THE IMPACT OF CONSTRAINT INDUCED MOVEMENT THERAPY ON QUALITY OF LIFE IN CHILDREN WITH HEMIPLEGIC CEREBRAL PALSY: A SYSTEMATIC REVIEW

Jones S• Armanyous A• Behmer R• Montgomery B• Osborne JSouthwest Baptist University • Department of Physical Therapy • Bolivar, Missouri

• Hemiplegic cerebral palsy (CP) is a non-progressive neurological disorder resulting in asymmetrical movement impairment in developing children.

• Common deficits reported in children with hemiplegic CP relate to decreased physical function and decreased quality of life (QOL).

• Constraint-induced movement therapy (CIMT) is a technique that restrains movement of the uninvolved extremity. Intensive task-oriented training is then initiated with the involved extremity.

• The functional benefits of CIMT in the treatment of children with hemiplegic CP are well established in the literature.

• Research shows QOL benefits in adult stroke patients after CIMT training. This study investigated if similar benefits are seen in children with hemiplegic CP.

• The purpose of this systematic review was to determine if CIMT had a positive impact on QOL or participation compared to traditional physical therapy for treatment of children with hemiplegic CP.

Although there is a large body of evidence supporting the positive impact of CIMT on functional outcomes, impact on QOL is not routinely assessed. Over 100 studies regarding the functional impact of CIMT were found in the literature, but only four were found to specifically measure the impact on QOL. These studies provide evidence that CIMT not only improves function in children with hemiplegic CP, but also produces a higher QOL which is sustained over time. Positive changes in QOL,however, cannot be assumed because a particular intervention improves function. Rather, researchers must consider more than functional gains and measure QOL specifically when evaluating the impact of physical therapy interventions.

The initial search produced 121 articles, and a total of four studies of moderate strength were found to meet criterion (one level Ib and three level II evidence). Comparison groups used alternative traditional therapy, bimanual intensive, or task-oriented therapy. QOL measures included the PMAL, CPQOL, KIDSCREEN 52 and the COPM. QOL was measured pre-treatment, post-treatment, and at a follow-up period (not greater than 12 months). CIMT treatment groups showed improved QOL or participation in various settings. Improvements in emotion, physical, and psychological well-being were maintained at the various follow-up periods.

• A systematic review of the literature was conducted. Four relevant databases were searched for peer-reviewed studies from within the last ten years. The quality and conduct of the studies was determined using the American Academy for Cerebral Palsy and Developmental Medicine Methodology.

• INCLUSION CRITERION: Studies included had at least level IV evidence, children with hemiplegic CP, the use of CIMT as a treatment intervention, and pre- and post-treatment measures of QOL or participation.

• SUBJECTS: In the included studies, a total of 119 children with hemiplegic CP, aged 7 months to 16 years of age, were randomly assigned to a CIMT treatment group or alternative treatment group.

Improvements in QOL cannot be assumed solely based on improved function, but should be measured routinely and specifically in clinical practice.

Special thanks  to  Hayley’s  family  for  sharing  photographs.We would like to thank Dr. Jones for her time commitment, guidance, and knowledge and Southwest Baptist University for providing resources and support.Contact (sarahjones@sbuniv.edu)References available upon request

Year Lead Author Design

Number of ParticipantsDescription of ParticipantsAges

Intervention Comparison Intervention

Outcome Measures

Results/Findings

2012 HsinRCT Level 1b

22 children with congenital unilateral spastic CP recruited from tertiary medical centerCIT group (n=11)Traditional rehabilitation (n=11)Children aged 6-8

CI group (elastic bandage and glove) and traditional group. Both groups received individualized home- based interventions of 3.5 to 4 hoursper day, 2x per wk for 4 wks.

Traditional rehabilitation

Bruininks-OseretskyTest of Motor Proficiency, PMAL, CP-specific Quality of Life instrument

CIT showed improvement in functional performance compared to traditional rehabilitation post treatment and 3 months follow-up. CIT program generated greater gains than traditional group in most health-related QOL domains in long-term, but not in short-term.CIT group improved in social well-being, self-esteem, participation, physical health, pain, impact of disability, and access to services.

2012 SakzewskiRCT Level II

63 children with CP of the spastic motor type (n=59) or with spasticity and dystonia (n=4)(33 males, 30 females)Ages 5-16.Mean age 10y 2mo [SD 2y 6mo]

CIMT group (glove while attending the day camp) or bimanual intensive training (BIM) group (instructions on bimanual tasks)

Bimanual training [BIM]

CPQOL- Child self-report and parent proxy report, KIDSCREEN-52 self-report, KIDSCREEN-52 parent proxy report

CPQOL - Children sustained changes in feelings about functioning participation, and physical health, and parents reported changes in their child’s  social  well-being. Children did not self report changes in their social or emotional well being.KIDSCREEN- CIMT group had significant improvement in emotions, physical well-being, and psychological well-being at 3 weeks post intervention, those changes were maintained.

2012 Branda’oRCT Level II

16 children with hemiplegic CP who attended school (difference of minimum 50% between the two limbs and functional wrist motion)3 yr 8 mo to 10 yr 3 mo

Participants placed in CIMT or HABIT group using concealed allocation, stratified by age and severity. The interventions were provided for 15 days, 6 hr daily, totaling 90 hr.

HABIT group The Manual Ability Classification System. PEDI, Parent Interviews, COPM

Both CIMT and HABIT groups had functional improvements. HABIT had greater benefits than CIMT on COPM measures. Parents reported greater improvements in HABIT group, but for both groups,parents reported satisfaction regarding improvement in daily function.

2004 TaubRCT Level II

18 children with diagnosis of hemiplegic CP or children less than 18 months and etiology of stroke confirmed by MRIAge 7-96 months

CIT group (bivalved cast) and conventional treatment group. 6 hours per day for 21 consecutive days for CI group and 2.2 hrs a week on average for traditional therapy

Traditional rehabilitation

EBS, PMAL, TAUT CI therapy group had increased amount and quality use of impaired extremity. Benefits maintained over 6 months. Parents reported improved QOL through the PMAL.

KEY: CIMT – Constraint induced modified therapy, CIT – Constraint-induced therapy, COPM – Canadian Occupational Performance Measure CP –cerebral palsy, EBS – emerging behaviors scale, HABIT – hand-arm bimanual intensive therapy, PEDI – pediatric evaluation of disability inventory, PMAL – pediatric motor activity log, QOL – quality of life, RCT – randomized controlled trial, TAUT – toddler arm use test

BACKGROUND & PURPOSE RESULTS

METHODS

CONCLUSIONS

CLINICAL RELEVANCE

ACKNOWLEDGEMENTS