Effect of constraint-induced movement therapy on lower extremity motor dysfunction in post-stroke patients: A systematic review and meta-analysis

Abstract

Objective: Constraint-induced movement therapy (CIMT) is a common treatment for upper extremity motor dysfunction after a stroke. However, whether it can effectively improve lower extremity motor function in stroke patients remains controversial. This systematic review comprehensively studies the current evidence and evaluates the effectiveness of CIMT in the treatment of post-stroke lower extremity motor dysfunction.

Methods: We comprehensively searched randomized controlled trials related to this study in eight electronic databases (PubMed, Embase, The Cochrane Library, Web of Science, CBM, CNKI, WAN FANG, and VIP). We evaluated CIMT effectiveness against post-stroke lower extremity motor dysfunction based on the mean difference and corresponding 95% confidence interval (95% CI). We assessed methodological quality based on the Cochrane Bias Risk Assessment Tool. After extracting the general information, mean, and standard deviation of the included studies, we conducted a meta-analysis using RevMan 5.3 and Stata 16.0. The primary indicator was the Fugl-Meyer Assessment scale on lower limbs (FMA-L). The secondary indicators were the Berg balance scale (BBS), 10-meter walk test (10MWT), gait speed (GS), 6-min walk test (6MWT), functional ambulation category scale (FAC), timed up and go test (TUGT), Brunnstrom stage of lower limb function, weight-bearing, modified Barthel index (MBI), functional independence measure (FIM), stroke-specific quality of life questionnaire (SSQOL), World Health Organization quality of life assessment (WHOQOL), and National Institute of Health stroke scale (NIHSS).

Results: We initially identified 343 relevant studies. Among them, 34 (totaling 2,008 patients) met the inclusion criteria. We found that patients treated with CIMT had significantly better primary indicator (FMA-L) scores than those not treated with CIMT. The mean differences were 3.46 (95% CI 2.74-4.17, P < 0.01, I2 = 40%) between CIMT-treated and conventional physiotherapy-treated patients, 3.83 (95% CI 2.89-4.77, P < 0.01, I2 = 54%) between patients treated with CIMT plus conventional physiotherapy and patients treated only with conventional physiotherapy, and 3.50 (95% CI 1.08-5.92, P < 0.01) between patients treated with CIMT plus western medicine therapy and those treated only with western medicine therapy. The secondary indicators followed the same trend. The subgroup analysis showed that lower extremity CIMT with device seemed to yield a higher mean difference in FMA-L scores than lower extremity CIMT without device (4.52, 95% CI = 3.65-5.38, P < 0.01 and 3.37, 95% CI = 2.95-3.79, P < 0.01, respectively).

Conclusion: CIMT effectively improves lower extremity motor dysfunction in post-stroke patients; however, the eligible studies were highly heterogeneous.Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=277466.

Keywords: constraint-induced movement therapy; lower extremity; meta-analysis; motor dysfunction; post-stroke.

Figure 1

Flow diagram of the study inclusion and exclusion process.

Figure 2

Forest plot. CIMT vs. conventional physiotherapy on the Fugl-Meyer Assessment total score (A) and Fugl-Meyer Assessment lower limb sub-scale (B,C).

Figure 3

Forest plot. CIMT vs. conventional physiotherapy on the Berg balance scale.

Figure 4

CIMT vs. conventional physiotherapy on the 10-meter walk test (A) and gait speed (B).

Figure 5

Forest plot. CIMT vs. conventional physiotherapy on the timed up and go test (A,B) and functional ambulation category scale (C).

Figure 6

Forest plot. CIMT vs. conventional physiotherapy on the modified Barthel index (A,B) and functional independence measure (C).

Figure 7

Forest plot. CIMT vs. conventional physiotherapy on the stroke-specific quality of life questionnaire (A) and World Health Organization quality of life assessment (B).

Figure 8

Forest plot. CIMT plus conventional physiotherapy vs. conventional physiotherapy alone on the Fugl-Meyer Assessment total score (A) and Fugl-Meyer Assessment lower limb sub-scale (B,C).

Figure 9

Forest plot. CIMT plus conventional physiotherapy vs. conventional physiotherapy alone on the Berg balance scale.

Figure 10

Forest plot. CIMT plus conventional physiotherapy vs. conventional physiotherapy alone on the 10-meter walk test [(A) s; (B) m/s].

Figure 11

Forest plot. CIMT plus conventional physiotherapy vs. conventional physiotherapy alone on the 6-min walk test (A,B), functional ambulation category scale (C), timed up and go test (D,E), weight-bearing (F) and Brunnstrom stage of lower limb function (G).

Figure 12

Forest plot. CIMT plus conventional physiotherapy vs. conventional physiotherapy alone on the modified Barthel index.

Figure 13

Forest plot. CIMT plus western medicine therapy vs. western medicine therapy alone on the Fugl-Meyer Assessment lower limb sub-scale (A), functional ambulation category scale (B) and National Institute of Health stroke scale (C).

Figure 14

Forest plot. CIMT with device vs. CIMT without device on the Fugl-Meyer Assessment lower limb sub-scale.