet these recommendations without increasing healthcare costs. A resource efficient method to augment intensity of training could be to involve caregivers in exercise training. A caregiver-mediated exercise programme has the potential to improve outcomes in terms of body function, activities, and participation in people with stroke. In addition, caregivers are more actively involved in the rehabilitation process, which may increase feelings of empowerment with reduced levels of caregiver burden and could facilitate the transition from rehabilitation facility (in hospital, rehabilitation centre, or nursing home) to home setting. As a consequence, length of stay might be reduced and early supported discharge could be enhanced.

OBJECTIVES

To determine if caregiver-mediated exercises (CME) improve functional ability and health-related quality of life in people with stroke, and to determine the effect on caregiver burden.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (October 2015), CENTRAL (the Cochrane Library, 2015, Issue 10), MEDLINE (1946 to October 2015), Embase (1980 to December 2015), CINAHL (1982 to December 2015), SPORTDiscus (1985 to December 2015), three additional databases (two in October 2015, one in December 2015), and six additional trial registers (October 2015). We also screened reference lists of relevant publications and contacted authors in the field.

SELECTION CRITERIA

Randomised controlled trials comparing CME to usual care, no intervention, or another intervention as long as it was not caregiver-mediated, aimed at improving motor function in people who have had a stroke.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials. One review author extracted data, and assessed quality and risk of bias, and a second review author cross-checked these data and assessed quality. We determined the quality of the evidence using GRADE. The small number of included studies limited the pre-planned analyses.

MAIN RESULTS

We included nine trials about CME, of which six trials with 333 patient-caregiver couples were included in the meta-analysis. The small number of studies, participants, and a variety of outcome measures rendered summarising and combining of data in meta-analysis difficult. In addition, in some studies, CME was the only intervention (CME-core), whereas in other studies, caregivers provided another, existing intervention, such as constraint-induced movement therapy. For trials in the latter category, it was difficult to separate the effects of CME from the effects of the other intervention.We found no significant effect of CME on basic ADL when pooling all trial data post intervention (4 studies; standardised mean difference (SMD) 0.21, 95% confidence interval (CI) -0.02 to 0.44; P = 0.07; moderate-quality evidence) or at follow-up (2 studies; mean difference (MD) 2.69, 95% CI -8.18 to 13.55; P = 0.63; low-quality evidence). In addition, we found no significant effects of CME on extended ADL at post intervention (two studies; SMD 0.07, 95% CI -0.21 to 0.35; P = 0.64; low-quality evidence) or at follow-up (2 studies; SMD 0.11, 95% CI -0.17 to 0.39; P = 0.45; low-quality evidence).Caregiver burden did not increase at the end of the intervention (2 studies; SMD -0.04, 95% CI -0.45 to 0.37; P = 0.86; moderate-quality evidence) or at follow-up (1 study; MD 0.60, 95% CI -0.71 to 1.91; P = 0.37; very low-quality evidence).At the end of intervention, CME significantly improved the secondary outcomes of standing balance (3 studies; SMD 0.53, 95% CI 0.19 to 0.87; P = 0.002; low-quality evidence) and quality of life (1 study; physical functioning: MD 12.40, 95% CI 1.67 to 23.13; P = 0.02; mobility: MD 18.20, 95% CI 7.54 to 28.86; P = 0.0008; general recovery: MD 15.10, 95% CI 8.44 to 21.76; P < 0.00001; very low-quality evidence). At follow-up, we found a significant effect in favour of CME for Six-Minute Walking Test distance (1 study; MD 109.50 m, 95% CI 17.12 to 201.88; P = 0.02; very low-quality evidence). We also found a significant effect in favour of the control group at the end of intervention, regarding performance time on the Wolf Motor Function test (2 studies; MD -1.72, 95% CI -2.23 to -1.21; P < 0.00001; low-quality evidence). We found no significant effects for the other secondary outcomes (i.e.

PATIENT

motor impairment, upper limb function, mood, fatigue, length of stay and adverse events; caregiver: mood and quality of life).In contrast to the primary analysis, sensitivity analysis of CME-core showed a significant effect of CME on basic ADL post intervention (2 studies; MD 9.45, 95% CI 2.11 to 16.78; P = 0.01; moderate-quality evidence).The methodological quality of the included trials and variability in interventions (e.g. content, timing, and duration), affected the validity and generalisability of these observed results.

AUTHORS' CONCLUSIONS

There is very low- to moderate-quality evidence that CME may be a valuable intervention to augment the pallet of therapeutic options for stroke rehabilitation. Included studies were small, heterogeneous, and some trials had an unclear or high risk of bias. Future high-quality research should determine whether CME interventions are (cost-)effective.

Synergistic effect of moxibustion and rehabilitation training in functional recovery of post-stroke spastic hemiplegia

OBJECTIVE

To evaluate the therapeutic benefit of combining moxibustion and rehabilitation training for functional recovery in post-stroke spastic hemiplegic patients.

METHODS

We randomly divided 84 cases subjecting to inclusion criteria into moxibustion plus rehabilitation training group (MRT group, n=44) and rehabilitation training group (RT group, n=40). Evaluation of therapeutic effect was observed before treatment, 2 weeks during treatment and 6 months after treatment. Spasticity was evaluated using modified Ashworth scale (MAS) and Clinical Spasticity Index (CSI), recovery of motor function was assessed by Brunnstrom recovery stages and Simplified Fugl-Meyer Motor Scale, and performance of activities of daily living (ADL) was measured, and the quality of life was assessed by Patient Reported Outcomes (PRO).

RESULTS

Evaluation of upper limbs, hands and lower limbs based on CSI and MAS revealed significant improvements in patients treated with MRT, compared to RT alone, both during and after therapy. CSI and MAS also showed significant improvement in patients at each time point in the MRT group, compared to RT group. Marked improvement in Fugl-Meyer Motor Scale was also observed in MRT group at each time point. Based on Brunnstrom grades of upper limbs, hands and lower limbs, significant differences between the two groups were recorded at all time points during and after therapy. Barthel index (BI) and PRO also confirmed the dramatic differences between the two therapy groups.

CONCLUSIONS

Our results demonstrate that combination therapy with moxibustion and rehabilitation training offers greater clinical benefits in relieving spasticity, promoting function recovery of motion, improving the performance of ADL, and increasing quality of life in post-stroke spastic hemiplegic patients, compared to RT alone.

The plasticity of intrinsic functional connectivity patterns associated with rehabilitation intervention in chronic stroke patients

INTRODUCTION

It has been demonstrated that rehabilitative interventions can promote motor function recovery in stroke patients. However, little is known regarding the neural mechanisms that underlie the rehabilitation treatments. The aim of this study was to investigate the plasticity of intrinsic functional connectivity patterns that are associated with rehabilitation intervention in chronic stroke patients.

METHODS

Twelve chronic stroke patients with subcortical lesions in the left motor pathway participated in a 4-week rehabilitation intervention and underwent resting-state functional magnetic resonance imaging (fMRI) scanning before and after the intervention. Both functional connectivity analyses of the ipsilesional (left) primary motor cortex (M1) and measurements of the lateralization index of the connectivity patterns were performed in both the stroke patients and healthy controls (HC).

RESULTS

Compared with the HC, the decreased connectivity of the ipsilesional M1 with the contralesional sensorimotor cortex (SMC), bilateral supplementary motor areas, and inferior parietal lobule due to stroke were remarkably restored after the intervention. More specifically, the lateralization index of the bilateral SMC tends to be the normal level. Moreover, comparing post- with pre-intervention, we observed significantly increased connectivity of ipsilesional M1 with the contralesional M1 and medial superior frontal gyrus (mSFG). Additionally, the index of pre-intervention connectivity with the contralesional mSFG was positively correlated with motor improvement.

CONCLUSION

The impact of rehabilitation intervention on intrinsic functional connectivity patterns throughout the brain was measurable on resting-state fMRI, and systematic assessment of resting-state functional connectivity can provide prognostic insight for later motor improvement.

Quality and Reporting of Cluster Randomized Controlled Trials Evaluating Occupational Therapy Interventions: A Systematic Review

Growing use of cluster randomized control trials (RCTs) in health care research requires careful attention to study designs, with implications for the development of an evidence base for practice. The objective of this study is to investigate the characteristics, quality, and reporting of cluster RCTs evaluating occupational therapy interventions to inform future research design. An extensive search of cluster RCTs evaluating occupational therapy was conducted in several databases. Fourteen studies met our inclusion criteria; four were protocols. Eleven (79%) justified the use of a cluster RCT and accounted for clustering in the sample size and analysis. All full studies reported the number of clusters randomized, and five reported intercluster correlation coefficients (50%): Protocols had higher compliance. Risk of bias was most evident in unblinding of participants. Statistician involvement was associated with improved trial quality and reporting. Quality of cluster RCTs of occupational therapy interventions is comparable with those from other areas of health research and needs improvement.

Constraint-induced movement therapy for upper extremities in people with stroke

BACKGROUND

In people who have had a stroke, upper limb paresis affects many activities of daily life. Reducing disability is therefore a major aim of rehabilitative interventions. Despite preserving or recovering movement ability after stroke, sometimes people do not fully realise this ability in their everyday activities. Constraint-induced movement therapy (CIMT) is an approach to stroke rehabilitation that involves the forced use and massed practice of the affected arm by restraining the unaffected arm. This has been proposed as a useful tool for recovering abilities in everyday activities.

OBJECTIVES

To assess the efficacy of CIMT, modified CIMT (mCIMT), or forced use (FU) for arm management in people with hemiparesis after stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group trials register (last searched June 2015), the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library Issue 1, 2015), MEDLINE (1966 to January 2015), EMBASE (1980 to January 2015), CINAHL (1982 to January 2015), and the Physiotherapy Evidence Database (PEDro; January 2015).

SELECTION CRITERIA

Randomised control trials (RCTs) and quasi-RCTs comparing CIMT, mCIMT or FU with other rehabilitative techniques, or none.

DATA COLLECTION AND ANALYSIS

One author identified trials from the results of the electronic searches according to the inclusion and exclusion criteria, three review authors independently assessed methodological quality and risk of bias, and extracted data. The primary outcome was disability.

MAIN RESULTS

We included 42 studies involving 1453 participants. The trials included participants who had some residual motor power of the paretic arm, the potential for further motor recovery and with limited pain or spasticity, but tended to use the limb little, if at all. The majority of studies were underpowered (median number of included participants was 29) and we cannot rule out small-trial bias. Eleven trials (344 participants) assessed disability immediately after the intervention, indicating a non-significant standard mean difference (SMD) 0.24 (95% confidence interval (CI) -0.05 to 0.52) favouring CIMT compared with conventional treatment. For the most frequently reported outcome, arm motor function (28 studies involving 858 participants), the SMD was 0.34 (95% CI 0.12 to 0.55) showing a significant effect (P value 0.004) in favour of CIMT. Three studies involving 125 participants explored disability after a few months of follow-up and found no significant difference, SMD -0.20 (95% CI -0.57 to 0.16) in favour of conventional treatment.

AUTHORS' CONCLUSIONS

CIMT is a multi-faceted intervention where restriction of the less affected limb is accompanied by increased exercise tailored to the person's capacity. We found that CIMT was associated with limited improvements in motor impairment and motor function, but that these benefits did not convincingly reduce disability. This differs from the result of our previous meta-analysis where there was a suggestion that CIMT might be superior to traditional rehabilitation. Information about the long-term effects of CIMT is scarce. Further trials studying the relationship between participant characteristics and improved outcomes are required.