Effectiveness of Constraint-Induced Movement Therapy for Functional Use in Children With Spastic Hemiplegic Cerebral Palsy: A Systematic Review

PURPOSE: The purpose of this systematic review is to understand the impact of constraint-induced movement therapy (CIMT) on functional tasks and independence in children with spastic hemiplegic cerebral palsy (CP). Childhood occupations require object handling, and over time poor hand function can have serious negative effects. CIMT may improve the use of the affected limb during functional activities. Statistically supported evidence regarding CIMT’s effectiveness is necessary to determine if it can increase performance quality and efficiency during functional activities including eating, dressing, personal hygiene and grooming, and personal device care to substantiate its use within occupational therapy practice. This study sought to answer the research question, Does CIMT improve function in children’s affected limbs to increase participation in activities of daily living (ADLs)?

DESIGN: A systematic review was conducted that collected and examined existing randomized controlled trials (RCTs) based on CIMT. We limited criteria for the study selection to RCTs that explored the use of CIMT to improve functional performance in children with CP under age 18 yr. EBSCOhost and the American Journal of Occupational Therapy were used to search for evidence-based research. Key words included “Cerebral palsy” AND “Children” OR “Under 18 years old” OR “Age 18” AND “Constraint induced movement therapy” OR “CIMT” AND “Randomized controlled trials” OR “RCT” OR “Controlled trial.” Both the Physiotherapy Evidence Database (PEDro) scale and the Jadad scale were applied by the investigators to all selected studies. The PEDro scale assesses scientific rigor and methodological quality of a study using a 10-point scale. The Jadad scale assesses the quality of published clinical trials and bias including random assignment, blinding, and attrition rates.

RESULTS: We conducted four searches that yielded 8,764 studies, including eight RCTs. Case-Smith, Deluca, Stevenson, and Ramey (2012) documented the beneficial effects of a 3- and 6-hr/day CIMT protocol, with the latter outperforming on each outcome measure. Significant improvements were seen in how well and how often children used their affected arm. Chen et al. (2012) found significant improvements in CIMT versus traditional rehabilitation in motor control, motor performance, daily function, grasping, amount and quality of hand use, reaction time, normalized movement time, and peak velocity. Sakzewski et al. (2011) analyzed the benefit of CIMT versus bimanual training, documenting significant improvements in unimanual capacity, bimanual performance, and movement efficiency, with CIMT containing the largest effect size. These studies demonstrated contrasting CIMT protocols in duration, intervention period, and restraints.

DISCUSSION: Included studies established significant improvements in functional outcomes. Comparative analyses found CIMT to significantly outperform the majority of other techniques. CIMT was found to increase participants’ occupational performance and function in daily life with regard to ADLs. CIMT can be completed in various settings, with different types of constraints, and significant effects have been documented with as little as 60 hr over the course of 10 days. We drew considerable implications from the data, particularly that progress in functional tasks is observed when a restraint is donned for a longer duration of time over a shorter intervention period.

CONCLUSION: Evidence supports CIMT as an effective therapeutic modality. The CIMT protocol needs standardization in the least restrictive manner for practice. Future research should incorporate varied levels of evidence, more rigorous PEDro and Jadad scoring, and streamlined outcome measures.

References

Case-Smith, J., DeLuca, S. C., Stevenson, R., & Ramey, S. L. (2012). Multicenter randomized controlled trial of pediatric constraint-induced movement therapy: 6-month follow-up. American Journal of Occupational Therapy, 66, 15–23. https://doi.org/10.5014/ajot.2012.002386

Chen, C., Kang, L., Hong, W., Chen, F., Chen, H., & Wu, C. (2012). Effect of therapist-based constraint-induced therapy at home on motor control, motor performance and daily function in children with cerebral palsy: A randomized controlled study. Clinical Rehabilitation, 27, 236–245. https://doi.org/10.1177/0269215512455652

Sakzewski, L., Ziviani, J., Abbott, D. F., MacDonell, R. A. L., Jackson, G. D., & Boyd, R. N. (2011). Randomized trial of constraint-induced movement therapy and bimanual training on activity outcomes for children with congenital hemiplegia. Developmental Medicine and Child Neurology, 53, 313–320. https://doi.org/10.1111/j.1469-8749.2010.03859.x