Participation Outcomes in a Randomized Trial of 2 Models of Upper-Limb Rehabilitation for Children With Congenital Hemiplegia

doi:10.1016/j.apmr.2010.11.022

Archives of Physical Medicine and Rehabilitation

Volume 92, Issue 4, April 2011, Pages 531-539

Presented in part to the Australasian Academy of Cerebral Palsy and Developmental Medicine, March 3–6, 2010, Christchurch, New Zealand; and the International Cerebral Palsy Conference, February 18–21, 2009, Sydney, Australia.

https://doi.org/10.1016/j.apmr.2010.11.022 Get rights and content

Abstract

Sakzewski L, Ziviani J, Abbott DF, Macdonell RA, Jackson GD, Boyd RN. Participation outcomes in a randomized trial of 2 models of upper-limb rehabilitation for children with congenital hemiplegia.

Objective

To determine if constraint-induced movement therapy (CIMT) is more effective than bimanual training to improve occupational performance and participation in children with congenital hemiplegia.

Design

Single-blind randomized comparison trial with evaluations at baseline, 3, and 26 weeks.

Setting

Community facilities in 2 Australian states.

Participants

Referred sample of children (N=64; mean age ± SD, 10.2±2.7y, 52% boys) were matched for age, sex, side of hemiplegia, and upper-limb function and were randomized to CIMT or bimanual training. After random allocation, 100% of CIMT and 94% of the bimanual training group completed the intervention.

Interventions

Each intervention was delivered in day camps (total 60h over 10d) using a circus theme with goal-directed training. Children receiving CIMT wore a tailor-made glove during the camp.

Main Outcome Measures

The primary outcome was the Canadian Occupational Performance Measure (COPM). Secondary measures included the Assessment of Life Habits (LIFE-H), Children's Assessment of Participation and Enjoyment, and School Function Assessment.

Results

There were no between-group differences at baseline. Both groups made significant changes for COPM performance at 3 weeks (estimated mean difference =2.9; 95% confidence interval [CI], 2.3–3.6; P<.001 for CIMT; estimated mean difference=2.8; 95% CI, 2.2–3.4; P<.001 for bimanual training) that were maintained at 26 weeks. Significant gains were made in the personal care LIFE-H domain following CIMT (estimated mean difference=0.5; 95% CI, 0.1–0.9; P=.01) and bimanual training (estimated mean difference=0.6; 95% CI, 0.2–1.1; P=.006).

Conclusions

There were minimal differences between the 2 training approaches. Goal-directed, activity-based, upper-limb training, addressed through either CIMT or bimanual training achieved gains in occupational performance. Changes in participation on specific domains of participation assessments appear to correspond with identified goals.

Section snippets

Participants

The study was approved by the Ethics in Human Research Committees at The Royal Children's Hospital, Melbourne; La Trobe University; The Royal Children's Hospital and Health Services District, Brisbane; and The University of Queensland.

Children were eligible if they had: (1) congenital hemiplegia (5–16y); (2) the ability to follow instructions; (3) predominant spasticity with Modified Ashworth Scale score higher than 1 and 3 or less for wrist flexors, forearm pronators, and/or thumb adductors

Results

Sixty-four children with congenital hemiplegia entered the study and 62 completed the intervention. One child from bimanual training withdrew after the first day due to preexisting emotional difficulties, and 1 was injured prior to the commencement of intervention. There were 18 TDC recruited (11 girls) with a mean age 8.7 years (range, 5–14y). The trial profile is depicted in figure 1.

Discussion

This randomized comparison trial of CIMT and bimanual training for children with congenital hemiplegia aimed to determine whether an activity-based intervention could impact perceived occupational performance and societal participation, an important consideration given the resource intensive nature of the interventions. Overall, results suggest there were minimal differences between the 2 intervention groups for the achievement of individualized outcomes and reduction of participation

Conclusions

In our large randomized comparison trial of CIMT and bimanual training, both interventions lead to equivalent gains in perceived occupational performance. Modest changes in participation in specific life habits were achieved by both groups, which corresponded with goals identified by children and their caregivers. Specifically focused interventions impacting participation would need to address a range of environmental, attitudinal, and child-related factors restricting societal participation.

Acknowledgements

We thank Rose Gilmore, OT, for the coordination of the Melbourne camps and Kerry Provan, OT, for the coordination of the Brisbane camps. We thank and acknowledge the support of the YMCA of Victoria and all the volunteers who helped during the camps, visiting volunteer therapists (Katrijn Klingels, Hilda Feys, PhD, from the Katholeik University Leuven, Anna Mackey, PhD, from the University of Auckland, Madonna Jeffries from Sunshine Coast Children's Therapy Centre, Queensland), the therapy staff

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Cited by (55)

At-home and in-group delivery of constraint-induced movement therapy in children with hemiparesis: A systematic review
2018, Annals of Physical and Rehabilitation Medicine
Citation Excerpt :
Most found a significant improvement at both posttreatment and follow-up. Four revealed a significant improvement at both posttreatment and follow-up [11,46,50,57]. One study showed a significant improvement at only posttreatment [48], whereas another found a significant improvement at only follow-up [47].
Constraint-induced movement therapy (CIMT) is increasingly recognized as an effective therapy for children with hemiparesis. However, the effectiveness of CIMT outside the standard rehabilitation protocol in clinical settings is less known. The aim of this systematic review was to investigate the effectiveness of CIMT conducted at home or in a group.
We searched CINAHL, PubMed and ScienceDirect in August 2017 to select articles of studies investigating the impact of CIMT performed at home and in a group on affected upper-limb ability, occupational performance, and quality of life of children. Quality was evaluated with the PEDro scale.
Among 374 reports of studies, 30 met the criteria; 15 examined CIMT at home and 15 in a group. CIMT with the 2 delivery models, at home or in a group, had a positive effect on the affected upper-limb ability and occupational performance. The quality of evidence was high for both these outcomes. However, the evidence was weaker and the results too limited to conclude on the impact on quality of life. The data also suggested that the glove may not be the best type of constraint.
CIMT performed at home or in a group may be a promising intervention for rehabilitation for children with hemiparesis, but more studies on the impact on quality of life are warranted.
Constraint-induced movement therapy improves upper limb activity and participation in hemiplegic cerebral palsy: A systematic review
2016, Journal of Physiotherapy
Questions: Does constraint-induced movement therapy improve activity and participation in children with hemiplegic cerebral palsy? Does it improve activity and participation more than the same dose of upper limb therapy without restraint? Is the effect of constraint-induced movement therapy related to the duration of intervention or the age of the children? Design: Systematic review of randomised trials with meta-analysis. Participants: Children with hemiplegic cerebral palsy with any level of motor disability. Intervention: The experimental group received constraint-induced movement therapy (defined as restraint of the less affected upper limb during supervised activity practice of the more affected upper limb). The control group received no intervention, sham intervention, or the same dose of upper limb therapy. Outcome measures: Measures of upper limb activity and participation were used in the analysis. Results: Constraint-induced movement therapy was more effective than no/sham intervention in terms of upper limb activity (SMD 0.63, 95% CI 0.20 to 1.06) and participation (SMD 1.21, 95% CI 0.41 to 2.02). However, constraint-induced movement therapy was no better than the same dose of upper limb therapy without restraint either in terms of upper limb activity (SMD 0.05, 95% CI –0.21 to 0.32) or participation (SMD –0.02, 95% CI –0.34 to 0.31). The effect of constraint-induced movement therapy was not related to the duration of intervention or the age of the children. Conclusions: This review suggests that constraint-induced movement therapy is more effective than no intervention, but no more effective than the same dose of upper limb practice without restraint. Registration: PROSPERO CRD42015024665. [Chiu H-C, Ada L (2016) Constraint-induced movement therapy improves upper limb activity and participation in hemiplegic cerebral palsy: a systematic review. Journal of Physiotherapy 62: 130–137]
Development and psychometric evaluation of a new measure for children's participation in hand-use life situations
2015, Archives of Physical Medicine and Rehabilitation
To describe the development of the Children's Assessment of Participation with Hands, a parent-report questionnaire that assesses children's participation in life situations requiring hand use specifically, and to investigate its construct validity (using Rasch analysis and known-group comparison) and reliability (test-retest reliability and internal consistency).
Cross-sectional, validation, and test-retest studies.
Schools.
Parents/caregivers (N=202) reported on their children aged 2 to 12 years with (n=97) and without disabilities (n=105).
Not applicable.
The Children's Assessment of Participation with Hands was developed based on a content review of existing children's participation measures and literature, expert review, and pilot testing. The Children's Assessment of Participation with Hands included 37 items measuring participation diversity, frequency, independence, and desire for change in specific hand-use life situations across 4 domains of self-care, recreation, education, and domestic life and community.
Evidence for construct validity of the Children's Assessment of Participation with Hands domains was established through Rasch analysis (after removing 2 misfitting items from the recreational domain and 1 item from the domestic life and community domain). Differences in summary scores of each domain between children with and without disabilities were also significant (P<.01). Test-retest reliability of the Children's Assessment of Participation with Hands was moderate to high (intraclass correlation coefficients, .69–.96), except for the desire for change dimension scale of the recreational domain (.40). Internal consistency was varied across the dimensions/domains.
Results provide preliminary evidence for the construct validity and reliability of the Children's Assessment of Participation with Hands that could be used in clinical and research settings to gain a specific understanding of the impact of children's hand-use difficulties on their participation in life situations requiring hand use.
Relation between unimanual capacities and bimanual performance in hemiplegic cerebral-palsied children: Impact of synkinesis
2015, European Journal of Paediatric Neurology
Citation Excerpt :
Few tools, however, are reliable and usable to assess bimanual capacities, and hardly any of them focus on bimanual performance. Yet the aim of any therapeutic action is not only to improve analytic or test situations, that is to say functional “capacities”, or what the child can do … but therapeutic action tends to improve real life situations, that is to say “performance”, or what the child really does, trying to have an effect on participation.2,3 Recent studies have focused on the relation between global motor capacity and global motor performance in CP children by using GMFM4,5; others have searched for a link between lesion aspects and unilateral motor capacity in the upper limb6; but few studies have focused specifically on the link between unimanual capacity and bimanual performance in the upper limb.7
Analyze the link between unimanual capacities and bimanual performance in cerebral-palsied (CP) hemiplegic children, aged between 5 and 18 years old, studying specifically the impact of synkinesis.
71 CP hemiplegic children (35 boys and 36 girls – with average age of 8 years and 6 months; MACS levels from I to III; GMFCS from I to IV) took part in a transversal study, assessed – Melbourne Test (MUUL) for unimanual capacities, and Assisting Hand Assessment (AHA) for bimanual performance – with a specific scale to analyze synkinesis during Box and Block test for affected and healthy hands, collecting synkinesis type, duration and intensity.
There is a strong correlation between unimanual capacities (MUUL) and bimanual performance (AHA) (r = 0.871). Neither age nor gender contribute to bimanual performance (AHA). Multiple linear regression shows that MUUL contributes to bimanual performance variance (AHA) by 70%. Synkinesis is partly correlated to capacities (MUUL) and accounts for 10% of the variance of the gap between capacities and bimanual performance.
A high relationship between unimanual capacities and bimanual performance is confirmed by this study; some authors demonstrated impact of sensory troubles, we demonstrate that synkinesis influences the use of unimanual capacities in bimanual performance.
Comparison of dosage of intensive upper limb therapy for children with unilateral cerebral palsy: How big should the therapy pill be?
2015, Research in Developmental Disabilities
Citation Excerpt :
Each task was capped at 120 s to reduce frustration with a maximum possible total score of 720 s. Outcomes of Study 1 (mCIMT vs bimanual therapy: 60 h full dose) have been previously reported (Sakzewski et al., 2011a, 2011b, 2011c). In this paper, we report secondary analysis comparing results from Study 1 to unpublished results of Study 2 (mCIMT vs bimanual therapy: total 30 h, half dose).
This study aimed to compare efficacy of two dosages of modified constraint induced movement therapy (mCIMT) and bimanual therapy on upper limb and individualized outcomes for children with unilateral cerebral palsy. This secondary analysis included two separate randomized trials that compared equal doses (high or low) of mCIMT to bimanual therapy; Study 1 (full dose – 60 h) n = 64 and; Study 2 (half dose – 30 h) n = 18 for children aged five to 16 years with unilateral cerebral palsy. Outcomes for both studies included the Melbourne Assessment of Unilateral Upper Limb Function, Assisting Hand Assessment, Jebsen Taylor Test of Hand Function and Canadian Occupational Performance Measure which were administered at baseline, three and 26 weeks. Mixed linear modelling was used to compare between dose (e.g. “full dose” to “half dose” of either mCIMT or bimanual therapy) on outcomes at three and 26 weeks post-intervention. There were no significant differences between groups at baseline, however, on average the half dose mCIMT group was younger with better hand function compared to the other groups. The full compared to half dose mCIMT group achieved greater gains in bimanual performance at three weeks and dexterity and quality of movement at 26 weeks. There were no between group differences for bimanual therapy doses. Half dose groups receiving either mCIMT or bimanual therapy did not make significant within group gains on any upper limb motor outcome, however gains in occupational performance were clinically meaningful.
These results suggest that a half dose (30 h) of either mCIMT or bimanual therapy may not be sufficient to impact upper limb outcomes, but made clinically meaningful gains in occupational performance for school aged children with UCP.
Dosing parameters of constraint-induced movement therapy in children with cerebral palsy. A literature review
2018, Rehabilitacion
El objetivo de esta revisión de la literatura fue determinar parámetros óptimos de dosificación de terapia de movimiento inducido por restricción (TMIR) para el mejoramiento de la función del miembro superior en niños con parálisis cerebral hemipléjica. Se realizó una búsqueda de artículos publicados entre 2010 y 2016, en ScienceDirect, Pubmed central, PEDro, SciELO y Wiley Online Library. Se seleccionaron 13 estudios que cumplieron con los criterios de inclusión. Los resultados más relevantes no encontraron diferencias significativas entre la efectividad de dosis moderadas y altas de TMIR y demostraron que se requieren al menos 54 h de TMIR modificada en niños menores de 5 años y 60 h en niños mayores para inducir cambios mantenidos. Los estudios variaron en cuanto a parámetros de dosificación y tipo de restricción utilizada. Dosis moderadas de TMIR modificada combinada con entrenamiento bimanual son óptimas para producir resultados mantenidos en la función del miembro superior en niños con parálisis cerebral hemipléjica. La edad, la colaboración de la familia y la naturaleza de la terapia adyuvante son factores que influyen en la relación dosis-respuesta.
The objective of this literature review was to determine optimal dosing parameters of constraint-induced movement therapy (CIMT) for the improvement of upper limb function in children with hemiplegic cerebral palsy. A search of articles published between 2010 and 2016 was performed in ScienceDirect, Central Pubmed, PEDro, SciELO and Wiley Online Library. Thirteen studies were selected that met the inclusion criteria. The most relevant results showed no significant differences between the effectiveness of moderate and high doses of CIMT and demonstrated that at least 54 h of modified CIMT are required in children under 5 years and 60 h in older children to induce sustained changes. Studies varied in terms of the dosing parameters and type of restriction used. Moderate doses of modified CIMT combined with bimanual training are optimal to produce sustained outcomes in upper limb function in children with hemiplegic cerebral palsy. Factors that influence the dose-response relationship are age, family collaboration, and the type of adjuvant therapy.

View all citing articles on Scopus

: Supported by the National Health and Medical Research Council of Australia (NHMRC) for Dora Lush postgraduate scholarship (scholarship no. NHMRC 384488), a Career Development (grant no. NHMRC 473860), and a project grant for INCITE: A Randomised Trial of Novel Upper Limb Rehabilitation in children with Congenital Hemiplegia (grant no. NHMRC 368500).

: 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 organization with which the authors are associated.

: Trial Registration Number: ANZCRT00320714.

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Original articleParticipation Outcomes in a Randomized Trial of 2 Models of Upper-Limb Rehabilitation for Children With Congenital Hemiplegia

Abstract

Objective

Design

Setting

Participants

Interventions

Main Outcome Measures

Results

Conclusions

Section snippets

Participants

Results

Discussion

Conclusions

Acknowledgements

Arch Phys Med Rehabil

Arch Phys Med Rehabil

International Classification of Functioning, Disability and Health

Geveva: WHO

The relationship between unimanual capacity and bimanual performance in children with congenital hemiplegia

Dev Med Child Neurol

Neuroimpairments, activity limitations, and participation restrictions in children with cerebral palsy

Dev Med Child Neurol

How do changes in body functions and structures, activity, and participation relate in children with cerebral palsy?

Dev Med Child Neurol

Impact of impairment on activity patterns of children

Arch Phys Med Rehabil

Leisure activities of cerebral palsied children

Isr J Psychiatry Relat Sci

Systematic review and meta-analysis of therapeutic management of upper limb dysfunction in children with congenital hemiplegia

Pediatrics

Modified constraint-induced therapy for children with hemiplegic cerebral palsy: a feasibility study

Dev Neurorehabil

Cortical reorganization after modified constraint-induced movement therapy in pediatric hemiplegic cerebral palsy

J Child Neurol

Case report: ICF-level changes in a preschooler after constraint-induced movement therapy

Am J Occup Ther

Effectiveness of modified constraint-induced movement therapy in children with unilateral spastic cerebral palsy: a randomized controlled trial

Neurorehabil Neural Repair

Original article
Participation Outcomes in a Randomized Trial of 2 Models of Upper-Limb Rehabilitation for Children With Congenital Hemiplegia