Effects of Lower Limb Constraint Induced Movement Therapy in People With Stroke: A Systematic Review and Meta-Analysis

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Effects of Lower Limb Constraint Induced Movement Therapy in People With Stroke: A Systematic Review and Meta-Analysis

Auwal Abdullahi^1,2*, Steven Truijen², Naima A. Umar³, Ushotanefe Useh⁴, Victor A. Egwuonwu⁵, Tamaya Van Criekinge² and Wim Saeys²

• ¹Neurological Rehabilitation Unit, Department of Physiotherapy, Bayero University Kano, Kano, Nigeria
• ²Department of Rehabilitation Sciences and Physiotherapy, University of Antwerp, Wilrijk, Belgium
• ³Department of Physiotherapy, Muhammad Abdullahi Wase Teaching Hospital, Kano, Nigeria
• ⁴Lifestyle Diseases Research Entity, Faculty of Health Sciences, North-West University, Mmabatho, South Africa
• ⁵Department of Medical Rehabilitation, Nnamdi Azikiwe University, Awka, Nigeria

Background: Constraint induced movement therapy (CIMT) is effective at improving upper limb outcomes after stroke.

Aim: The aim of this study was to carry out a systematic review and meta-analysis of the effects of lower limb CIMT studies of any design in people with stroke.

Materials/ Method: PubMED, PEDro, OTSeeker, CENTRAL, and Web of Science were searched from their earliest dates to February 2021. Lower limbs CIMT studies that measured outcomes at baseline and post-intervention were selected. Sample size, mean, and standard deviation on the outcomes of interest and the protocols of both the experimental and control groups were extracted. McMaster Critical Review Form was used to assess the methodological quality of the studies.

Result: Sixteen studies with different designs were included in this review. The result showed that lower limb CIMT improves functional, physiological and person's reported outcomes including motor function, balance, mobility, gait speed, oxygen uptake, exertion before and after commencement of activities, knee extensor spasticity, weight bearing, lower limb kinematics and quality of life in people with stroke post intervention. However, there were only significant differences in quality of life in favor of CIMT post-intervention [mean difference (MD) = 16.20, 95% CI = 3.30–29.10, p = 0.01]; and at follow-up [mean difference (MD) = 14.10, 95% CI = 2.07–26.13, p = 0.02] between CIMT and the control group. Even for the quality of life, there was significant heterogeneity in the studies post intervention (I² = 84%, p = 0.01).

Conclusion: Lower limb CIMT improves motor function, balance, functional mobility, gait speed, oxygen uptake, weigh bearing, lower limb kinematics, and quality of life. However, it is only superior to the control at improving quality of life after stroke based on the current literature.

Introduction

Constraint Induced Movement Therapy (CIMT) is a translational motor rehabilitation technique following injury of the Central Nervous System (CNS). The technique originated many decades ago from use in primates; and was translated to humans following stroke and other neurological conditions (1). The original concept involved constraint of the unaffected limb and forced use of the affected one (2). Subsequent studies in humans involved voluntary massed tasks or shaping practices with the affected limb. Consequently, CIMT has been reported to be effective at improving real world arm use, motor function, and kinematic outcomes by inducing changes in the functions and structures of the brain (3–7). However, there have been many modifications over the years of the original protocol of CIMT, including but not limited to the length of time for the tasks practice, the constraint, and the use of a transfer package (7–9).

The effects of CIMT on the recovery of motor function of the upper limb have been well-investigated (7, 10). The practicability of the protocol for upper limbs could be because of the unilateral nature of the use of these limbs in most of our activities of daily living (ADL). For the lower limbs, this may seem difficult since humans are bipedal, and this requires them to use the two limbs simultaneously for ADL especially during walking. However, the positive results in the recovery of motor function of the upper limb following CIMT persuaded the neuroscientific community to consider translating the technique to the lower limbs. Consequently, a lower limb CIMT protocol was designed to comprise mainly of intensive practice with the affected limb, shaping activities, transfer package, and encouraging the increased use of the affected limb (11). So far, there are several small sample size studies that have investigated the effects of lower limb CIMT on gait parameters, balance, and motor function using different study designs such as case reports, experimental studies, quasi-experimental studies, and randomized controlled trials (RCTs) (12). These studies reported that lower limbs CIMT improved gait speed, step length, motor function, functional mobility, balance, and kinematic outcomes. However, small sample size studies may overestimate the effect of an intervention (13–15). Second, the only difference in the protocols of the CIMT and control groups was the use of a constraint in the CIMT group, with no difference in the types of tasks used in most of these studies, including the intensity. According to Abdullahi, task practice is the most important component of CIMT (16, 17). Therefore, it is possible that the effects of lower limb CIMT reported in those studies were overestimated.

In addition, in upper limb CIMT constraint is used to immobilize the unaffected limb to prevent movement at joints essential for the functioning of the limb. This is to done to maximize the use of the affected limb, and to help recover function. However, for lower limb CIMT, the types of constraints used include encouraging weight bearing on the affected limb, the use of an insole in the affected limb, the use of knee braces or a splint, and attaching weight to the ankle of the affected limb (12). Constraining one of the limbs may cause asymmetry which could negatively affect normal functions such as walking, especially since humans are bipedal. The aim of this study was to therefore carry out a systematic review and meta-analysis on the effects of lower limb CIMT on outcomes after stroke such as gait parameters, balance, motor function, functional mobility, and quality of life. This review sought to answer this question: What are the effects of lower limb CIMT on this information is important as, to date, there does not seem to be any review and/ or meta-analysis on the effects of lower limb CIMT following stroke.

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