Improving Quality of Life for Children With Cerebral Palsy in Vietnam: Implementation of Intensive Models of Rehabilitation

PURPOSE: It is estimated that 500,000 Vietnamese children live with Cerebral Palsy (CP), yet only a limited number will receive rehabilitation services.^{1, 3} Constraint induced movement therapy (CIMT) is an intensive intervention in which the child’s non-affected arm is constrained while the child is engaged in high intensity repetitive task practice using the affected arm.^{2, 4} Through a grant funded by US AID, Vietnamese therapists were trained to use pediatric CIMT and developed models to use in the Vietnam healthcare system. In addition, pediatric assessments were validated for use in the Vietnamese culture. The aims of this study include: (1) to determine if two models of pediatric CIMT could be delivered with acceptable fidelity in two hospitals in Vietnam and (2) to determine if high quality pediatric CIMT could improve the motor skills and real-world abilities of Vietnamese children with hemiplegic CP.

DESIGN: This prospective non-randomized study examined the delivery of CIMT in two partner hospitals in Vietnam. Therapists at the Hanoi Rehab Hospital delivered a low dose (30 hours) CIMT protocol while therapists in Ho Chi Minh City (HCMC) Children’s Hospital delivered a high dose (72 hours) CIMT protocol. Therapists and parents delivered daily CIMT sessions over 4 to 6 weeks. All children were diagnosed with hemiplegic CP and recruited from a convenience sample of patients receiving therapy at each hospital.

METHOD: Outcome measures were the Goal Attainment Scale (GAS), ABILHAND-Kids, Pediatric Motor Activity Log (PMAL), and the Box and Blocks. GAS goals were set at baseline eval and the ABILHAND Kids, PMAL, and Box and Blocks were administered at baseline, pre- and post-CIMT. Fidelity was measured using the CIMT Fidelity of Implementation Tool. Therapists video recorded 2 CIMT sessions each week; videos were viewed and rated using Fidelity measure. Data was analyzed using t-test for the GAS (mean of 50 and std. dev. of 10) and repeated measures ANOVA for the ABILHAND kids, PMAL, and box and blocks.

RESULTS: Twenty children between 22 months to 6.9 years completed CIMT programs, 10 at each hospital (avg. age 3.5 yr. Hanoi, 4.6 yrs. HCMC). Both hospitals delivered CIMT program per protocol with prescribed dosage. The Hanoi therapists’ fidelity score was a 2.52 (on 1 to 4-point scale) indicating acceptable to high fidelity and adherence to CIMT protocols. HCMC fidelity data analysis is on-going. GAS t-scores (62.7 for Hanoi, 52.8 for HCMC) indicate children met or exceeded individual goals. There was a significant difference (p < 0.05) between pre- and post-CIMT scores on ABIKHAND-Kids and PMAL at both hospitals. There was a statistically significant difference in the Box and Blocks scores for the HCMC group only (n=10, p=0.015). Children in the Hanoi group improved scores on the Box and Blocks post-CIMT, although results were not statistically significant (n=5, p=0.13). This could be due to the small sample size.

CONCLUSION: Therapists successfully partnered with families to implement quality CIMT, per protocol. Children in both the low and high dose CIMT groups showed improvements in performance of everyday activities and individual therapy goals. These results are similar to recent pediatric CIMT studies implemented in the US when fidelity of treatment was measured.⁴ The results of this study advances the delivery of evidence-based practice in Vietnam and provides insight into how high quality pediatric CIMT can be provided in areas where resources are limited (i.e. rural areas). CIMT programs can maintain essential elements while being modified to fit in various settings in collaboration with families and caregivers.

References

1. Dao, H. T., Pichaiyongwongdee, S., Sullivan, P. E., Prasertsukdee, S., & Apinonkul, B. (2018). Are physical therapists in Viet Nam ready to implement evidence-based practice? A survey. BMC Medical Education,18(1).

2. Gelkop, N., Burshtein, D.G., Lahav, A., Brezner, A., AL-Oraibi, S., Ferre, C.L., & Gordon A. M. (2015). Efficacy of Constraint-Induced Movement Therapy and Bimanual Training in Children with Hemiplegic Cerebral Palsy in an Educational Setting, Physical & Occupational Therapy In Pediatrics, 35:1, 24-39.

3. Khandaker, G., Van Bang, N., Dũng, T.Q., Giang, N.T.H., Chau C.M., Van Anh, N.T., VanThuong, N., Badawi, N., & Elliot, E.J. (2017). Protocol for hospital based-surveillance of cerebral palsy (CP) in Hanoi using the Pediatric Active Enhanced Disease Surveillance mechanism (PAEDS-Vietnam): a study towards developing hospital-based disease surveillance in Vietnam. BMJ Open 7(11), e017742.

4. Ramey S.L., DeLuca S., Stevenson R.D., Case-Smith J., Darragh A. Conaway, M. (2019). Children with Hemiparesis Arm and Movement Project (CHAMP): protocol for a multisite comparative efficacy trial of paediatric constraint-induced movement therapy (CIMT) testing effects of dosage and type of constraint for children with hemiparetic cerebral palsy. BMJ Open, 9 (1).