Furthering the Evidence and Clinical Practice of Constraint-Induced Movement Therapy: Effects of Multiple Treatment Epochs

PURPOSE: Constraint-induced movement therapy (CIMT) is a well-known, evidence-based treatment for children with cerebral palsy (CP; Novak et al., 2013) with high levels of demonstrated efficacy. The aim of this study is to provide initial evidence regarding the efficacy of multiple treatment epochs of CIMT in a clinical cohort of children with CP. CIMT is designated one of the most efficacious treatments for children with CP (Novak et al., 2013). To date, trials have reported outcomes only for children who received one course of CIMT, and Eliasson et al. (2014) identified the topic of multiple treatments as one of the most pressing clinical and scientific questions facing the field.

DESIGN: This study is a prospective clinical cohort trial with pre- and posttreatment assessments administered and scored blind to individual child and treatment response variables. Participants included 28 children ranging in age from 11 mo to 10 yr (M = 31 mo) who displayed asymmetrical CP. On the Manual Abilities Classification System, 25% were Level II, 54% Level III, and 18% Level IV, and one child was Level V. Twenty children went through two CIMT epochs and eight through three epochs. Plus, two children were seen at least annually between age 1 and 11 yr. The CIMT protocol for these two children in later years included increased bilateral days interspersed within the 4-wk treatment protocol. All children were treated in a neuromotor research clinic. Parents voluntarily sought multiple treatments.

METHOD: The CIMT protocol was delivered by licensed, certified occupational therapists or physical therapists trained to provide the therapy protocol. Therapy was 6 hr/day, 5 days/wk for 4 wk in a natural environment; constraint was full-time until the last 3 treatment days, when transfer to bimanual skills occurred. Assessments include Emerging Behaviors Scale (EBS) with multiverified documentation of new upper-extremity skills, the Pediatric Motor Activity Log (PMAL) measuring how well and how often the child uses the hemiparetic arm or hand (rated independently by therapists and parents), and the Directed Play (DP) measuring unilateral and bilateral functional abilities. Content of daily therapy notes was analyzed, adding findings about rate and magnitude of progress, along with age-appropriate Assisting Hand Assessment measures.

RESULTS: The first treatment resulted in large, significant gains for all children on the EBS, with a range of 3 to 19 new skills and a mean of 13.2 (SD = 4.2); 71% gained at least 15 skills. The second treatment, on average 14 mo later, produced mean gains of 7.3 (SD = 4.7), while the third treatment produced mean gains of 6.5 (SD = 4.2). The PMAL parent and therapist ratings, plus therapy logs, reveal a similar pattern of positive pre- to posttreatment responses for all three treatments, with largest gains after the first treatment. Similarly, DP scores for functional abilities increased most after Treatment 1 (M = 23.2, SD = 1.4); Treatment 2 mean gain was 14.2 and Treatment 3 mean gain was 16.7. Small but significant loss of gains occurred during the intertreatment intervals for many children. Assessment and video data for the children seen annually during the first 11 yr of life will be presented. These children consistently demonstrated improvement across development.

CONCLUSION: This evidence supports the conclusion that multiple CIMT treatments produce important continued functional gains for most children with hemiparetic CP. Additionally, findings confirm the significance of home maintenance through the use of a transfer package.

References

Eliasson, A., Krumlinde-Sundholm, L., Gordon, A. M., Feys, H., Klingels, K., Aarts, P. B. M., . . . Hoare, B. (2014). Guidelines for future research in constraint-induced movement therapy for children with unilateral cerebral palsy: An expert consensus. Developmental Medicine and Child Neurology, 56, 125–137. https://doi.org/10.1111/dmcn.12273

Novak, I., McIntyre, S., Morgan, C., Campbell, L., Dark, L., Morton, N., Stumbles, E., . . . Goldsmith, S. (2013). A systematic review of interventions for children with cerebral palsy: State of the evidence. Developmental Medicine and Child Neurology, 55, 885–910. https://doi.org/10.1111/dmcn.12246