Constraint-induced movement therapy in children with unilateral cerebral palsy

Abstract

Background: Unilateral cerebral palsy (CP) is a condition that affects muscle control and function on one side of the body. Children with unilateral CP experience difficulties using their hands together secondary to disturbances that occur in the developing fetal or infant brain. Often, the more affected limb is disregarded. Constraint-induced movement therapy (CIMT) aims to increase use of the more affected upper limb and improve bimanual performance. CIMT is based on two principles: restraining the use of the less affected limb (for example, using a splint, mitt or sling) and intensive therapeutic practice of the more affected limb.

Objectives: To evaluate the effect of constraint-induced movement therapy (CIMT) in the treatment of the more affected upper limb in children with unilateral CP.

Search methods: In March 2018 we searched CENTRAL, MEDLINE, Embase, CINAHL, PEDro, OTseeker, five other databases and three trials registers. We also ran citation searches, checked reference lists, contacted experts, handsearched key journals and searched using Google Scholar.

Selection criteria: Randomised controlled trials (RCTs), cluster-RCTs or clinically controlled trials implemented with children with unilateral CP, aged between 0 and 19 years, where CIMT was compared with a different form of CIMT, or a low dose, high-dose or dose-matched alternative form of upper-limb intervention such as bimanual intervention. Primarily, outcomes were bimanual performance, unimanual capacity and manual ability. Secondary outcomes included measures of self-care, body function, participation and quality of life.

Data collection and analysis: Two review authors independently screened titles and abstracts to eliminate ineligible studies. Five review authors were paired to extract data and assess risk of bias in each included study. GRADE assessments were undertaken by two review authors.

Main results: We included 36 trials (1264 participants), published between 2004 and 2018. Sample sizes ranged from 11 to 105 (mean 35). Mean age was 5.96 years (standard deviation (SD) 1.82), range three months to 19.8 years; 53% male and 47% participants had left hemiplegia. Fifty-seven outcome measures were used across studies. Average length of CIMT programs was four weeks (range one to 10 weeks). Frequency of sessions ranged from twice weekly to seven days per week. Duration of intervention sessions ranged from 0.5 to eight hours per day. The mean total number of hours of CIMT provided was 137 hours (range 20 to 504 hours). The most common constraint devices were a mitt/glove or a sling (11 studies each).We judged the risk of bias as moderate to high across the studies.

Key results: Primary outcomes at primary endpoint (immediately after intervention)CIMT versus low-dose comparison (e.g. occupational therapy)We found low-quality evidence that CIMT was more effective than a low-dose comparison for improving bimanual performance (mean difference (MD) 5.44 Assisting Hand Assessment (AHA) units, 95% confidence interval (CI) 2.37 to 8.51).CIMT was more effective than a low-dose comparison for improving unimanual capacity (Quality of upper extremity skills test (QUEST) - Dissociated movement MD 5.95, 95% CI 2.02 to 9.87; Grasps; MD 7.57, 95% CI 2.10 to 13.05; Weight bearing MD 5.92, 95% CI 2.21 to 9.6; Protective extension MD 12.54, 95% CI 8.60 to 16.47). Three studies reported adverse events, including frustration, constraint refusal and reversible skin irritations from casting.CIMT versus high-dose comparison (e.g. individualised occupational therapy, bimanual therapy)When compared with a high-dose comparison, CIMT was not more effective for improving bimanual performance (MD -0.39 AHA Units, 95% CI -3.14 to 2.36). There was no evidence that CIMT was more effective than a high-dose comparison for improving unimanual capacity in a single study using QUEST (Dissociated movement MD 0.49, 95% CI -10.71 to 11.69; Grasp MD -0.20, 95% CI -11.84 to 11.44). Two studies reported that some children experienced frustration participating in CIMT.CIMT versus dose-matched comparison (e.g. Hand Arm Bimanual Intensive Therapy, bimanual therapy, occupational therapy)There was no evidence of differences in bimanual performance between groups receiving CIMT or a dose-matched comparison (MD 0.80 AHA units, 95% CI -0.78 to 2.38).There was no evidence that CIMT was more effective than a dose-matched comparison for improving unimanual capacity (Box and Blocks Test MD 1.11, 95% CI -0.06 to 2.28; Melbourne Assessment MD 1.48, 95% CI -0.49 to 3.44; QUEST Dissociated movement MD 6.51, 95% CI -0.74 to 13.76; Grasp, MD 6.63, 95% CI -2.38 to 15.65; Weightbearing MD -2.31, 95% CI -8.02 to 3.40) except for the Protective extension domain (MD 6.86, 95% CI 0.14 to 13.58).There was no evidence of differences in manual ability between groups receiving CIMT or a dose-matched comparison (ABILHAND-Kids MD 0.74, 95% CI 0.31 to 1.18). From 15 studies, two children did not tolerate CIMT and three experienced difficulty.

Authors' conclusions: The quality of evidence for all conclusions was low to very low. For children with unilateral CP, there was some evidence that CIMT resulted in improved bimanual performance and unimanual capacity when compared to a low-dose comparison, but not when compared to a high-dose or dose-matched comparison. Based on the evidence available, CIMT appears to be safe for children with CP.

Conflict of interest statement

Brian Hoare* is employed by Monash Health. In 2014, he received an honorarium from Allergan Australia for travel to Sri Lanka as part of a multi‐disciplinary team to teach and train local physicians and therapists in the management of the upper limb in children with CP. The honoraria covered flights and accommodation for the trip, which were paid for directly by Allergan. This update does not review products manufactured by Allergan and Brian Hoare has no personal financial interest in Allergan, Botox®, or any related product.

*Brian Hoare, Christine Imms and Leeanne Carey are authors on the included study Hoare 2013, and were not involved in assessing the eligibility of this study for inclusion, extracting data from this study for purposes of this review, assessing the risk of bias in this study, or grading the quality of the evidence from this study.

Margaret Wallen is an author on the included study Wallen 2011 and was not involved in assessing the eligibility of this study for inclusion, extracting data from this study, assessing the risk of bias in this study, or grading the quality of the evidence from this study.

Megan Thorley ‐ none known.

Michelle Jackman ‐ none known.

Leeanne Carey* ‐ none known.

Christine Imms* is employed by the Australian Catholic University (ACU). ACU has provided support to CI for travel to conferences in which presentations were made about research in CP. CI received a philanthropic travel grant and other support from her university employer for unrelated studies.

Figures

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Study flow diagram

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'Risk of bias' summary: Review authors' judgements about each 'Risk of bias' item for each included study. Note: Not all studies used self‐reported outcome measures, so a 'Risk of bias' rating could not be ascribed. This explains the absence of ratings for some of the studies. No ratings are entered for Kirton 2016b (CIMT + sham TMS), as it is the same study as Kirton 2016a (CIMT + r TMS), immediately above it in the 'Risk of bias' summary.

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'Risk of bias' graph: Review authors' judgements about each 'Risk of bias' item presented as percentages across all included studies. Note: Not all studies used self‐reported outcome measures, so a 'Risk of bias' rating could not be ascribed. This explains the absence of data in the corresponding domain in this graph. The total risk is