571
ORIGINAL ARTICLE
The Effects of Constraint-Induced Therapy on Kinematic
Outcomes and Compensatory Movement Patterns: An
Exploratory Study
Crystal Massie, MSOT, Matthew P. Malcolm, PhD, OTR, David Greene, PhD, OTR, Michael Thaut, PhD
ABSTRACT. Massie C, Malcolm MP, Greene D, Thaut M.
The effects of constraint-induced therapy on kinematic out-
comes and compensatory movement patterns: an exploratory
study. Arch Phys Med Rehabil 2009;90:571-9.
Objective: To determine changes in kinematic variables and
compensatory movement patterns of survivors of stroke com-
pleting constraint-induced therapy (CIT).
Design: Pre-post, case series.
Setting: Clinical rehabilitation research laboratory.
Participants: Men (n⫽7) and women (n⫽3) with unilateral
stroke occurring at least 9 months prior to study entry with
moderate, stable motor deficits.
Intervention: Participants completed 10 consecutive week-
days of CIT for 6 hours a day comprised of trainer-supervised,
functionally based activities using massed practice.
Main Outcome Measures: Kinematic measures included
movement time, average velocity, trajectory stability, shoulder
abduction, and segmental contribution. Functional measures
included Wolf Motor Function Test (WMFT) performance
time and functional ability scores and Motor Activity Log
(MAL) “how-well” scores. All measures were administered
before and after the 2-week CIT intervention.
Results: Movement time, average velocity, and trajectory
stability significantly improved after CIT. Participants used
more shoulder flexion to reach after CIT, but also demonstrated
increased compensatory shoulder abduction. Functional scores
also significantly improved, including WMFT performance
time and functional ability and MAL scores. There was no
change in trunk movement or amount of elbow extension.
Conclusions: CIT improved motor capacities in the hemi-
paretic arm as reflected in the functional outcomes and in some
kinematic measures. Participants’ reliance on common com-
pensatory movements was not beneficially affected by CIT.
The results of this study demonstrate that while functional
capacity and some movement strategies in the hemiparetic arm
improve after CIT, participants may not overcome their reli-
ance on common compensatory movement patterns. Based on
From the NeuroRehabilitation Research Laboratory, Department of Occupational
Therapy (Massie, Malcolm); Department of Occupational Therapy (Greene); and
Center for Biomedical Research in Music (Thaut), Colorado State University, Fort
Collins, CO.
From a thesis submitted to the Academic Faculty of Colorado State University in
partial fulfillment of the requirements for the degree of Master of Science.
Supported by the National Institutes of Health (grant no. 1RO1 HD045751-01A0)
and a Scholarship Advancement Award, Department of Occupational Therapy, Col-
orado State University.
No commercial party having a direct financial interest in the results of the research
supporting this article has or will confer a benefit on the authors or on any organi-
zation with which the authors are associated.
Reprint requests to Matthew P. Malcolm, PhD, OTR, Dept of Occupational
Therapy, Colorado State University, Fort Collins, CO, 80523, e-mail: malcolm2@
cahs.colostate.edu.
0003-9993/09/9004-00496$36.00/0
doi:10.1016/j.apmr.2008.09.574
these findings, this study suggests that CIT may encourage
subjects to generate movement through compensatory and/or
synergy-dominated movement rather than promote the normal-
ization of motor control. This outcome highlights the need to
develop CIT further as an intervention that improves functional
capacity and more normative movement strategies.
Key Words: Rehabilitation; Stroke.
© 2009 by the American Congress of Rehabilitation
Medicine
TROKE IS THE LEADING cause of adult long-term dis-
S ability in the United States, often resulting in reaching impair-
ments that may limit autonomy in activities of daily living and
quality of life.1 After a stroke, the capacity for central control of
movement is typically severely compromised because of damage
to neural mechanisms that control voluntary movement.2 This
damage leads to weakness, abnormal muscle tone, and stereotyp-
ical movement synergies that collectively limit functional reach.
Consequently, survivors of stroke often rely on compensatory
movement strategies to accomplish reaching tasks.3-6 Compensa-
tory strategies are considered maladaptive and are often detrimen-
tal to recovery of necessary movement capacities (eg, use of
elbow extension or shoulder flexion).5 Although neurorehabilita-
tion research has recently demonstrated that structured, specific,
and intensive training protocols increase the amount of hemipa-
retic limb use, less attention has been given to normalizing move-
ment strategies poststroke.7
CIT is a more recently developed intervention designed to
restore motor skill capacity through massed practice of func-
tional activities with the stroke-affected upper extremity.8,9
Training concepts of CIT focus on re-establishing basic limb
use by increasing attention to and use of the affected side. The
signature protocol of CIT is well supported as an intervention
of 6 hours of therapy a day for 10 consecutive weekdays while
wearing a restraining mitt on the less affected extremity for
up to 90% of waking hours.10-14 The efficacy of the signature
CIT intervention was demonstrated in the recently completed
EXCITE trial,11 which investigated over 200 survivors of stroke in
a randomized controlled design. Along with other smaller CIT
trials, findings from the EXCITE project demonstrated a sub-
stantial and lasting increase in amount of hemiparetic arm use.
With the success of CIT, considerable efforts have also been
made to develop modified CIT protocols.10,15-18 There is, how-
ever, no consensus on the most efficacious form of modified
CIT.19 Although evidence supports modified CIT protocols,
Sterr et al10 found that 6 hours a day of training is superior to
List of Abbreviations
CIT constraint-induced therapy
EXCITE Extremity Constraint Induced Therapy Evaluation
MAL Motor Activity Log
WMFT Wolf Motor Function Test
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572 KINEMATIC ANALYSIS OF CONSTRAINT-INDUCED THERAPY, Massie

3 hours a day. This finding suggests that intensity may be the Table 1: Demographic Characteristics of Participants
main factor that differentiates modified and the signature CIT Time Since
protocol.19 Given the limited consistency across modified CIT Participant Sex Age (y) Stroke (y) Side of Stroke
protocols and a greater amount of evidence supporting signa-
1 F 81 1.00 RCVA
ture CIT protocol, the current study employed the standard, 6
2 F 62 2.75 LCVA
hours a day of intervention.
3 F 70 5.30 LCVA
The bulk of CIT outcomes have focused on functional mea-
4 M 38 1.67 LCVA
sures of change including the WMFT and the MAL. However,
5 M 64 1.00 LCVA
inconsistencies in the quality of movement ratings using the
6 M 77 7.00 RCVA
WMFT functional ability scale are reported in CIT litera-
7 M 66 2.08 RCVA
ture.11,20 The MAL is a participant-rated quality of movement
8 M 45 1.75 LCVA
scale based on different activities of daily living, and reported
9 M 42 3.41 RCVA
outcomes indicate real-world improvements after CIT.11
10 M 67 0.83 RCVA
Kunkel et al13 have suggested that while subject ratings of
Range 3 F;7 M 38–81 0.83–5.30 5 RCVA; 5 LCVA
quality of movement on the MAL substantially improved after
Mean ⫾ SD NA 61.2⫾14.7 2.68⫾2.04 NA
CIT, movement still exhibited a substantial deficit. One method
that has been proposed to clarify movement deficits after CIT Abbreviations: F, female; LCVA, left cerebral vascular accident; M,
is kinematic motion analysis because it can objectively and male; NA, not applicable; RCVA, right cerebral vascular accident.
quantitatively describe the geometry of movement in clinically
relevant outcome measures.7 Furthermore, postintervention
changes in motor control strategies involving range of motion,
multijoint control, movement velocity, and timing are readily temporal parameters of reach and in functional outcome mea-
detected through kinematic analyses. Outcomes that rely on sub- sures (ie, WMFT and MAL).
ject ratings or therapist perceptions of movement validly demon-
strate improvements in functional capacity but are limited in METHODS
revealing specific changes in poststroke movement strategies.
To our knowledge, such specific assessment of postinterven- Participants
tion kinematics has not been reported on the signature CIT A convenience sample of participants enrolled in a separate
protocol. A limited number of studies, however, have em- randomized controlled CIT study was used for this study. Ten
ployed kinematic motion analysis to objectively and quantita- participants (3 female; 5 left cerebral vascular accident) with a
tively measure changes after modified CIT protocols.15,16,18,21 mean age ⫾ SD of 61⫾14.7 years participated and gave
These studies reported spatiotemporal measures such as move- written consent in accordance with the policies of the local
ment duration, reaction time, normalized movement units, and institutional review board. Table 1 summarizes participant de-
normalized jerk scores. Caimmi et al15 demonstrated improve- mographics. Participants were recruited from the community
ments in normalized jerk scores and movement duration but did and met the following inclusion criteria: at least 9 months
not include assessment of any change in motor strategy in the poststroke of unilateral clinical presentation; at least 10° of
context of compensatory or synergy-driven movement. Simi- active wrist extension and 10° of extension in at least 2 fingers
larly, Wu et al18 reported significant improvement in normal- and thumb; approximately 30° of active shoulder flexion; at
ized movement time after CIT. In contrast, Wu et al21 found no least half the normative passive range of motion at all upper-
significant improvement in movement time when comparing a extremity joints; ability to follow simple instructions and mul-
modified CIT protocol with traditional rehabilitation. Based on tistep commands; endurance to complete 6 hours of training; a
commonly reported outcome measures (both functional and score of 24 or higher on the Mini-Mental State Examination23;
kinematic), movement deficits that remain after signature or the ability to sit independently without back or arm support for
modified implementation of CIT protocol, and the extent to 5 minutes; and the ability to stand with or without the assis-
which such changes in movement capacities depend on com- tance of a cane, quad cane, or hemiwalker for 2 minutes.
pensatory motor strategies, are unclear. Exclusion criteria included the following: any health problems
Carr and Shepherd6 suggest that compensatory strategies are judged by the screening physician to put the client at significant
the result of using available movements given the poststroke risk of harm during the study, other neurologic conditions (eg,
state of the central nervous system, which leads to long-term multiple sclerosis, Parkinson disease), drugs or injections treat-
functional limitations. Because CIT is an intervention focused ing spasticity within 3 months of participation, significant
on overcoming learned nonuse by massed practice of available stroke-affected arm use during daily living (MAL “amount-of-
movement strategies, limited attention may be directed to the use” scoreⱖ2.5), and a pain score greater than 5 on the McGill
quality of movements being performed. Therefore, distinguish- Pain Scale. These are typical selection criteria in CIT studies.11
ing between recovery of normalized movement patterns and Participants were required to obtain a medical release from
compensatory movement patterns is critical to understand the their primary physicians.
mechanisms underlying functional improvements after CIT (ie,
overcoming learned nonuse).7,22 To clarify further the role of Intervention
CIT on motor recovery in the chronic stage of stroke, this study Participants completed 2 weeks of CIT training based on the
employed a detailed kinematic motion analysis to determine recently published EXCITE multicenter clinical trial.11 During
how CIT influenced movement patterns, including compensa- 10 consecutive weekdays, participants completed a daily
tory strategies and spatiotemporal parameters of movement. 6-hour on-site trainer-supervised program of functionally based
We hypothesized that participants would exhibit changes in activities using massed practice. Task parameters (eg, spatial
movement strategies after CIT that may or may not change the and/or temporal) were manipulated in each successive period
extent to which survivors of stroke rely on compensatory of task practice requiring increased control of the affected arm
reaching strategies. A secondary hypothesis was that partici- and hand.24 Global feedback was provided at the end of a
pants would demonstrate significant improvement in spatio- training task, and during task practice if performance substan-

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 KINEMATIC ANALYSIS OF CONSTRAINT-INDUCED THERAPY, Massie
tially strayed from the intended goal.24 The therapy trainers did
not verbally prompt participants to limit compensatory strate-
gies. Examples of tasks include playing checkers, washing
windows, and stacking blocks. Short rest breaks (⬇5min) were
taken throughout the day as needed to prevent excessive fa-
tigue. In addition to training, participants were instructed to
wear a padded mitt on their less-affected side for 90% of their
waking hours. Compliance with study protocol was monitored
by a home diary that participants completed daily during the
2-week intervention, and with a mitt compliance device. The
mitt compliance device, housed within the padded mitt, in-
cluded a capacitive sensor and timer circuit that actively re-
corded wearing time. These time logs were reviewed daily with
a therapy-trainer to monitor compliance with the intervention
and mitt-wearing protocol. If the amount of mitt wearing
strayed from 90%, a trainer educated and problem-solved with
the participant to increase mitt-wearing compliance within
safety limitations. Safety while wearing the padded mitt was
emphasized, and participants were instructed on specific times
to remove the mitt (eg, while driving).
Evaluations
Kinematic motion analysis acquisition. A reaching task
comprised of flexion-extension movements at the elbow and
shoulder was used, because these movements are core compo-
nents of functional reach used during daily activities.25,26 See
figure 1 for experimental setup. Participants sat comfortably in
a chair directly in front of a table with a 10° incline. Two
targets, 7.7cm in diameter, were positioned in the sagittal plane
of the hemiparetic arm at the point where the tip of the middle
finger made contact at maximal arm extension and at a natural
returning position. If the participant was unable to make con-
tact with the middle finger consistently, the most distal part of
the hand that could make contact with the targets was used. The
reaching task consisted of 4 flexion-extension movements al-
ternating between the 2 targets, and participants were asked to
reach as fast as they could.
Arm kinematics were recorded at 60Hz with a 3-dimensional
camera-based motion analysis system.a One camera was placed
Fig 1. Schema of experimen-
tal setup. Seated subjects
reached with the stroke-
affected arm between a
proximal target and a distal
target placed at maximum
reach of the stroke-affected
arm in a sagittal plane. Par-
ticipants were instructed to
tap back and forth as fast as
they could, alternating be-
tween proximal and distal
targets.
573
directly ahead of the participant, and 2 were placed at 45°
angles diagonally ahead of the participant. Reflective markers
were placed on the sternal notch, shoulder, elbow, and wrist of
the paretic arm. A metal probe was taped onto a rubber finger
protector placed on the middle finger of the participant (if a
participant was unable to use the middle finger, the probe was
attached on the part of the hand that could make contact with
the target). The metal probe served as a switch to complete a
simple series circuit containing a 9-V battery. Output from the
series circuit was a 9-V signal going to the event synchroni-
zation unit, creating a synchronization signal. The event syn-
chronization unit also received input from the 3 cameras,
superimposed the synchronization signal, and sent the signal to
videocassette recorders. Software processed the 3 camera
views and computed a sequence of 3-dimensional coordinates
for each reflective marker, relative to the coordinate system
built into the table surface (Motus).a Movement coordinates
were calculated based on the following axes: medial-lateral
was the x-axis, anterior-posterior was the y-axis, and inferior-
superior was the z-axis. Joint angles and movement velocities
were calculated by kinematic analysis software (Motus).a All
data were exported to Microsoft Excelb for data reduction and
then to SPSSc for data analysis.
The primary hypothesis addressed movement pattern changes
in relation to compensatory strategies. To consider the impact of
compensatory trunk movement on overall reach and how mul-
tiple segments collectively produce a reaching movement, mul-
tisegment contribution was defined as the proportion of total
movement accounted for by movement at the trunk, shoulder,
and elbow. The relative contribution of each joint, djt calcu-
lated in centimeters for both shoulder and elbow, was based on
the following equation:
冋冉 冊 共 册
jta
d jt ⫽ * dtarget ⫺ dtrunk兲
jta ⫹ jtb
where dtarget (cm) is the distance between the targets, dtrunk
(cm) is the trunk anterior displacement during reach, and jta
and jtb are the excursion angles from proximal to distal target
Arch Phys Med Rehabil Vol 90, April 2009
574 KINEMATIC ANALYSIS OF CONSTRAINT-INDUCED THERAPY, Massie
contacts for each joint. Anterior trunk displacement (cm) was
computed as sagittal movement (y-axis) of the sternal notch
marker (see fig 1). Elbow flexion/extension was the angle
between vectors formed by the shoulder to elbow and elbow to
wrist where full extension equaled 180°. Shoulder flexion/
extension was the angle between vectors of elbow to shoulder
markers and a unit vector projecting vertically from the shoul-
der marker as projected on the yz-plane (arm alongside
body⫽0°). A mean for each segment was calculated based on
the 4 reaching cycles.
Excessive amounts of shoulder abduction often contribute to
the compensatory reaching strategy after stroke. Shoulder ab-
duction was defined as the angle between vectors of elbow to
shoulder markers and a unit vector projecting vertically from
the shoulder marker as projected on the xz-plane (arm along-
side body⫽0°). Measured in degrees, shoulder abduction was
calculated as a mean of 4 reaches at (1) proximal target contact,
(2) the maximum amplitude of the wrist marker during flexion
and extension movements, and (3) distal target contact.
Spatiotemporal parameters included 3 different measures:
(1) trajectory variability, (2) total movement time in seconds,
and (3) average reach velocity in centimeters a second. We
assessed variability of the trajectory as previously defined by
Thaut et al.26 From the spatial distribution (frontal plane) of the
wrist marker as it reached maximum amplitude, mean distance
and coefficient of variation were calculated and used as a
measure of variability. A tighter clustering of coordinates will
result in a decrease in the coefficient of variation, suggesting a
more stable trajectory (ie, the wrist follows a more consistent
path). Total movement time was recorded in seconds. A reach
velocity (cm/s) was calculated for each reaching movement
within the trial as vreach ⫽ dwrist /treach, where dwrist was the
sagittal displacement of the wrist, and treach was the reaching
time from proximal to distal target contact; the mean of the 4
reach velocities was calculated.
Kinematic data were collected on the unaffected side of 4
participants to provide a descriptive analysis of unaffected
upper-extremity arm movements to compare with the stroke-
affected side. These data were not used for statistical purposes
and are reported to elucidate the differences between the
stroke-affected and unaffected movement patterns.
Functional assessments. The WMFT and MAL (“how-
well” scale) were conducted at baseline and posttest. The
WMFT is a laboratory-based motor assessment of 17 differ-
ent tasks, including 15 timed tasks, and has established
reliability.9,13,27 The WMFT incorporates gross and fine motor
tasks, integrating different upper-extremity movements such as
reaching, lifting a pencil, turning a key, and folding a towel.
The speed tasks are videotaped and subsequently scored for
functional ability of movement on a 6-point ordinal scale. The
mean performance time and functional ability scores of the
stroke-affected upper extremity are reported for the WMFT.
The MAL, as described by Uswatte et al,28 is a reliable and
valid measure of participants’ perception of real-world use of
the hemiparetic arm conducted as a semistructured interview.
Two 6-point scales may be used: one measures amount of use,
and the other measures how well participants feel they can use
the hemiparetic arm. These scales are anchored at 6 points
(0⫽never use, 5⫽same as prestroke). Uswatte28 suggest that
the amount-of-use scale may be artificially inflated because of
the nature of CIT training that focuses on increasing the amount of
use in the stroke-affected side. The “how-well” scale is not subject
to such inflations in amount of use and therefore is a better
indicator of quality of movement improvement. The “how-well”
scale was used for purposes of this study with mean scores
reported.
Arch Phys Med Rehabil Vol 90, April 2009
Statistical Analysis
Kinematic variables including segmental contribution and
shoulder abduction were analyzed statistically using 2-tailed, de-
pendent-sample t tests. Spatiotemporal parameters and WMFT
performance time measures were analyzed using 1-tailed, de-
pendent-sample t tests. Ordinal data from functional quality of
movement measures (WMFT functional ability and MAL
“how-well”) were analyzed using a 1-tailed Wilcoxon signed-
rank test. The significance level was set at ␣ equal to .05 for all
statistical comparisons and was not adjusted considering mul-
tiple comparisons in light of the preliminary nature and size of
the study.
RESULTS
Kinematic Outcomes
Unaffected reach. Data from the unaffected side (n⫽4; par-
ticipants 2, 7, 8, 10) are presented to illustrate differences between
unaffected and stroke-affected reaching patterns. Figure 2A (top
panel) illustrates the reaching strategy of a representative par-
ticipant (participant 10, presented as a mirror-image) and the
segmental contribution to the total reaching movement. With
the unaffected arm, the trunk remained relatively stable in a
neutral position and contributed very little to the overall reach-
ing movement. During reach, shoulder flexion and adduction
occurred as the elbow extended. Shoulder abduction was great-
est when the hand contacted the proximal target and decreased
as the shoulder flexed and elbow extended (fig 3). The trajec-
tories were smooth and followed a consistent and stable tra-
jectory (fig 4C).
Stroke-affected reach. With the stroke-affected side, trunk
displacement accounted for a large proportion of the overall
movement compared with the trunk displacement when reach-
ing with the unaffected side (see fig 2B, bottom panel). The
remaining distance was attributed to approximately equal con-
tributions from the shoulder and elbow. In the representative
participant (participant 10), the trunk, shoulder, and elbow appear
to move as a unit rather than the trunk remaining stable while the
shoulder flexes and the elbow extends. Figure 5 illustrates the
change in contribution of each segment (ie, trunk, shoulder, el-
bow) after CIT. Shoulder flexion accounted for 15.47⫾4.69cm
before CIT and significantly increased to 16.69⫾4.05cm post-CIT
(t⫽–2.496; P⫽.034; d⫽1.22). Trunk movement decreased from
6.71⫾2.75cm pre-CIT to 6.42⫾2.94cm post-CIT, but this change
was not significant (t⫽.44; P⫽.67). Elbow extension accounted
for 12.32⫾5.26cm pre-CIT and decreased to 11.4⫾5.9cm after
CIT, but also not significantly (t⫽1.3; P⫽.22).
Shoulder abduction as a compensatory movement. Par-
ticipants demonstrated excessive shoulder abduction during
reach with the stroke-affected arm, as illustrated in figure 3.
The amount of shoulder abduction at the time of contact with
the proximal target significantly increased from 39.5°⫾5.58°
pre-CIT to 42.74°⫾3.0° post-CIT (t⫽–2.42; P⫽.04; d⫽
– 0.77). At midtrajectory before CIT, the shoulder was ab-
ducted 44.95°⫾9.50° and significantly increased to 47.41°⫾
6.90° after CIT (t⫽–2.595; P⫽.018; d⫽– 0.30). There was a
decrease in shoulder abduction from midtrajectory to the point
of contact with the distal target. The amount of shoulder
abduction at the time of contact with the distal target decreased
by .28° after CIT, but this was not significant (t⫽.125; P⫽.90).
Spatiotemporal parameters. Spatiotemporal parameters
included trajectory stability, movement time, and mean reach
velocity. The scatter plots in figure 4 represent the trajectory
coordinates of the wrist marker. When the participant reached
with the stroke-affected arm before CIT training, the coordi-
 KINEMATIC ANALYSIS OF CONSTRAINT-INDUCED THERAPY, Massie 575

Fig 2. Graphical representa-

tion of group means (unaf-
fected, nⴝ4; stroke-affected,
nⴝ10) of the relative amount
of movement accounted by
trunk movement, shoulder
flexion, and elbow extension
(left) and schematic reaching
of a representative subject’s
(subject 10) strategy of the af-
fected limb pre-CIT and of the
unaffected limb (right). Trunk
and arm configurations are
shown at proximal contact
(gray) and at distal contact
(dashed lines). (A) Reach with
the unaffected side occurred
with shoulder flexion and el-
bow extension with little
movement at the trunk. Sche-
matic (subject 10) is shown as
a mirror-image. (B) Pre-CIT
reach with the stroke-affected
arm. The bird’s-eye view of a
representative reaching strat-
egy (subject 10) illustrates
that the trunk and arm moved
together as fixed unit with
large trunk displacement and
little shoulder flexion.

nates of the wrist were not closely clustered around the mean
and had higher maximum amplitudes. The wrist trajectory
followed a more consistent path (closer clustering) after CIT.
Trajectory variability, expressed as a coefficient of variation,
significantly decreased from 58.85%⫾10.51% pre-CIT to
47.91%⫾17.9% post-CIT (t⫽2.727; P⫽.007; d⫽.85). Move-
ment time to complete 4 reaching cycles significantly de-
creased from 9.17⫾2.7s pre-CIT to 7.58⫾3.14s after CIT
(t⫽3.991; P⫽.002; d⫽1.88). The mean reaching velocity also
increased significantly from 26.05⫾14.33cm/s pre-CIT to
34.31⫾17.19cm/s post-CIT (t⫽–2.95; P⫽.01; d⫽1.39). Re-
sults for movement effectiveness outcomes are displayed in
table 2.
Functional outcomes. The results of the functional out-
comes are reported in table 2. WMFT performance time signifi-
cantly decreased from 37.66⫾32.03s pre-CIT to 25.06⫾27.3s
post-CIT (t⫽2.614; P⫽.014; d⫽1.23), and functional ability as
scored on WMFT significantly improved from 2.45⫾0.66 units
to 2.69⫾0.54 units after CIT (z⫽–2.19; P⫽.014; r⫽0.49). A
score of 3 on the WMFT functional ability scale indicates that
the participant accomplishes the task, but movement is influ-
enced by synergy or performed slowly or with effort. MAL
“how-well” scores significantly improved after CIT from
2.45⫾0.80 units to 2.90⫾0.74 units (z⫽–1.68; P⫽.047). A
score of 3 on the MAL indicates that participants perceived
they were able to use their weaker arm for that activity, but
movements were slow or made only with some effort.
DISCUSSION
A limited number of studies have employed objective and
quantitative measures to investigate change in movement pat-
terns after CIT, and these studies have focused primarily on
modified CIT protocols and spatiotemporal parameters of
movement.15,16,18,21 The goal of our study was to expand on
this previous work by examining those parameters that are
perhaps most clinically meaningful—for example, how motor
patterns and strategies change in relation to common compen-
satory movements. While we found that after CIT, the timing
and trajectory control improved during hemiparetic reach, our
results also revealed that the intervention promoted increased
reliance on compensatory movements.
Relating to our hypothesis of changes in movement strategy
after CIT, we sought to determine how trunk movement com-
bines with shoulder flexion and elbow extension to accomplish
goal-directed reach. Previous research indicates that stroke
disrupts interjoint coordination between the shoulder and
elbow29,30; however, the contribution of trunk movement re-
lating to this interjoint coordination has not been examined.
Conversely, all 3 segmental contributions to movement have
been studied independently.31 Less clear is how these 3 seg-
ments collectively interact and contribute to movement as part
of a compensatory movement strategy. Our kinematic reaching
task was set up to determine how each segment contributes collec-
tively to movement and how CIT influences change in contribution.

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576 KINEMATIC ANALYSIS OF CONSTRAINT-INDUCED THERAPY, Massie

Fig 3. Schematic illustration of

shoulder abduction regression
post-CIT (grayⴝunaffected;
solidⴝpre-CIT; dashedⴝpost-
CIT). Participants used signifi-
cantly more shoulder abduction
post-CIT during the early stages
of reach (P<.05). Compared with
the unaffected side, clearly illus-
trated is the increased use of
shoulder abduction as a com-
pensatory strategy that in-
creased post-CIT.

In order for a participant to produce the same overall
reaching distance, an increase in contribution from all of the
segments together was not expected; and if a change oc-
curred in 1 segment, an opposite change would occur in at
least 1 other segment. For example, a pre-post decrease in
trunk contribution might be paralleled by an increase in
shoulder flexion. The findings from our study indicated that
the amount of shoulder flexion significantly accounted for
more of the reaching movement after CIT. As a result of
accomplishing more of the reach with shoulder flexion, less
movement was needed at the elbow and trunk during the
reaching task. Accordingly, the amount of trunk flexion and
elbow extension decreased slightly, although these de-
creases were not significant. The kinematic data revealed
that CIT did not significantly reduce the participants’ com-
pensatory use of trunk movement during reach. Although the
nature of CIT training tasks required increasing amounts of
forward reach, the training may have had limited focus on
improving the participant’s ability to recruit both shoulder
and elbow muscle groups.

Fig 4. (A) Scatter plot of a

representative subject’s tra-
jectory variability (subject 8).
(B) Clearly illustrated is
closer clustering of coordi-
nates post-CIT. Post-CIT co-
efficient of variation for the
group mean (nⴝ10) was
47.91%ⴞ10.5%, which was a
significant post-CIT decrease
(P<.017). (C) The coefficient
of variation for unaffected
reach group mean (nⴝ4) was
24.57%ⴞ9.9%.

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 KINEMATIC ANALYSIS OF CONSTRAINT-INDUCED THERAPY, Massie
Fig 5. Segmental contribution in distance. Mean distance (cm) and
SE are represented at pre-CIT (black) and post-CIT (pre). After CIT,
shoulder flexion accounted for significantly more movement
(*P<.05); the decreases in elbow and trunk movement were not
significant.
In addition to excessive trunk movement, increased shoulder
abduction during reach is a common compensatory movement
after stroke. As is clearly illustrated in figure 3, reaching
patterns substantially differ comparing the unaffected side with
the stroke-affected side. Interestingly, the finding that the
amount of shoulder abduction significantly increased after CIT
suggests that this intervention may promote compensatory
rather than normalized movements at the shoulder. The CIT
protocol is predicated on improving functional capacity by
dramatically increasing the amount of hemiparetic arm use
through massed practice. Conversely, and perhaps explaining
increased reliance on compensatory patterns, CIT typically
places limited emphasis on how movements are executed. That
is to say, CIT is less focused on the normalization of move-
ment. Participants may use compensatory strategies such as
shoulder abduction to accomplish training tasks with little
regard for quality of movement. This strategy may be amplified
as participants experience fatigue. Muscles controlling com-
pensatory movements may be more easily recruited,3 and there-
fore that strategy is used to complete training tasks.
The results of the present study extend our knowledge of the
impact of CIT on precise movement strategy changes. Com-
pensatory movement strategies (ie, trunk movement and shoul-
der abduction) have not been studied in signature protocols of
CIT, nor have they been reported in previous modified CIT
kinematics studies.15,16,18,21 Modified CIT protocols may influ-
ence compensatory movements, but the reported kinematics
Table 2: Descriptive and Inferential Statistics for Spatiotemporal Kinematic and Clinical Assessments
Pre-CIT
Assessment Mean ⫾ SD
Movement time (s) 9.17⫾2.74
Average velocity (cm/s) 26.05⫾14.33
Trajectory variability (%) 58.85⫾10.52
Functional outcome measures
WMFT performance time (s)* 37.66⫾32.03
WMFT functional ability (mean score, 0–5)† 2.45⫾0.66
MAL how-well (mean score, 0–5)† 2.47⫾0.80
*Statistic was 1-tailed, paired-samples t test. ES was Cohen d and was corrected for appropriate sign.
†
Statistic was Wilcoxon signed-rank pairs. ES was calculated based on r⫽z /公N.
‡
P⬍.05.
577
protocol have not systematically investigated these character-
izations of movement. Additionally, movement strategies such
as shoulder flexion and elbow extension generally have not
been reported, with 1 exception. Caimmi et al15 reported a
small but nonsignificant increase in the angle of the elbow at
the end of the reaching movement. Our results parallel this
finding such that CIT did not significantly improve the amount
of elbow extension.
After CIT, the spatiotemporal control of movement im-
proved, and our results parallel previous findings from modi-
fied CIT studies15,16,18,21 showing decreased movement time
during a kinematic task performed at a self-selected pace.15,18
Our results expand on those findings by reducing movement
time variability as participants were asked to perform as fast as
they could. Further, in our study, movement times significantly
decreased when participants were instructed to reach back and
forth as fast as they could. Consistent with this finding, mean
reach velocity of the wrist marker, another spatiotemporal
measure, significantly increased post-CIT. The significant im-
provement in being able to reach more quickly can be attrib-
uted to improvement in motor skill capacity as promoted during
CIT. For example, participants were asked to move faster, thus
increasing temporal demands during subsequent task trials.
The findings from our study provide evidence that CIT
improved the stability of reaching trajectories. Based on the
methods of Thaut et al,26 a decrease in trajectory variability
translates to greater stability of movement during reach, such
that participants had more control over the trajectory. After
CIT, as participants reached back and forth between the targets,
this trajectory path was more consistent. This finding supports
repetitive training of movements, such as are required during
CIT, to improve the ability to make smoother and steadier
reaching patterns. CIT training requires repetitive reaching
movements during a variety of tasks in many different planes
of movement. As such, participants gain more control of their
ability to reach even though the reach may still rely in part on
compensatory movements.
Implications for Intervention
Based on the present study, there are important implications
of the overall impact of CIT on specific movement strategies in
survivors of stroke. Improvements on the WMFT, a commonly
reported functional outcome, demonstrate that CIT increases
motor capacities that allow survivors of stroke to complete
basic movement tasks more rapidly. Such results of the WMFT
and our other functional outcomes are similar to the recently
completed EXCITE trial,11 and support the idea that CIT
improves basic motor skills. However, and perhaps more im-
Statistical Analysis
Post-CIT Critical
Mean ⫾ SD Value P‡ Effect size
7.58⫾3.13 3.99 .002 1.88
34.31⫾17.19 –2.95 .013 1.39
47.92⫾17.90 2.73 .007 0.85
25.06⫾27.28 2.61 .014 1.23
2.69⫾0.54 –2.19 .014 0.49
2.90⫾0.74 –1.68 .047 0.38
Arch Phys Med Rehabil Vol 90, April 2009
578 KINEMATIC ANALYSIS OF CONSTRAINT-INDUCED THERAPY, Massie
portantly, our results extend beyond basic measures of func-
tional capacity to explain how CIT influences motor patterns
employed by participants. For example, increased functional
ability may be attributed to the greater use of shoulder flexion
during reach and the ability to reach faster. Although our
results from functional measures (ie, WMFT functional ability
scale and MAL “how-well” scale) suggest that quality of
movement improves, our kinematic data present a different
picture: CIT promoted reliance on compensatory movement
patterns involving shoulder abduction and had little or no
impact on compensations with the trunk. These findings high-
light 2 important considerations for CIT and stroke rehabilita-
tion research. First, quality of movement outcome measures
commonly used have limited sensitivity to detect such specific
changes in motor strategies including compensatory move-
ment. Second, our findings also support the idea that tradition-
ally, CIT is focused on the amount of movement rather than the
execution of normalized movements. Although there is much
debate over the differentiation between true motor recovery
and compensatory motor recovery, there is a consensus that the
mechanisms underlying recovery and the impact of therapy on
these mechanisms must be better understood.32,33 To that end,
more emphasis should be given to how interventions affect
functional capacity and movement strategy, to understand fur-
ther the impact of interventions on recovery of motor skills.
This study is an initial step toward understanding how CIT
influences movement strategies. The potential for CIT to en-
train normative movement patterns better while still improving
functional capacity may be improved with an evaluation of the
specific techniques used in CIT.
Study Limitations and Future Directions
We acknowledge some limitations within the current study.
First, the change observed with kinematic motion analysis is
not indicative of entire motor control system changes. The
ability to control movement is a complex process involving
many factors. Further research to study different aspects within
the motor control system will enhance the understanding of
how rehabilitation influences the central nervous system. For
instance, future studies could combine electromyography with
kinematic motion analysis. Second, the kinematic task was
based on a gross-motor reaching movement requiring speed
using the trunk, shoulder, and elbow. Future studies should
include analysis of all degrees of freedom in the upper limb,
change in total range of motion, and the influence of the self-
selected versus fast movements. Finally, the small sample size
limits the generalizability of our findings to the larger stroke
population. As such, the next phase of investigations should
include a random-control design in a larger group of survivors
of stroke.
CONCLUSIONS
The results of this study demonstrate that spatiotemporal
parameters of movement improved after CIT, and there was
greater use of the shoulder during reach. However, while
functional capacity and some movement strategies in the hemi-
paretic arm improved after CIT, participants did not overcome
their reliance on common compensatory movement patterns.
After CIT, shoulder abduction was more pronounced, and
subjects continued to rely on trunk movement to accomplish
reach. Based on these findings, our study provides initial evi-
dence that CIT may encourage subjects to generate movement
through compensatory and/or synergy-dominated movement
rather than promote the normalization of motor control. This
outcome highlights the need to study CIT further as an inter-
Arch Phys Med Rehabil Vol 90, April 2009
vention that improves functional capacity and normalized
movement strategies.
Acknowledgment: We thank Gary Kenyon, MS, for his support
of kinematic data collection procedures.
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