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1 ORIGINAL ARTICLES EURA MEDICOPHYS 2007;43:139-4 The Constraint Induced Movement Therapy: a systematic review of randomised controlled trials on the adult stroke patients Aim. The aim of this study was to analyse the evidence of effectiveness on adult stroke patients of the Constraint Induced Movement Therapy (CIMT), an original rehabilitation method that consists in strongly encouraging patients to use the affected arm, mainly immobilising the unaffected arm. Methods. We only took into account the randomised controlled trials on CIMT where the experimental treatment was compared with a conventional treatment without any discrepancy of organization or session duration. As we could not measure the statistical significance of differences between treated and control patients, we compared their respective post-treatment percent changes and computed the minimal clinically important difference (MCID), defined as a change of at least 10% of the maximum score of the scale used. Results. The literature search found 13 randomised controlled trials (RCTs), 4 of which were excluded because they aimed at comparing different intensity of CIMT. The 9 RCTs finally included into the review applied the CIMT in either acute, subacute or chronic stroke patients and according to different modalities. Findings were positive in all studies, but the MCID was reached only in smaller ones, which may have been influenced by patients characteristics. Conclusion. Although all studies achieved positive results, it is impossible to draw any clear-cut conclusion on the effectiveness of the CIMT. The main limitations are the lack of homogeneity in the outcome measures used, the inadequacy of data provided and the small samples size. Multicentre studies, using robust outcome measures and Submitted for publication on February 15, 200. Accepted for publication on October 2, 200. E-pub ahead of print on May 28, Address reprint requests to: D. Bonaiuti, Dipartimento di Riabilitazione, Ospedale S. Gerardo, via Pergolesi 28, Monza, Milano. bonaiuti@katamail.com D. BONAIUTI, L. REBASTI, P. SIOLI Department of Rehabilitation S. Gerardo Hospital, Monza, Milan, Italy considering both motor- and sensory-disabled patients are needed. Key words: Constraint Induced Movement Therapy - Stroke - Cerebrovascular accidents - Extremities. The learned non-use theory is derived from experiments with monkeys, in which one forelimb was deafferented by dorsal rhizotomy 1 and never used because of the loss of sensory feedback; if the unaffected limb was restricted, the animals were forced to employ the deafferented limb, and if the restriction was maintained for 1 to, there was a permanent improvement in their ability to use it. 2 This theory has been traslated to stroke patients, considering the clinical impression that some of them use their affected arm less than what could be expected on the basis of their actual motor impairment. 3 One practical derivation of this theory is the Constraint Induced Movement Therapy (CIMT), which is aimed at forcing the use of the affected limb in poststroke hemiparesis by immobilising the unaffected arm. Many studies have attempted to show the effectiveness of this method, but only few of them are randomised controlled trials (RCTs). Reviews that focus on intervention studies often ignore the much greater scientific validity of RCTs compared with the other experimental designs. The Vol No. 2 EUROPA MEDICOPHYSICA 139

2 BONAIUTI THE CONSTRAINT INDUCED MOVEMENT THERAPY present review is limited only to such trials and has the main objective to answer to the following question: is there any evidence that CIMT is more effective at improving arm function in adult patients with hemiparesis following stroke than a good quality, conventional therapy delivered equally intensively? Materials and methods Search A literature searching from 19 to July 2005 was conducted in the following databases: Medline, Embase, Cinhal, Cochrane Library. The key words used were: stroke, cerebrovascular disorders, hemiplegia, hemiparesis, rehabilitation, CIMT, exercise therapy. Selection of articles was based on title and abstract. In case of uncertainty, the entire text was read. The following inclusion criteria were applied: studies concerning the CIMT in adult stroke patients; studies designed and reported as randomised clinical trials; control group patients treated with conventional rehabilitation methods; outcome measured at impairment and/or disability level; separate results provided for the affected arm with respect to general disability scores; published, full-length articles; publication after 19. No language restriction was applied. Quality assessment of the selected studies was assessed independently by two raters (D. B. and L. R.) based on the 19 methodological criteria from van Tulder et al. 4 that we recognized more adherent to rehabilitation studies than Jada criteria. Any disagreements were resolved by discussion. Analysis of data Because of the insufficient data presentation of the most of the studies, statistical analysis (a meta-analysis) was not possible to do. We tried to check the mean change as the percentage of maximum score in each measure: being impossible to measure the significance, it was possible to analyse the percentage of the difference between treated and controls and the minimal clinically important difference (MCID). 5 Results A systematic search of the literature resulted in the identification of 19 studies on adult stroke patients concerning CIMT intended as training of the more affected arm and restraint of the less affected one. Thirteen were randomised controlled trials 5-17 and were, therefore, considered for the present overview, while were reviews 3, and were not taken into account. Besides, we only included studies where the CIMT was compared with another conventional rehabilitation technique, thus excluding the 3 RCTs that contrasted CIMT trainings of different intensity. 10, 14, 15 We also excluded the study where the treatment did not comprise the restraint of the less affected arm. 17 The 9 RCTs finally included in our revision involved a total of 243 patients (113 CIMT patients and 130 control patients). The number of patients included in each single trial ranged from to 9. In all studies, positive results were defined by a P value <0.05. Study characteristics and results (summarized as either = positive for the experimental group, or 0 = no difference with respect to the control group) and reviewers ratings are presented in Table I. Methodological quality ratings were discordant only for 3 studies, but for all of them assessors finally found an agreement. Final scores ranged from 5 7 to In all studies, eligibility criteria were specified and a method of randomisation was applied; in none of the studies was the patient or the care provider blinded. Only in one study 5 there was both a short- and a long-term follow-up. For all studies eligibility criteria were: ability to extend at least 10 at the metacarpo-phalangeal and interphalangeal joints and 20 at the wrist; disability in activities of daily living when using the affected upper extremity; no excessive spasticity; no problems with balance; no severe cognitive deficits; no severe uncontrolled medical disorders. In the experimental groups, in studies 5-7, 11, 13, 1 the treatment lasted and the training lasted h per day; only in one study on acute stroke patients the training was limited to 2 h per day because of fatigue. In the other 3 studies 8, 9, 12 the treatment lasted 10 weeks and was a modified CIMT: 30 min of physical 140 EUROPA MEDICOPHYSICA June 2007

3 THE CONSTRAINT INDUCED MOVEMENT THERAPY BONAIUTI therapy and 30 min of occupational therapy, twice per week, and a restraint of the unaffected limb for 5 h per day, for 5 days per week. The restraint was considered as a necessary component of the training program in all studies and lasted from 5 h up to 90% of waking time during the day. In one study, 1 duration of restraint was progressively increased, from 1 to h. Whereas 2 studies 7, 11 contrasted experimental and control treatments of different intensity, the other studies used the same daily session duration for the experimental and control techniques. The final assessment was always performed once, at the end of the treatment, except for one study 5 that extended the follow-up to and 12 months after the end of the therapy. In each study one or more outcome measures were applied. The main outcome measures recorded are presented in Tables II, III, IV. The ones that were more frequently used were the Action Research Arm Test (ARA) (8 studies), the Motor Activity Log (MAL) (5 studies), the Fugl Meyer assessment (FMA) (5 studies), the Wolf Motor Function test (WMFT) (2 studies). Five studies 5, 7, included chronic stroke patients, three 8, 9, 1 subacute and one acute stroke patients. Only in one study 5 were results described separately in patients with motor and sensory deficits, showing a significantly higher effectiveness in the latter ones. A MCID, i.e. a difference of at least 10% in post-treatment improvement between the experimental and the control groups, was reached only in smaller studies. Discussion With respect to past revisions, 3, in the present overview we have included some new studies, 13, 1 with 43 more subjects undergone CIMT and compared to 49 more control patients. The CIMT applied in these studies seems less stringent than that described previously, either as to restraint or to training. In the study by Dromerick et al., patients were restrained with a padden mitten; in the study by Ploughman et al., 1 the time of restraint progressively augmented from 1 h up to a mean duration of 2.7 h per day. Besides, Ploughman et al. did not use any specific training but the forced use of the impaired limb during the restraint. All the RCTs considered describe different versions of CIMT: although the forced use of the hemiparetic limb was the key element of treatment in all studies, different kinds of restraint and training have been applied. Moreover, control groups could have the same or a different sessions duration and the sample size was sometimes very small. These elements heavily influence the conclusions about the effectiveness of a therapy. Even adding the above mentioned new studies, we still have too much heterogeneity and insufficient data to try drawing any conclusions about the effectiveness of the CIMT, as did the past reviews. In our revision we considered only the studies that did not have discrepancy in the duration or intensity of the training between the experimental and the control groups, 5,, 9, 12, 1 thus avoiding the bias of a more intensive treatment in the former groups. 23 Like in the past reviews, we found the obstacle of the lack of homogeneity in the outcome measures. We recorded mainly tests at the impairment level (WMFT), at the focal disability level (ARA, FMA) and subjective measures (MAL): these instruments have different ceiling effects and accuracy as to dexterity, ability and speed of movement. Their results could not be translated into improvements in the activities of daily living. The MAL could be a better tool for assessing this aspect. 24 However, as outlined by Van der Lee et al., 25 this measure has some reliability problem and, given that it is a subjective scoring by patients who are heavily invested in the treatment, it is an unblinded rating of arm use. 2 In his meta-analysis,18 Van der Lee showed that effect sizes calculated in 2 studies5, did not reach statistical significance (demonstrated using the 95% confidence intervals), even in larger studies. 5 In our revision as well we found a significant but minor effect for larger samples. 5, 13 This suggests that the efficacy of the method might reveal less important in future multi- center studies. 27, 28 In our review, we established the clinical relevance of the effects of the CIMT considering the minimal clinically important difference, defined as a change of at least 10% of the maximum score of the scale used. 5 The MCID permits to measure change with respect to the baseline and to avoid a ceiling effect of the scales. The MCID has been provided for all studies considered (Tables II, III, IV): excluding Suputtitada et al. s study, 13 it was reached only in the smaller studies,, 8, Vol No. 2 EUROPA MEDICOPHYSICA 141

4 BONAIUTI THE CONSTRAINT INDUCED MOVEMENT THERAPY TABLE I. Randomised clinical trials on Constraint Induced Movement Therapy included in the revision. Taub 7 Van der Lee 5 Dromerick Page 8 Page 9 Author Wittemberg 11 Page 12 Suputtitada 13 Emory Motor, Funct, AMAT, MAL ARA (primary), FMA, MAL ARA (primary), Barthel and FIM FMA (primary), ARA, MAL, WMFT FMA, ARA, MAL MAL, WMFT, AMPS (process skills) FMA, ARA, MAL ARA Outcomes Lenght of treatment Follow-up 1 month, 2 years 1, 2, 3, weeks, months, 12 months (at the end) Inclusions Chronic >1 year. Ability to extend at least 10 at the metacarpophalangeal and interphalangeal joints and 20 at the wrist, no problem balance, disability in ADL using the involved upper extremity, no serious cognitive deficits, no excessive spasticity, no serious uncontrolled medical problems, <75 years of age, right dominance Chronic >1 year. RA< year-old. MMSE>22, no balance problems, no severe aphasia Acute <14 days. Persistent hemiplegia like NIHSS 1-2, preserved cognitive function as indicated by 0 or 1 on the consciousness and neglect items of the NIHSS, presence of the protective response as indicated by scores of >3 on the upper arm item of the motor assessment scale, non upper limbs injuries or pathologies that limit the use before the stroke Subacute: 1- months. Ability to extend at least 10 at the metacarpophalangeal and interphalangeal joints and 20 at the wrist, modmmse >70, no haemorrhagic or bilateral lesions(including contra lateral lacunes), age years, no excessive spasticity defined by a score of 2 or higher on the modashworth Spasticity Scale, no excessive pain in the affected limb as measured by score of 4 or higher on a 10 point VAS, discharged from all forms of physical rehabilitation Subacute: 1- months. Ability to extend at least 10 at the metacarpophalangeal and interphalangeal joints and 20 at the wrist, modmmse >70, no haemorrhagic or bilateral lesions(including contralateral lacunes), age years, no excessive spasticity defined by a score of 2 or higher on the modashworth Spasticity Scale, no excessive pain in the affected limb as measured by score of 4 or higher on a 10 point VAS, discharged from all forms of physical rehabilitation Chronic >1 year. Functional impairment of the affected side(mal <2.7), ability to extend at least 10 at the metacapophalangeal and interphalangeal joints and 20 at the wrist Chronic >1 year. Ability to extend at least 10 at the metacarpophalangeal and interphalangeal joints and 20 at the wrist, modmmse >70, no haemorrhagic or bilateral lesions (including contralateral lacunes), age years, no excessive spasticity defined by a score of 2 or higher on the mod Ashworth Spasticity Scale, no excessive pain in the affected limb as measured by score of 4 or higher on a 10 point VAS, discharged from all forms of physical rehabilitation Chronic Ploughman 1 ARA, CMII 2weeks Subacute (< 4 months). First ictus, CMII 2-, MMSE >2 MAL: motor activity log; ARA: action research arm test; FMA: Fugl Meyer assessment of motor recovery after stroke; FIM: functional independence measure; WFMT: Wolf Motor Function Test; AMPS: Assessment of Motor and Process Skills; CMII: Chedoke-McMaster Impairment Inventory; AMAT: Arm Motor Activity test; EMF = emory motor function test. 142 EUROPA MEDICOPHYSICA June 2007

5 THE CONSTRAINT INDUCED MOVEMENT THERAPY BONAIUTI TABLE I. Randomised clinical trials on constraint induced movement therapy included in the revision. No. of Results Methodological patients Treatment Controls ( or 0) scores (max 19) ssss 4 patients. Restrain devices worn for 14 days during 90% of waking hours, h training focused on restoring the ability to use the affected limb in ADLs 33 patients, forced use therapy hobby-type activities and ADLs in group of 4 patients h/d. Restraint 11 patients, 2 h per day, 5 days per week for 2 consecutive weeks. Occupational therapy treatment: upper limbs training which used the affected arm as much as possible, with a variety of functional tasks. Restrain for at least h per day 2 patients modified CIMT: 30 min of physical therapy and 30 min of occupational therapy 3 times per week for. All of OT concentrated on affected limb use in functional tasks, most of physical therapy concentrated on affected limb stretching as well on dynamic/standing balance activities and gait training. Shaping to extend motor capacity beyond previous performances. Restrain 5 h/5days 4 patients modified CIMT: 30 min of physical therapy and 30 min of occupational therapy 3 times per week for. All of OT concentrated on affected limb use in functional tasks, most of physical therapy concentrated on affected limb stretching as well on dynamic/standing balance activities and gait training. Shaping to extend motor capacity beyond previous performances. Restraint 5 h/d 9 patients restraint h/d (4 h/d in weekend): hand splint and sling ensemble h/d PT, OT and recreational therapy, improving motor tasks performance by successive approximation 7 patients modified CIMT: 30 min of physical therapy and 30 min of occupational therapy 3 times/week for. OT concentrated on affected limb use in functional tasks, PT concentrated on affected limb stretching as well on dynamic/standing balance activities and gait training. Shaping to extend motor capacity beyond previous performances. Restrain 5 h/5days 33 patients h of daily affected upper extremity training. Restraint for 5 d/w 10 patients forced use therapy (FUT): only restraint involving wearing a mitten from the fingers to the elbow on the unaffected hand, progressively from 1 h to h/day, and conventional treatment 5 patients 2 sessions of passive range of movement, exercises on muscle tone etc., 10 min sessions where patients were told that they had much greater ability with their affected limb, daily 15 min exercises at home 33 patients bimanual training (neurodevelopmental treatment NDT) h/d 9 patients. The same intensity of the CIM group. Occupational therapy treatment: compensatory techniques for ADL, strength and ROM 2 patients: TR: 30 min of physical therapy and 30 min of occupational therapy 3 times per week for. During the majority of PT and OT some compensatory techniques 2 patients: controls: no therapy 5 patients TR: 30 min of physical therapy and 30 min of occupational therapy 3 times per week for. During the majority of PT and OT some compensatory techniques patients no therapy 7 patients 3 h/day on weekdays and no on weekends, training aimed to improve task performance with the non affected side and passive therapy 4 patients TR: 30 min ofpt and 1 30 min of OT 3 times/week for. Neuromuscular facilitation PNF. During the majority of PT and OT some compensatory techniques patients controls: no therapy 3 patients bimanual upper extremity training by conservative neurodevelopmental technique 13 patients conventional treatment Vol No. 2 EUROPA MEDICOPHYSICA 143

6 BONAIUTI THE CONSTRAINT INDUCED MOVEMENT THERAPY TABLE II. Action research arm test: results at baseline to end of treatment (change related to the maximum score of 57). Authors Change treatment- controls (%) No. of patients Pretest Post-test Change Pretest Post-test Change treatment SD treatment SD treatment control SD control SD controls mean mean (%) mean mean (%) Acute Dromerick (44.7) (28.7) (1) Acute Suputtitada (30-57) (15-54) 4 5 (15.8) (8.4) (8,7) Subacute Page Not 37.3 Not C1 Not 48 CI Not ,1 C1=treatment avai- avai- (20.2) 37 C2 avai- 3. C2 avai- (2.4) C1 (17.7) C2=control lable lable lable lable (1.2) C2 (21.4) Subacute Page Not 53 Not C1 Not 49 C1 Not C1= avai- avai- (27.2) 50 C2= avai- 51 C2 avai- (5.2) (21.9) treatment lable lable lable lable (1.7) (25.4) Subacute Ploughman Not avai- (85) Not avai- (74) (11) lable lable Chronic Page Not 37.8 Not C1 Not 27.5 C1 Not C1=treatment avai- avai- (20) 28.3 C2 avai C2 avai- (12.4) C1 (25.1) C2=control lable lable lable lable (7.9) C2 (27:9) Chronic Van der Lee , (10.2) (2.9) (7.2) TABLE III. Fugl Meyer assessment scale: results at baseline to end of treatment (change related to the maximum score of 55). Authors Change treatment- controls (%) No. of patients Pretest Post-test Change Pretest Post-test Change treatment SD treatment SD treatment control SD control SD controls mean mean (%) mean mean (%) Subacute Page Not 43 Not C1 Not 49.4 CI Not -0.9 C1 12,3 C1=treatment avai- avai- (20.7) 37 C2 avai- 39. C2 avai- (-1.) (22) C2=control lable lable lable lable 2. C2 8.8 (4.7) (1) Subacute Page Not 50.5 Not C1 Not 55.5 C1 Not C1=treatment avai- avai- (1.8) 57.5 C2 avai- 57 C2 avai- (-1.3) (18) C2=control lable lable lable lable (0.9) (17.) Chronic Page Not 49.2 Not C1 Not 49.2 C1 Not C1 2.4 C1=treatment avai- avai- (33.4) C2 avai C2 avai- (10.9) (4.3) C2=control lable lable lable lable -2.9 C (5.3) (20.5) Chronic Van der Lee (1.8) (0.1) (18) 9, 12 whose results might have been influenced by patients characteristics. In van der Lee s study, 5 the MCID was reached in a subgroup of patients with chronic sensory disorders: in the Author s opinion, this means that the learned non-use phenomenon exists only as a consequence of the loss of sensory feedback, as demonstrated in the original theory developed in deafferented monkeys 144 EUROPA MEDICOPHYSICA June 2007

7 THE CONSTRAINT INDUCED MOVEMENT THERAPY BONAIUTI TABLE IV. Motor activity log: results from baseline to end of treatment (change related to the maximum score of 5). Authors Change treatment- controls (%) No. of patients Pretest Post-test Change Pretest Post-test Change treatment SD treatment SD treatment control SD control SD controls mean mean (%) mean mean (%) Amount of use Subacute Page Not 3.10 Not C1 Not 1.2 CI C1=treatment avai- avai- (70) 0. C2 avai- 1 C2 (10) (0) C2=control lable lable lable (8) (2) Chronic Van der Lee (14) (10) (4) Chronic (Total MAL) Not Not Wittemberg 1 avai- Not avai- available lable lable Quality of use Subacute Page Not 2.03 Not C1 Not 0.3 CI Not C1=treatment avai- avai- (50) 0.5 C2 avai- 0. C2 avai- () (7) C2=control lable lable lable lable (-2) (72) Chronic Van der Lee (10) (10) (0) Chronic Taub 1 9 Not Not 2 Not Not avai- avai- (40) avai- avai- (8) (32) lable lable lable lable with no permanent motor impairment. 29 In no other study were patients with sensory and with motor impairment considered separately. The efficacy of treatment found in some studies could be attributed to another reason than the restraint and into the quality of the forced use: the intensive behavioural training aid to transfer the gains made in the clinic to the life. 30 Taub outlines the importance of a 1 week training for therapists that are about to start CIMT and the too limited attention paid to the affected arm during treatment in most published trials. 31 Although the content of the training sessions is not described in all studies, the majority of them uses occupational therapy, with shaping extended motor capacity beyond previous performances. 32 The duration of restraint, corresponding to 90% of the waking time in the first study, 7 reached a maximum of h per day in the successive studies: however, this does not seem a relevant issue for the efficacy of the treatment; indeed, it improves the adherence to therapy. Only few studies consider the problem of patient s compliance and adherence to the training (forced use with restraint). In the study by Ploughman et al. 1 none of the subjects included in the experimental group achieved the maximum time of restraint planned, despite repeated encouragement; they only reached 1/3 of the scheduled duration. Only Wittemberg et al. 11 record that all subjects were compliant and Van der Lee et al. 5 describe the withdrawals, but not patients adherence. This is a very important methodological issue, that should be addressed in future trials. Conclusions Since Taub s studies, 1, 2, 7 many trials have been carried out on CIMT. Most of them have a too small sample and do not show homogeneity in the assessment methods, what hampers any conclusion about the effectiveness of the treatment. The conclusion of this revision is unsatisfactory like most of the revision in rehabilitation: the studies suggest an effectiveness of CIMT in stroke patients but multicenter trials are needed to overcome the problem of small sample size (and one such trials is actually Vol No. 2 EUROPA MEDICOPHYSICA 145

8 BONAIUTI THE CONSTRAINT INDUCED MOVEMENT THERAPY ongoing) 33 and until the positive results of some study are replicated in independent research centres, on larger populations, using more robust outcome measures in poststroke sensory and motor disorders, it necessary to be cautious about the effectiveness of this rehabilitation therapy. References 1. Taub E. Movement in non human primates deprived of somatosensory feedback. In: Keogh JF editor. Exercise and Sports sciences reviews. Santa Barbara: Journal Publishing Affiliates; 1977.p Taub E, Wolf SL. Constraint-induced movement techniques to facilitate the upper extremity use in stroke patients. Top Stroke Rehabil 1997;3: van der Lee JH. Constraint induced movement therapy: some thoughts about theories and evidence. J Rehabil Med 2003;41 Suppl: van Tulder MW, Assendelft WJ, Koes BW, Bouter LM. Method guidelines for systematic reviews in the Cochrane Collaboration Back Review Group for Spinal Disorders. 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Effectiveness of modified constraint-induced movement therapy on upper limb function in stroke patients. Acta Neurol Taiwan 2005;14: van der Lee JH. Constraint-induced therapy after stroke: more of the same or something completely different? Curr Opin Neurol 2001;14: Wolf SL, Blanton S, Baer H,Breshears J, Butler A. Repetitive task practice: a critical review of constraint-induced movement therapy in stroke. Neurologist 2002;8: Hakkennes S, Keating JL. Constraint-induced movement therapy following stroke: a systematic review of randomised controlled trials. Aust J Physiother 2005;51: Grotta JC, Noser EA, Ro T, Boake C, Levin H, Aronowski J, Schallert T. Constraint-induced movement therapy. Stroke 2004;35 (11 Suppl 1): Siegert RJ. Constraint-induced movement therapy: time for a little restraint? Clin Rehabil 2004;18: van der Lee JH, Snels I AK, Beckerman H, Lankhorst GJ. Exercise therapy for arm function in stroke patients: a systematic review of randomised controlled trials. Clin Rehabilitation 2001;15: Taub E, Uswatte G, Mark VW, Morris DM. The learned non use phenomenon: implication for rehabilitation. Eura Medicophys 200;42: van der Lee JH, Beckerman H, Lankhorst GJ, Bouter LM. Constraintinduced movement therapy. Phys Ther 2000;80: Dromerick AW. Evidence-based rehabilitation: the case for and against constraint-induced movement therapy. J Rehabil Res Dev 2003;40:vii-ix. 27. Alberts JL, Butler AJ, Wolf SL. The effects of constraint-induced therapy on precision grip: a preliminary study. Neurorehabil Neural Repair 2004;18: Wolf SL, Thompson PA, Morris DM, Rose DK, Winstein CJ, Taub E et al. The EXCITE trial: attributes of the Wolf Motor Function Test in patients with subacute stroke. Neurorehabil Neural Repair 2005;19: Taub E. Somatosensory deafferentation research with monkeys: implications for rehabilitation medicine. In: Ince LP editor. Behavioral psychology in rehabilitation medicine: clinical applications. Baltimore; Williams and Wilkins; p Smania N. CI therapy: an original concept in rehabilitation. Eura Medicophys 200;42: Taub E. Constraint- induced movement therapy and massed practice. Stroke 2000;31: Morris DM, Taub E, Mark VW. Contraint-induced movement therapy (CI therapy): characterizing the intervention protocol. Eura Medicophys 200;42: Winstein CJ, Miller JP, Blanton S, Taub E, Uswatte G, Morris D et al. Methods for a multisite randomized trial to investigate the effect of constraint-induced movement therapy in improving upper extremity function among adults recovering from a cerebrovascular stroke. Neurorehabil Neural Repair 2003;17: EUROPA MEDICOPHYSICA June 2007