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Effectiveness of Constraint Therapy in Children with Hemiplegia:A Systematic Review Dhaliwall, Aman; Hales, Michael; Honarbakhsh, Behnad; Hunt, Meggan; Peters, Laura; Roxborough, Lori 2006

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The Effectiveness of Constraint Therapy: A Systematic ReviewThe Effectiveness The Effectiveness of Constraint of Constraint Therapy: A Therapy: A Systematic ReviewSystematic ReviewMegganMegganHuntHuntAman DhaliwalAman DhaliwalLaura PetersonLaura PetersonBehnadBehnadHonarbakhshHonarbakhshMichael HalesMichael HalesSupervisor: Lori Supervisor: Lori RoxboroughRoxboroughCollaborator: Collaborator: LousiaLousiaPulfreyPulfreyOutlineOutlineOutlineHistory of ConstraintHistory of Constraint3 types of intervention3 types of interventionOverview of 15 studiesOverview of 15 studiesClinical questions discussedClinical questions discussedConclusionsConclusionsWhat is Constraint Therapy?History of the ideaCortical Reorganization?After stroke, cortical areas responsible for the affected area(s) receive less neuronal stimulation.   ?After CIMT, cortical reorganization occurs, leading to an enlargement of the previously affected area and improvement in motor function4. 3 types of intervention1)Constraint Induced Movement Therapy(CIMT)   Constraint + Structured Practice + Feedback + Repetition Eg. All waking hours, 6-8 hrs/day 1:1 therapy, 2-3 consecutive weeks3 types of intervention2) Modified Constraint Induced Movement Therapy  (modified CIMT)Constraint + Practice + modified times3 types of intervention3) Forced Use TherapyConstraint Only  (no added therapy)Constraint Therapy in Children ?The EvidencePast reviews suggest a positive trendin the effectiveness of constraint therapy, but evidence is weak.  Our Review, Inclusion criteria: -All three types of Constraint Therapy -Children 0-18 years old with hemiplegia -All outcomes -English language -All research designsMethods: Search Strategy?Electronic search terms:?"(hemiparesisOR hemiplegia OR cerebral palsy OR diplegiaOR diparesisOR quadriplegia OR quadriparesis)  ?AND("constraint induced therapy" OR "constraint therapy" OR "constraint induced movement therapy" OR "learned nonuse" OR ?CIMT?OR "forced use" OR "physical restraint" OR "CI therapy")  ?AND(Ped$ OR child$). Methods: Search Strategy?Databases: ?Medline, CINAHL, EMBASE, PubMed, PEDRO, Cochrane, Cochrane Central, ACP Journal Club, DARE, EBM Reviews, Psycinfo, and ProQuestDissertations and Theses?Hand searched:?Physical Therapy, Physiotherapy Canada, Australian Journal of Physiotherapy, Physiotherapy (1995-March 2006) ?Physiotherapy Research International, Physiotherapy Theory and Practice (1998-March 2006). ?Authors contacted ?Reference lists searchedMethods: ScreeningInitial Search: 61 articlesAfter title screen: 39 articlesAfter abstract screen: 28 articlesAfter full-text screen: 15 articles included in systematic reviewAuthors contactedQuality Assessment and Data Abstraction?Review followed the AACPDM methodology. ?Group Designs: ?Sackett?sLevels of Evidence ?AACPDM Quality Assessment Scale?SSRDs: ?SSRD Levels of Evidence ?Quality Rigor and Evaluative Criteria?Data Abstraction formsLevels of Evidence-GroupLevelIntervention (Group) studiesISystematic Review of randomized controlled trials (RCT?s)Large RCT (with narrow confidence intervals)IISmaller RCT?s(with wider confidence intervals)Systematic Reviews of cohort studies?Outcomes research?(very large ecologic studies)IIIHigh quality cohort studies (must have concurrectcontrol group)Systematic Reviews of Case Control StudiesCase-control StudyIVCase SeriesPoor quality cohort and poor quality case-control studyVExpert opinionBench researchExpert opinion based on theory or physiologic researchCommon sense/ anecdotesLevels of Evidence-Single Subject DesignLevelIntervention (Single Subject) studiesIN-of-1 randomized controlled trialIIABABA design Alternating treatments design Multiple baseline designs (concurrent or non-concurrent; across subjects, settings or behaviors)IIIABA designIVAB design (with replication on >1 subject)VAB design (with 1 subject only)Grading the ResearchEffectiveLevelQuality ScoreGROUPCharles et al 2006                              YesII  5/7 Taubet al 2004YesII5/7Sung et al 2005YesII3/7Willis et al 2002YesII3/7Elaissonet al 2005YesIII4/7Bonnier et al 2005YesIV6/7Gordon et al 2006YesIV5/7SSRDDeluca et al 2003YesII3/7Naylor et al 2005YesIII4/7 Charles et al 2001YesIII3/7Crocker et al 1997YesIII2/7Pierce et al 2002YesIII2/7Karmanet al 2003YesIV 3/7 Glover et al 2002YesIV 1/7Quality Score: strong = 6 or 7, moderate = 4 or 5, and weak = 3 or less Group Design:  Charles et al, 2006?Level II ?22 subjects ?Age range: 4-8 yrs ?Intervention Group:Sling via CIMTfor 6hrs/session, 10/12 consec. Days ?Therapy:play/shaping/functional tasks ?Outcomes:JebsonTaylor Hand Test, Bruininks-Oseretsky[subset8] (motor proficiency), Caregiver Functional Use Survey, Hand Held Dynamometer, Modified Ashworth ScaleSingle Subject Design: Naylor & Bower, 2005?Level III SSRD ?9 subjects ?Age range: 21 mo-61 mo  ?Intervention:Gentle restraint, mCIMT, 1 hour/day, 7 days/week for 4 weeks.  ?Therapy:Fine motor and play activities, 1 hour/day, 7 days/week for 4 weeks.  ?Outcomes:Quality of Upper Extremity Skills Test Goals of this ReviewGoals of this ReviewGoals of this Review1) Is there a general benefit?1) Is there a general benefit?Is there a long term effect?Is there a long term effect?2) Is there a particular age that is appropriate?2) Is there a particular age that is appropriate?3) Is there improvement in ICF components?3) Is there improvement in ICF components?4) Are there any complications?4) Are there any complications?5) Is one protocol or type of therapy best?5) Is one protocol or type of therapy best?1) Is there a general benefit? Long term effects??All15 studies showed improvement ?7 of 15 studies reported follow up data ?Maintenance of function was reported in 4 studies-including fine motor function, dexterity & movement efficiency ?2 studies showed maintenance of improved frequency of use of affected limb at both 3 & 6 month follow up2) International Classification of Function?Functioning and disability: ?Body Structure/ Function ?Activities/ Participation?Contextual Factors?Environmental Factors ?Personal FactorsICF: Body Function/Activity?Body functions are the physiologic functions of body systems. ?Activity is the execution of a task or action by an individual. ?Body function and activitywere the primary outcomes of interest in our studies.ICF: Body Function/ActivityStatistically significant improvements in:?coordination, dexterity, & hand manipulation ?movement efficiency ?fine motor function, dissociated movement, grasp, protective extension, & weight bearing through the affected limb  ?speed and precision of movement.   ?new motor patterns ?amount of useof the affected limb.  ICF: Body Function/Activity?Follow up results: ?6 studies demonstrated maintenance or improvement of upper extremity function, however, only 3 studies showed statistical significance.ICF: Environmental Factors?The physical, social, and attitudinal environment in which people live and conduct their lives.ICF: Environmental FactorsImprovements found in: ?care-givers?perception of amountand qualityof use (at post intervention in one study and at 1 & 6 month follow-up in another study). 3) Age AppropriatenessGordon et al., 2006: Studied age-dependence of the effectiveness of CIMT.Children divided into older group (9-13), and younger group (4-8).No differencein outcomes between older and younger children.Age AppropriatenessCoordination of fine finger force development during grasping approximates that of adults by the age of 8 years ?Age range in studies: 7 mos-18 yrs ?Positive results obtained in both age groups across studies. ?4 studies with different age groups showed significant improvements in quality of movement.Age Appropriateness?Further research is necessary to determine optimal age for constraint.?Difficult to compare outcomes across studies because of differences in the:?Methodology?Mode of constraint?Restraint duration?Outcome measureAge Appropriateness?Age specific detrimental effects: ?Potentially permanent repercussions for motor skill development in the constrained limb due to corticospinaltract development during the first years of life.4) Documented Complications?Nospecific report of complications and/or adverse effects of treatment ?Participant withdrawal/dropouts, safety and side effect considerationsDocumented ComplicationsWithdrawal/dropouts:?15 studies   5with dropout reports3with reason provided?Eliassonet. al, 2005: 3 subjects rejected the glove constraint?Willis et. al, 2002: 1 withdrawal due to uncooperative child?Charles et. al, 2006: 1 withdrawal due to lack of subject?s tolerance of the intervention  Documented ComplicationsSafety and side effect considerations ?No long term complications or side effects noted in any of the studies under review?Taubet al., 2004:reports of mild skin redness, rash, pinching due to the cast constraint (all treated with Neosporin and band aids) ?Crocker et al., 1997:an irritated subject that withdrew from play activities, removed constraint and would not stick to protocolsDocumented Complications?The lack of reported side effects does notmean that we ignore complications. ?A potential for complications should always be considered prior to any application of constraint therapy. ?Individualized assessment and treatment needs to be considered at all time ?Perhaps a trial period would be appropriate5) The Million Dollar Question?.Is there a specific PROTOCOL?Variability in study parameters?Of the 15 studies: 5 used CIMT, 8 used mCIMT, 2 used a forced use protocol?There is a wide variety of frequency and duration of therapy and constraint?Several different types of restraints were used throughout the intervention period in all 15 studies (ie: glove, casts, slings, splints, gentle episodic physical restraint)Is there a specific PROTOCOL??No study has compared one protocol to another?Is it: ?Constraint alone??Therapy??Duration and frequency of constraint?Is there a Specific PROTOCOL??Lack of adequate rationale for the choice of protocol?It remains unclearas to which parameters are most effective in achieving the desired outcomesConclusionsConclusionsConclusionsRecommendations?Constraint therapy appears suitable for children of all ages?Various forms of restraint show success?No single protocol is better than anotherProtocol Summary?Ages 7 mo ?18 yrs ?Study Population size 1 ?45 ?Avgtime wearing constraint 12hrs/day ?Avgtime in therapy 5 hrs/day ?Avgduration of intervention 20 days ?Common outcome measures: Jebsen-Taylor test, PMAL, Peabody, Bruininks-OseretskyLimitations?Limited clinical experience of authors ?English language studies ?Depth of our search ?Reliability and validity of scales absent ?Unable to compare across studies due to variety of variables ?Small sample sizes ?Low level of evidence within selected researchFuture Research?Comparison of protocols ?Long term outcomes greater than 8 months ?RCT?sor higher level studies ?Structured practice alone compared to a constraint intervention ?Critical age of development and use with the very young ?Researchers from various areasBottom Line?All three forms of constraint therapy reviewed appear to promote a positivechange in functional use of an affected upper limb in children with hemiplegia. However, further research is required to determine any specific protocol.References1) TaubE, UswatteG, Morris DM. Improved motor recovery after stroke and massive cortical reorganization following Constraint-Induced Movement therapy. Phys Med RehabilClinN Am.2003 Feb;14(1 Suppl):S77-91, ix. 2) Ro T, NoserE, BoakeC, Johnson R, GaberM, SperoniA, Bernstein M, De JoyaA Scott Burgin W, Zhang L, TaubE, GrottaJC, Levin HS. Functional reorganization and recovery after constraint-induced movement therapy in subacutestroke: case reports. Neurocase. 2006 Feb;12(1):50-60. 3) Taub, E. (1980).  Somatosensory deafferentationresearch with monkeys; implications for rehabilitation medicine.  In: BehaviouralPsychology in Rehabilitation medicine: Clinical Applications.  Baltimore, Maryland, USA: Williams and Wilkens.  371-401. 4) HakkennesS, Keating JL. Constraint-induced movement therapy following stroke: a systematic review of randomized control trials. AustJ Physiotherapy. 2005; 51(4):221-31. 5) Charles, J., & Gordon, A.M. (2005).  A Critical Review of Constraint-Induced Movement Therapy and Forced Use in Children with Hemiplegia.  Neural Plasticity, 12(2-3), 245-261. 6) Winstein, C., Miller, P., Blanton, S., Taub, E., Morris, D., Uswatte, G., Nichols, D., & Wolf, S. (2003). Methods for a multi-site randomized trial to investigate the effect of Constraint-Induced Movement therapy in improving upper extremity function among adults recovering from a cerebrovascularstroke. Neurorehabilitationand Neural Repair, 17, 137-152. 7) Boyd, R.N., Morris, M.E., Graham, H.K. (2001).  Management ofupper limb dysfunction in children with cerebral palsy: a systematic review.  European Journal of Neurology, 8(5), 150-166. 8) Horner RH, Carr EG, Halle J, McGee, G, Odom S, WoleryM. The use of single-subject research to identify evidence-based practice in special education. Exceptional Children. 2005;71:165-79. 9) Charles J, Wolf S, Schneider J, Gordon A. Efficacy of child-friendly form of constraint-induced movement therapy in hemiplegic cerebral palsy: a randomized control trial. Developmental Medicine & Child Neurology, 2006, 48. 10) Charles J, LavinderG, Gordon A. Effects of constraint-induced therapy on hand function in children with hemiplegic cerebral palsy. Pediatric Physical Therapy. 2001, 13,2, 68-76.11) Crocker M, MacKay-Lyons M, McDonnell E. Forced use of the upper extremity in cerebral palsy: a single-case design. American Journal of Occupational Therapy, 1997, 51, 10, 824-833.12) DeLucaS, Echols K, Ramey S, TaubE. Pediatric Constraint-Induced Movement Therapy for a Young Child With Cerebral Palsy: Two Episodes of Care. Physical Therapy; 2003, 83, 11, 1003-1013 13) Deluca S. Intensive movement therapy with casting for children with hemipareticcerebral palsy: A randomized controlled crossover trial. Dissertation Abstracts International: Section B: The Sciences & Engineering, 2002, 63, 5-B, 2619. US. 14) EliassonA, KrumlindeSundholmL, Shaw K, Wang C. Effects of constraint-induced movement therapy in young children with hemiplegic cerebral palsy: an adapted model.Developmental Medicine Child Neurology, 2005, 47, 4, 266-275 15) Glover J, MateerC, YoellC, Speed S. The effectiveness of constraint induced movement therapy in two young children with hemiplegia. Pediatric Rehabilitation, 2002, 5, 3, 125-131. 16) Gordon A, Charles J, Wolf S. Efficacy of constraint-induced movement therapy on involved upper-extremity use in children with hemiplegic cerebral palsy is not age-dependent. Pediatrics, 2006 Mar, 117, 3, e363-73, United States 17) KarmanN, MarylesJ, Baker R, SimpserE, Berger-Gross P. Constraint-induced movement therapy for hemiplegic children with acquired brain injuries. Journalof Head Trauma Rehabilitation, 2003, 18, 3, 259-267. 18) Naylor C, Bower E. Modified constraint-induced movement therapy for young children with hemiplegic cerebral palsy: a pilot study. Developmental Medicine Child Neurology, 2005, 47, 6, 365-369. 19) Bonnier B, EliassonA, KrumlindeSundholmL. Effects of constraint-induced movement therapy in adolescents with hemiplegic cerebral palsy: A day camp model. Scandinavian Journal of Occupational Therapy, 2005, 13, 1, 13-22, Norway. 20) Pierce S, Daly K, Gallagher K, GershkoffA, Schaumburg S. Constraint-induced therapy for a child with hemiplegic cerebral palsy: a case report. Archives of Physical Medicine and Rehabilitation, 2002, 83, 10, 1462-1463, United States. 21) Sung I, RyuJ, PyunS, YooS, Song W, Park M. Efficacy of forced-use therapy in hemiplegic cerebral palsy. Archives of Physical Medicine and Rehabilitation, 2005, 86, 2195-2198. 22) TaubE, Ramey S, DeLucaS, Echols K. Efficacy of Constraint-Induced Movement Therapy for Children with Cerebral Palsy with Asymmetric Motor Impairment. Pediatrics, 2004, 113, 2, 305-312.  23) Willis J, MorelloA, Davie A, Rice J, Bennett J. Forced use treatment of childhood hemiparesis. Pediatrics, 2002, 110, 1 I, 94-96.24) O?Donnell M, DarrahJ, Adams R, Butler C, DamianoD, RoxboroughL. AACPDM Methodology for Developing Systematic Reviews of Treatment Interventions. 2004. Thank YouThank YouThank YouLori RoxboroughLousiaPulfreySusan HarrisAudience

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