Modified constraint-induced therapy for children with hemiplegic cerebral palsy: a randomized trial

Abstract

Aim Conventional constraint‐based therapies are intensive and demanding to implement, particularly for children. Modified forms of constraint‐based therapies that are family‐centred may be more acceptable and feasible for families of children with cerebral palsy (CP)‐but require rigorous evaluation using randomized trials. The aim of this study was to determine the effects of modified constraint‐induced therapy compared with intensive occupational therapy on activities of daily living and upper limb outcomes in children with hemiplegic CP. Method In this assessor‐blinded pragmatic randomized trial, 50 children (27 males, 23 females; age range 19mo–7y 10mo) with hemiplegic CP were randomized using a concealed allocation procedure to one of two 8‐week interventions: intensive occupational therapy (n=25), or modified constraint‐induced therapy (n=25). Manual Ability Classification System (MACS) levels of the participants were, level I n=2, II n=37, III n=8, and level IV n=1; Gross Motor Function Classification System (GMFCS) levels were, level I n=33, level II n=15, and level III n=1. Participants were recruited through three specialist CP centres in Australia and randomized between January 2008 and April 2010. Children randomized to modified constraint‐induced therapy wore a mitt on the unaffected hand for 2 hours each day, during which time the children participated in targeted therapy. The primary outcome was the Canadian Occupational Performance Measure (COPM – measured on a 10‐point scale) at completion of therapy. Other outcome measures were Goal Attainment Scaling, Assisting Hand Assessment, Pediatric Motor Activity Log, Modified Ashworth Scale, Modified Tardieu Scale, and a parent questionnaire. Assessments were carried out at 10 weeks and 6 months following randomization. Results All participants were included in the analysis. Between‐group differences for all outcomes were neither clinically important nor statistically significant. The mean difference in COPM was 0.3 (95% confidence interval [CI] −0.8 to 1.4; p=0.61) and mean difference in COPM satisfaction was 0.1 (95% CI −1.1 to 1.2; p=0.90). Minor adverse events were reported by five of the 25 participants in the modified constraint‐induced therapy group and by one of the 25 in the intensive occupational therapy group. All adverse events were related to participants’ lack of acceptance of therapy. Interpretation Modified constraint‐induced therapy is no more effective than intensive occupational therapy for improving completion of activities of daily living or upper limb function in children with hemiplegic CP.

Efficacy of Upper Limb Therapies for Unilateral Cerebral Palsy: A Meta-analysis

“…Thirteen types of UL interventions and numbers of participants were identified: NDT (2 studies; n = 122), 12,13 intramuscular injections of BoNT-A and OT (11 studies; n = 322), [14][15][16][17][18][19][20][21][22][23][24] cCIMT (3 studies; n = 56), 6,[25][26][27][28] mCIMT (15 studies; n = 578), 7,[29][30][31][32][33][34][35][36][37][38][39][40][41][42][43][44][45][46][47] hybrid model (mCIMT and bimanual training; 2 studies; n = 68), 8,9 forced-use therapy (2 studies; n = 54), 48,49 HABIT (1 study; n = 20), 50 OT home programs (1 study; n = 35), 51 UL lycra splints (1 study; n = 16), 52 contextfocused therapy (1 study; n = 128), 53 mirror box therapy (1 study; n = 10), 54 acupuncture combined with OT (1 study; n = 75), …”

Constraint-induced movement therapy of upper limb of children with cerebral palsy in clinical practice: systematic review of the literature

“…CIMT was not employed in its classic form and was modified with respect to the constraint method, duration of constraint (days or weeks), type and duration of therapy, intervention setting (home, school or clinic) and intervention provider (therapist, parent or teacher). The first significant variant was the method employed to constrain the unaffected limb, for which a range of techniques was used, such as a mitt 21,22,[24][25][26]28 , sling [17][18][19][20] , cast 27 and splint…”

“…Wallen M et al 28 Significant improvements in post-intervention "satisfaction" and "performance" (COPM) in both groups…”

“…Along with other measures, Sakzewski et al 26 used the Box and Block Test and Children's Hand-Use Experience Questionnaire (CHEQ) as secondary outcome measures. Along with previously described measures, Wallen et al 28 used the Modified Tardieu Scale (MTS) and Modified Ashworth Scale as secondary outcome measures for the evaluation of spasticity of the elbow flexors as well as the wrist pronators and extenders.…”

Importance for CP Rehabilitation of Transfer of Motor Improvement to Everyday Life

“…13,14 There are several studies reviewed by Sakzewski et al in which CIMT was delivered in the home. 15,16 Training was implemented in these studies adhering to the guidelines of Novak et al, 17 but no use of the transfer package was reported. Thus, even though training was done in the home, systematic steps were not reported to have been taken to integrate use of the more-affected arm into daily life activities, which the transfer package accomplishes by a variety of means.…”