Constraint-Induced Movement Therapy in Children With Hemiplegic Cerebral Palsy: A Scoping Review of Functional Outcomes and Neuroplasticity-Related Evidence
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To synthesize the available evidence on the effects of constraint-induced movement therapy (CIMT) in children with hemiplegic cerebral palsy (CP), focusing on upper limb functional outcomes and neuroplasticity-related changes assessed through direct or indirect measures.
Methods
This scoping review was conducted in accordance with PRISMA-ScR guidelines and was prospectively registered on the Open Science Framework (DOI: 10.17605/OSF.IO/DU8RE). A search of four databases (PubMed, Scopus, Embase, and Web of Science) was performed to identify studies involving children (0–18 years) with CP who received CIMT as the primary intervention. Eligible studies assessed neuroplasticity through neuroimaging or neurophysiological techniques.
Results
Eleven studies involving 221 children met the inclusion criteria. CIMT protocols varied in duration, intensity, and setting (e.g., clinical, home-based, camp-based). Across studies, CIMT was associated with improvements in upper limb function and spontaneous use. Neuroplastic changes included increased activation in the contralateral sensorimotor cortex, normalization of somatosensory responses, and structural brain adaptations. Adjunctive therapies such as repetitive transcranial magnetic stimulation, transcutaneous auricular vagus nerve stimulation, or occupational therapy further enhanced outcomes.
Conclusion
CIMT is an effective intervention that promotes cortical reorganization and improves motor function in children with hemiplegic CP. Customizing rehabilitation based on neurophysiological profiles may optimize clinical outcomes.
Recent investigations into cerebral palsy (CP) have underscored the critical involvement of somatosensory system dysfunction in the emergence of atypical motor patterns. The primary somatosensory cortex (S1), also known as the postcentral gyrus, is situated in the parietal lobe and plays an essential role in the processing of afferent sensory inputs from the body, including tactile stimuli, temperature, nociception, and proprioception [1,2]. Once these sensory signals reach S1, they are integrated and interpreted to support accurate perceptual awareness and facilitate the generation of appropriate motor outputs. A hallmark of the somatosensory cortex is its somatotopic organization: discrete cortical territories correspond to specific regions of the body. This organizational principle was first elucidated by Wilder Penfield in the 1940s [3] through pioneering studies involving direct cortical stimulation, leading to the development of the sensory homunculus, a schematic depiction in which the cortical representation of each body part is scaled in proportion to its sensory innervation density [3]. Notably, body regions such as the hands and lips occupy disproportionately large cortical areas due to their heightened tactile acuity and functional significance [2,3].
In individuals with CP, particularly in hemiplegic presentations, aberrant somatosensory processing frequently disrupts the feedback mechanisms critical for motor learning, resulting in impaired sensorimotor integration [4-6]. The asymmetry in functional capability between the affected and less affected upper limbs is often paralleled by differences in somatosensory processing [7]. Children with hemiplegic CP commonly develop an early preference for the use of the less affected limb in daily activities, even when impairment in the contralateral limb is relatively mild [8]. This compensatory behavior fosters a phenomenon referred to as “learned nonuse,” which further entrenches motor asymmetries.
Among the rehabilitative approaches aimed at counteracting this maladaptive pattern, constraint-induced movement therapy (CIMT) has emerged as a high-efficacy intervention. In a comprehensive evidence-based framework proposed by Novak and colleagues, CIMT was classified in the “green” category, indicating strong empirical support for its effectiveness [9]. The therapy involves intensive, task-specific training of the affected limb, thereby promoting functional use, enhancing intrinsic motivation, and leveraging experience-dependent neuroplasticity mechanisms.
Several systematic reviews, including the Cochrane review, have summarized the clinical effectiveness of CIMT in children with unilateral CP, largely focusing on school-aged populations and randomized controlled trials (RCTs). However, the extent to which CIMT induces neuroplastic changes, and how such changes are assessed through neuroimaging/neurophysiological measures or neuroplasticity-related proxies, has been less explicitly synthesized. Therefore, this scoping review aimed to map and synthesize the available evidence on the effects of CIMT in children with hemiplegic CP, with a focus on upper limb functional outcomes and neuroplasticity-related changes assessed through direct or indirect measures.
MATERIALS AND METHODS
Search strategy
This scoping review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines [10], to ensure transparency and methodological consistency (Supplementary Material S1). This review was prospectively registered on the Open Science Framework (OSF) under the DOI: 10.17605/OSF.IO/DU8RE.
A comprehensive literature search was conducted across four electronic databases: PubMed, Scopus, Embase, and Web of Science, without time restrictions, and encompassing all studies published up to January 2026. The search strategy combined MeSH (Medical Subject Headings) and free-text terms to identify studies addressing the effects of CIMT on neuroplasticity in children with CP (Supplementary Material S2). The search terms included: ((“Plasticity” OR “Neuroplasticity” OR “Neuronal Plasticity” OR “Cortical Reorganization” OR “Brain Reorganization”) AND (“Cerebral palsy” OR “Motor impairment” OR “Motor rehabilitation”) AND (“Cimt” OR “Constraint induced movement therapy” OR “mCIMT” OR “Modified CIMT”)).
Eligibility criteria
PCC Model
To ensure methodological rigor, the study selection process followed the PCC (Population, Concept, Context) framework, in line with the PRISMA-ScR guidelines [10]:
- Population: Studies that include pediatric participants (aged <18 years) with a clinical diagnosis of CP.
- Concept: Studies that investigated or applied CIMT as a primary intervention.
- Context: Studies that assessed neuroplasticity-related and/or functional outcomes associated with CIMT-based interventions, including measures of cortical reorganization, brain activity, neural mechanisms, or functional recovery, assessed through direct or indirect measures.
Inclusion criteria
Studies were included if they involved pediatric participants (aged <18 years) diagnosed with CP and investigated the application of CIMT as the primary intervention. Eligible studies had to assess neuroplasticity-related outcomes and/or functional outcomes considered as indirect markers of experience-dependent plasticity, such as cortical reorganization, changes in brain activity, or functional recovery, assessed through neurophysiological, neuroimaging, or standardized functional outcome measures. Studies in which CIMT was delivered alone or in combination with adjunctive interventions (e.g., neuromodulation or occupational therapy) were included, provided that CIMT represented a core component of the rehabilitation protocol. Only peer-reviewed experimental, quasi-experimental, and clinical studies published in English were considered.
Exclusion criteria
Studies were excluded if they involved adult populations or animal models, or if CIMT was not the main intervention. Additional exclusions included case reports, systematic reviews, meta-analyses, conference abstracts, narrative reviews, study protocols, and methodological papers without empirical data. Studies not available in full text or not published in English were also excluded.
A PRISMA-ScR flowchart summarizing the study selection process and exclusion reasons is presented in Fig. 1.
Study selection
The search results from all databases were imported into Rayyan, where duplicates were identified and removed. Two independent reviewers (MCV, RM) conducted a blind screening of titles and abstracts to determine eligibility based on predefined criteria. Disagreements were resolved through discussion or consulting with a third reviewer (MGM). The inter-rater agreement was 84%. Full-text articles of selected studies were then independently reviewed by the same reviewers, with conflicts resolved similarly.
Data extraction and charting
Data extraction was independently performed by MCV and RM using a structured form in Microsoft Excel. Extracted variables included study design, participant characteristics (sample size, age, sex), intervention details, and neuroplasticity-related outcomes. Data consistency was ensured through cross-checking. Discrepancies resolved through consensus with MGM. Given the heterogeneity in study designs and outcomes, data were organized descriptively for narrative synthesis.
Data synthesis
Due to substantial variability in interventions and outcome measures, a meta-analysis was not feasible. Instead, a qualitative narrative synthesis was conducted using the SWiM (Synthesis Without Meta-analysis) framework [11]. This approach facilitated the identification of patterns and themes across studies regarding CIMT effectiveness, neuroplasticity outcomes, and gender-related differences. Table 1 summarizes the main characteristics of the included studies.
RESULTS
Study selection
A total of 488 records were identified through database searches: 46 from PubMed, 71 from Scopus, 265 from Embase, and 106 from Web of Science. All records were imported into the Rayyan review software, where 58 duplicates were identified and removed. This resulted in 107 records available for title and abstract screening, which was independently performed by two reviewers within the Rayyan platform. Following this phase, 33 articles were selected for full-text assessment. Of these, 6 were excluded due to the unavailability of the full-text PDF. As a result, 11 studies met the inclusion criteria and were included in the qualitative synthesis.
A detailed overview of the selection process, including reasons for exclusion at each stage, is provided in the PRISMA-ScR flow diagram (Fig. 1).
Overview of included studies
This scoping review included 11 studies, involving a total of 221 children with hemiparetic CP, aged between 10 months and 19 years. The studies adopted a range of designs, including RCTs [12,13], experimental studies with or without neurophysiological assessment, and camp-based interventional designs. The research was conducted across North America, Europe, and Asia.
All studies investigated the effects of CIMT or modified CIMT (mCIMT), with protocols varying in duration (5 days to 3 weeks), frequency (daily to alternate days), and total treatment hours ranging from 30 to 90 hours. Some interventions were delivered in camp-based or ecological settings [7,14], while others incorporated home tasks or group occupational therapy sessions. Several studies also included neurophysiological or imaging techniques to assess brain plasticity, such as magnetoencephalography (MEG), functional magnetic resonance imaging (fMRI), functional near-infrared spectroscopy, transcranial magnetic stimulation (TMS), and diffusion tensor imaging.
Adjunct therapies were integrated into many protocols. For example, repetitive TMS (rTMS) was paired with CIMT in three studies [13,15,16], and transcutaneous auricular vagus nerve stimulation (taVNS) was used in combination with CIMT in infants in the study by McGloon et al. [17] Occupational and/or physical therapy was frequently added to reinforce functional training, as in the studies by Jobst et al. [18], Manning et al. [19], and Matusz et al. [7].
Despite the heterogeneity in interventions and outcome measures, CIMT was generally well tolerated. Dropouts were minimal and mostly related to technical limitations during neuroimaging (e.g., MRI anxiety, incomplete scans). No adverse events directly attributable to CIMT were reported.
Across all studies, CIMT was consistently associated with functional improvements in upper limb use, alongside evidence of neuroplasticity, including increased sensorimotor activation, reorganization of cortical networks, and structural brain changes. These findings reinforce the role of CIMT as an effective and adaptable intervention in pediatric neurorehabilitation.
Standard CIMT and treatment dosage
Several studies investigated conventional CIMT protocols and intensity levels. Sterling et al. [20] demonstrated that a 3-week CIMT program (3 hours/day) improved spontaneous upper limb use and was associated with increased gray matter volume in the contralateral sensorimotor cortex, as measured via voxel-based morphometry (VBM).
Similarly, Friel et al. [12] implemented a standard CIMT protocol of 6 hours per day for 15 consecutive weekdays (totaling 90 hours) in children with unilateral CP, reporting significant gains in bimanual function and cortical reorganization.
Coker et al. [21] adopted a shorter CIMT protocol (6 hours/day for 5 consecutive days), which still fulfilled the core criteria of standard CIMT. Although the study primarily focused on gait parameters, such as stability and symmetry, it highlights the potential feasibility and benefits of brief, high-intensity CIMT formats.
These findings support the effectiveness of traditional CIMT dosing schedules, whether intensive or brief, in promoting functional and, in some cases, neuroplasticity-related outcomes.
CIMT combined with occupational and physical therapy
CIMT is frequently paired with occupational therapy to enhance sensorimotor outcomes. Jobst et al. [18] implemented a 3-week CIMT protocol incorporating 40 hours of occupational therapy, reporting improvements in paretic hand use and somatosensory processing, supported by MEG and MRI data.
Similarly, Manning et al. [19] delivered CIMT alongside 20 hours per week of occupational therapy over three weeks, observing functional gains in upper limb use and sensorimotor network reorganization via fMRI.
Although Matusz et al. [7] did not include a combined OT program, the study demonstrated normalization of sensory responses in somatosensory areas of the affected hemisphere following CIMT, as measured by fMRI.
In addition, Friel et al. [12] compared CIMT with Hand-Arm Bimanual Intensive Therapy (HABIT) within a camp-based setting (6 hours/day for 3 weeks), reporting similar improvements in upper limb function and evidence of cortical reorganization through MRI.
CIMT combined with neuromodulation
Several studies have explored the combination of CIMT with neuromodulation. Gillick et al. [13] integrated CIMT with low-frequency rTMS in a randomized trial: 80% of children in the active rTMS group surpassed the minimal detectable change threshold in Assisting Hand Assessment (AHA) scores versus 22% in the sham group. Mufti et al. [22] applied rTMS priming followed by 1 Hz stimulation combined with mCIMT, reporting enhanced upper limb function (Quality of Upper Extremity Skills Test, QUEST), reduced spasticity (Modified Ashworth Scale, MAS), and neurophysiological changes. Kuo et al. [15] found functional improvements and increased cortical excitability after a 10-day rTMS+ CIMT intervention. McGloon et al. [17] explored the use of taVNS paired with CIMT, reporting gross motor improvements and plasticity, driven functional gains, supporting taVNS as a safe and promising adjunct for pediatric neurorehabilitation.
In these studies, neuromodulation techniques such as rTMS were implemented as adjunctive interventions, and neurophysiological measures (e.g., motor threshold or cortical excitability) were used to characterize between-group differences related to neuromodulation, rather than to directly assess neuroplastic changes induced by CIMT alone.
CIMT in camp-based and ecological settings
Delivering CIMT in enriched, structured environments such as therapeutic camps has shown promising results. Cao et al. [14] implemented a camp-based CIMT protocol (6 hours/day for 2 weeks), reporting sustained improvements in upper limb function (Melbourne Assessment, AHA) and a shift in cortical activation from the ipsilateral to the contralateral hemisphere. Similarly, Friel et al. [12] examined the efficacy of CIMT and HABIT within a camp setting (6 hours/day for 3 weeks), observing comparable gains in hand function and cortical reorganization. In contrast, Cope et al. [16] evaluated a home-based wearable CIMT model (2 hours/day for 3 weeks), which was found to be feasible and acceptable, with positive trends in affected arm use. These findings suggest that both structured camp-based and ecological home-based CIMT interventions may effectively promote functional outcomes in children with unilateral CP.
Functional and neuroplastic outcomes
Most of the included studies assessed upper limb function using standardized outcome measures such as the AHA [12-14], QUEST [22], Jebsen–Taylor Test of Hand Function (JTTHF) [20], and the Pediatric Motor Activity Log (PMAL) [16]. In addition, some studies employed goal-oriented or participation-level measures such as the Canadian Occupational Performance Measure (COPM) [16], Goal Attainment Scaling (GAS) [17], ABILHAND-Kids, and Pediatric Evaluation of Disability Inventory (PEDI) [18].
Neurophysiological and imaging-based outcomes were explored in a subset of the studies. For example, Sterling et al. [20] reported increased gray matter volume in the contralateral sensorimotor cortex using VBM; Cao et al. [14] observed a shift in cortical activation patterns using fMRI; Matusz et al. [7] and Jobst et al. [18] described sensory system reorganization through MEG and EEG. Changes in cortical excitability and organization were also documented using TMS [13,15].
Taken together, these findings suggest that CIMT interventions in pediatric populations are associated not only with functional improvements in upper limb use but also with measurable neuroplastic adaptations across different modalities of assessment.
DISCUSSION
This scoping review aimed to synthesize the available evidence on cortical neuroplastic adaptations associated with CIMT in children with hemiparetic CP. The 11 included studies suggest that CIMT, across various protocols and delivery modalities, can influence neuroplastic mechanisms in the developing brain.
Intervention parameters varied widely, with total durations ranging from 15 to 90 hours and daily sessions from 1 to 6 hours. In several studies, CIMT was delivered in combination with other approaches, such as occupational therapy, neuromodulation (e.g., rTMS or taVNS), or within enriched environments like therapeutic camps. Despite this heterogeneity, the reviewed studies consistently reported evidence of measurable cortical reorganization, particularly in the sensorimotor areas contralateral to the affected limb.
Several studies reported increased activation in the somatosensory and motor cortices following CIMT, as well as structural changes such as increased gray matter volume [20] and functional connectivity shifts toward contralateral hemisphere dominance [12,14]. These outcomes align with established models of activity-dependent plasticity, which suggest that intensive, task-specific training can drive both functional and anatomical remodeling of the brain [23]. In some studies, CIMT was also associated with sensory system reorganization [7,18], indicating that somatosensory input modulation may be an additional mechanism of action.
Moreover, functional improvements, such as enhanced upper limb use, improved grip and reach accuracy, and spontaneous use of the affected hand, were frequently observed in parallel with neurophysiological changes.
Notably, this review also highlights a key aspect of CIMT’s implementation in clinical practice: its increasing integration into multimodal rehabilitation frameworks. In several studies, CIMT was not delivered in isolation but rather as part of a broader therapeutic strategy aimed at reinforcing interhemispheric balance and sensorimotor function. These findings suggest that CIMT may act as a catalyst for neuroplasticity when combined with context-specific, child-adapted interventions.
Concerns about the potential negative effects of constraint on the less affected limb, particularly regarding sensory deprivation or maladaptive plasticity, were reported in some experimental literature [24]. However, in the included studies, no enduring adverse sensory effects were documented, and parental reports at follow-up confirmed the acceptability of the interventions. Still, these risks warrant consideration, especially during critical periods of development.
This work is intended to complement previous systematic reviews (including the Cochrane review), which primarily focused on clinical effectiveness in school-aged children and RCTs. By contrast, the present scoping review specifically maps neuroplasticity-related outcomes (neuroimaging, neurophysiological measures and neuroplasticity-related proxies) alongside upper-limb functional changes, thereby providing a mechanistic perspective that helps interpret clinical improvements within an experience-dependent plasticity framework.
The comparison with broader literature confirms and extends previous findings. As reviewed by Charles and Gordon [25] and more recently by Robert et al. [26], CIMT is among the most studied interventions capable of eliciting neurophysiological changes in children with CP. The present synthesis adds to this body of knowledge by emphasizing that these effects are observable even in early developmental stages and that advanced neuroimaging and neurophysiological techniques (e.g., MRI, MEG, TMS) are increasingly used to document such changes.
Dropout rates were minimal and primarily related to the technical limitations of neuroimaging procedures, such as scanner-related anxiety, motion artifacts, or interference from epileptiform activity [13,17]. These aspects underscore the need for child-friendly, feasible neurophysiological assessments in future pediatric rehabilitation research.
In conclusion, CIMT emerges from this review not only as an effective intervention to improve upper limb function but also as a powerful modulator of neuroplastic mechanisms in the pediatric brain. Its impact spans across functional, structural, and sensory domains. Future research should aim to refine intervention parameters, integrate neurophysiological monitoring in routine practice, and personalize rehabilitation strategies based on individual patterns of plasticity.
This scoping review showed a comprehensive synthesis of current evidence on the neuroplastic effects of CIMT in children with hemiplegic CP, highlighting both functional outcomes and cortical reorganization. A key strength lies in the integration of heterogeneous methodologies, including neuroimaging and neurophysiological techniques, across different clinical and ecological settings (e.g., home-based, camp-based, and hospital-based interventions). This broad perspective enhances the ecological validity and translational value of the findings.
However, several limitations must be acknowledged. First, the number of included studies remains limited, with small sample sizes and considerable variability in study design, intervention protocols, and outcome measures. This heterogeneity precludes quantitative synthesis and limits the generalizability of results. Additionally, many studies lacked long-term follow-up, making it difficult to assess the persistence of neuroplastic changes over time. The absence of standardized biomarkers for neural plasticity, along with inconsistencies in imaging protocols and timing of assessments, further limits the ability to compare findings across studies. Finally, a relevant limitation of the present review concerns studies in which CIMT was combined with neuromodulation techniques, such as rTMS or taVNS. In these multimodal interventions, it is not possible to disentangle the specific contribution of CIMT from that of neuromodulation, nor to determine whether the observed neuroplastic changes are attributable to CIMT alone or to a synergistic effect. Future studies employing factorial designs or appropriate control conditions are needed to clarify the independent and combined effects of these interventions.
Future research should aim to address these gaps by conducting large-scale, longitudinal studies with harmonized CIMT protocols and standardized neurophysiological and neuroimaging outcomes. Personalized approaches based on baseline neurofunctional profiles may also help identify responders to CIMT and optimize intervention strategies. Moreover, combining CIMT with adjunctive neuromodulatory techniques, such as rTMS or taVNS, holds promise and warrants investigation to clarify synergistic mechanisms.
Conclusions
This scoping review has highlighted that the application of CIMT represents a valuable approach for stimulating and promoting functionally advantageous neuroplasticity, resulting in improved motor and sensory function in children with hemiplegic CP. The forced use of the affected upper limb by constraining the less affected one encourages greater engagement of the contralateral somatosensory cortex, as evidenced by increased activation patterns and, in some cases, structural changes such as enhanced grey matter volume in the sensorimotor areas. Clinical outcomes across studies also reported greater spontaneous use of the paretic limb, improved precision in upper limb tasks, and favorable modulation of sensory processing. These findings underscore the potential of CIMT to support plastic reorganization across functional, structural, and sensory domains in the developing brain.
CONFLICTS OF INTEREST
No potential conflict of interest relevant to this article was reported.
FUNDING INFORMATION
MGM was supported by Current Research Funds 2026, Ministry of Health, Italy.
AUTHOR CONTRIBUTION
Conceptualization: Maggio MG, Valeri MC, Calabrò RS. Methodology: Maggio MG, Calabrò RS, Morone G. Data curation: Maggio MG, Valeri MC, Maione R. Software: Maggio MG, Maione R, Calabrò RS. Validation: all authors. Formal analysis: Maggio MG, Maione R. Project administration: Calabrò RS, Morone G. Funding acquisition: Calabrò RS. Investigation: Maggio MG, Valeri MC, Maione R, Calabrò RS. Resources: Maggio MG, Valeri MC, Calabrò RS, Morone G. Writing – original draft: Maggio MG, Valeri MC, Maione R. Writing – review & editing: Maggio MG, Maione R, Valeri MC, Militi A, Cinnera AM, Ciancarelli I, Calabrò RS, Morone G. Visualization: all authors. Supervision: Maggio MG, Calabrò RS, Morone G. Approval of final manuscript: all authors.
ACKNOWLEDGMENTS
The authors thank all collaborators who contributed to data collection and methodological supervision.
Artificial intelligence–assisted tools were used exclusively for language editing and stylistic refinement of the manuscript. No AI tools were used for the generation of scientific content, data analysis, interpretation of results, or the drawing of conclusions. The authors take full responsibility for the content of the manuscript.
DATA AVAILABILITY STATEMENT
Data supporting the findings of this review are available from the corresponding author upon reasonable request.
Improvements in somatosensory outcomes (SWM, 2PD, stereognosis, proprioception, kinesthesia) and changes in cortical somatosensory processing assessed with MEG
Post-intervention changes in sensory activation (neurophysiological assessment of sensory responses) accompanied by changes in sensory/motor outcomes (SWM, 2PD, ROM, dynamometry)
To evaluate the feasibility and potential of taVNS combined with CIMT to enhance functional movement, gross motor skills, and upper limb function in infants with hemiplegia by leveraging activity-dependent neuroplasticity
N=3 infants (10–14 months) with hemiplegia; GMFCS I–IV
taVNS+CIMT, 4 weeks, 40 hours total; outcomes assessed post, 1- and 3-month follow-up
QUEST, GMFM-88, DAYC-2, Goal Attainment Scaling
Feasibility/safety: adherence/retention and adverse events; Clinical outcomes: changes in QUEST, GMFM-88, DAYC-2, and Goal Attainment Scaling at post-intervention and follow-ups (1 and 3 months)
To evaluate structural brain changes and motor improvements post-CIMT
N=10 children, aged 2–7 years, hemiparetic CP
3 h/day CIMT for 3 weeks, VBM MRI pre/post/follow-up
PMAL-R, structural MRI
Structural MRI (VBM): increased gray-matter volume in sensorimotor regions; Clinical: increased spontaneous arm use assessed with PMAL-R (pre/post/follow-up)
JTTHF, AHA, Box and Block, ABILHAND-Kids, COPM, PEDI
CIMT vs. HABIT: comparable changes in JTTHF, AHA, Box and Block, ABILHAND-Kids, COPM, and PEDI; Neuroimaging/neurophysiology (DTI/TMS): outcomes reported irrespective of CST reorganization type
Evaluate the feasibility and efficacy of rTMS+CIMT to promote recovery of the paretic hand in CP
N=19 children with unilateral CP, aged 8–17 years, 10 F/ 9 M
2 Groups: 10 patients real rTMS+CIMT (5 treatments of real rTMS and 5 of CIMT on alternate weekdays for 2 weeks), 9 patients Sham rTMS+CIMT (13 days of continuous long-arm casting with 5 skin-check session, 10 hours total)
AHA,COPM, stereognosis
Safety/feasibility: completion/adverse events; Clinical outcomes: changes in AHA, COPM, and stereognosis after rTMS+CIMT vs. sham
4. Bonanno M, Militi A, La Fauci Belponer F, De Luca R, Leonetti D, Quartarone A, et al. Rehabilitation of gait and balance in cerebral palsy: a scoping review on the use of robotics with biomechanical implications. J Clin Med 2023;12:3278.
5. De Luca R, Bonanno M, Settimo C, Muratore R, Calabrò RS. Improvement of gait after robotic-assisted training in children with cerebral palsy: are we heading in the right direction? Med Sci (Basel) 2022;10:59.
6. Maggio MG, Baglio F, Arcuri F, Borgnis F, Contrada M, Diaz MDM, et al. Cognitive telerehabilitation: an expert consensus paper on current evidence and future perspective. Front Neurol 2024;15:1338873.
9. Novak I, Morgan C, Fahey M, Finch-Edmondson M, Galea C, Hines A, et al. State of the evidence traffic lights 2019: systematic review of interventions for preventing and treating children with cerebral palsy. Curr Neurol Neurosci Rep 2020;20:3.
10. Tricco AC, Lillie E, Zarin W, O'Brien KK, Colquhoun H, Levac D, et al. PRISMA extension for Scoping Reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med 2018;169:467-73.
11. Campbell M, McKenzie JE, Sowden A, Katikireddi SV, Brennan SE, Ellis S, et al. Synthesis Without Meta-analysis (SWiM) in systematic reviews: reporting guideline. BMJ 2020;368:l6890.
12. Friel KM, Ferre CL, Brandao M, Kuo HC, Chin K, Hung YC, et al. Improvements in upper extremity function following intensive training are independent of corticospinal tract organization in children with unilateral spastic cerebral palsy: a clinical randomized trial. Front Neurol 2021;12:660780.
13. Gillick BT, Krach LE, Feyma T, Rich TL, Moberg K, Thomas W, et al. Primed low-frequency repetitive transcranial magnetic stimulation and constraint-induced movement therapy in pediatric hemiparesis: a randomized controlled trial. Dev Med Child Neurol 2014;56:44-52.
14. Cao J, Khan B, Hervey N, Tian F, Delgado MR, Clegg NJ, et al. Evaluation of cortical plasticity in children with cerebral palsy undergoing constraint-induced movement therapy based on functional near-infrared spectroscopy. J Biomed Opt 2015;20:046009.
15. Kuo HC, Litzenberger J, Nettel-Aguirre A, Zewdie E, Kirton A. Exploring clinical and neurophysiological factors associated with response to constraint therapy and brain stimulation in children with hemiparetic cerebral palsy. Dev Neurorehabil 2022;25:229-38.
16. Cope SM, Liu XC, Verber MD, Cayo C, Rao S, Tassone JC. Upper limb function and brain reorganization after constraint-induced movement therapy in children with hemiplegia. Dev Neurorehabil 2010;13:19-30.
17. McGloon K, Humanitzki E, Brennan J, Summers P, Brennan A, George MS, et al. Pairing taVNS and CIMT is feasible and may improve upper extremity function in infants. Front Pediatr 2024;12:1365767.
20. Sterling C, Taub E, Davis D, Rickards T, Gauthier LV, Griffin A, et al. Structural neuroplastic change after constraint-induced movement therapy in children with cerebral palsy. Pediatrics 2013;131:e1664-9.
21. Coker P, Karakostas T, Dodds C, Hsiang S. Gait characteristics of children with hemiplegic cerebral palsy before and after modified constraint-induced movement therapy. Disabil Rehabil 2010;32:402-8.
23. Kleim JA, Jones TA. Principles of experience-dependent neural plasticity: implications for rehabilitation after brain damage. J Speech Lang Hear Res 2008;51:S225-39.
24. Eliasson AC, Holmefur M. The influence of early modified constraint-induced movement therapy training on the longitudinal development of hand function in children with unilateral cerebral palsy. Dev Med Child Neurol 2015;57:89-94.
25. Charles JR, Gordon AM. A repeated course of constraint-induced movement therapy results in further improvement. Dev Med Child Neurol 2007;49:770-3.
26. Robert MT, Gutterman J, Ferre CL, Chin K, Brandao MB, Gordon AM, et al. Corpus callosum integrity relates to improvement of upper-extremity function following intensive rehabilitation in children with unilateral spastic cerebral palsy. Neurorehabil Neural Repair 2021;35:534-44.
Constraint-Induced Movement Therapy in Children With Hemiplegic Cerebral Palsy: A Scoping Review of Functional Outcomes and Neuroplasticity-Related Evidence
Fig. 1. PRISMA 2020 flow diagram of evaluated studies.
Fig. 1.
Constraint-Induced Movement Therapy in Children With Hemiplegic Cerebral Palsy: A Scoping Review of Functional Outcomes and Neuroplasticity-Related Evidence
Improvements in somatosensory outcomes (SWM, 2PD, stereognosis, proprioception, kinesthesia) and changes in cortical somatosensory processing assessed with MEG
Post-intervention changes in sensory activation (neurophysiological assessment of sensory responses) accompanied by changes in sensory/motor outcomes (SWM, 2PD, ROM, dynamometry)
To evaluate the feasibility and potential of taVNS combined with CIMT to enhance functional movement, gross motor skills, and upper limb function in infants with hemiplegia by leveraging activity-dependent neuroplasticity
N=3 infants (10–14 months) with hemiplegia; GMFCS I–IV
taVNS+CIMT, 4 weeks, 40 hours total; outcomes assessed post, 1- and 3-month follow-up
QUEST, GMFM-88, DAYC-2, Goal Attainment Scaling
Feasibility/safety: adherence/retention and adverse events; Clinical outcomes: changes in QUEST, GMFM-88, DAYC-2, and Goal Attainment Scaling at post-intervention and follow-ups (1 and 3 months)
To evaluate structural brain changes and motor improvements post-CIMT
N=10 children, aged 2–7 years, hemiparetic CP
3 h/day CIMT for 3 weeks, VBM MRI pre/post/follow-up
PMAL-R, structural MRI
Structural MRI (VBM): increased gray-matter volume in sensorimotor regions; Clinical: increased spontaneous arm use assessed with PMAL-R (pre/post/follow-up)
JTTHF, AHA, Box and Block, ABILHAND-Kids, COPM, PEDI
CIMT vs. HABIT: comparable changes in JTTHF, AHA, Box and Block, ABILHAND-Kids, COPM, and PEDI; Neuroimaging/neurophysiology (DTI/TMS): outcomes reported irrespective of CST reorganization type
Evaluate the feasibility and efficacy of rTMS+CIMT to promote recovery of the paretic hand in CP
N=19 children with unilateral CP, aged 8–17 years, 10 F/ 9 M
2 Groups: 10 patients real rTMS+CIMT (5 treatments of real rTMS and 5 of CIMT on alternate weekdays for 2 weeks), 9 patients Sham rTMS+CIMT (13 days of continuous long-arm casting with 5 skin-check session, 10 hours total)
AHA,COPM, stereognosis
Safety/feasibility: completion/adverse events; Clinical outcomes: changes in AHA, COPM, and stereognosis after rTMS+CIMT vs. sham
, Maria Chiara Valeri, MSc2,*
