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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 2006-10-05

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The Effectiveness of Constraint Therapy: A Systematic Review Meggan Hunt Aman Dhaliwal Laura Peterson Behnad Honarbakhsh Michael Hales Supervisor: Lori Roxborough Collaborator: Lousia Pulfrey Outline History of Constraint 3 types of intervention Overview of 15 studies Clinical questions discussed Conclusions What is Constraint Therapy? History of the idea Cortical 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 intervention 1) Constraint Induced Movement Therapy (CIMT) Constraint + Structured Practice + Feedback + Repetition Eg. All waking hours, 6-8 hrs/day 1:1 therapy, 2-3 consecutive weeks 3 types of intervention 2) Modified Constraint Induced Movement Therapy (modified CIMT) Constraint + Practice + modified times 3 types of intervention 3) Forced Use Therapy Constraint Only  (no added therapy) Constraint Therapy in Children – The Evidence Past reviews suggest a positive trend in 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 designs Methods: Search Strategy • Electronic search terms: – "(hemiparesis OR hemiplegia OR cerebral palsy OR diplegia OR diparesis OR 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 ProQuest Dissertations 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 searched Methods: Screening Initial Search: 61 articles After title screen: 39 articles After abstract screen: 28 articles After full-text screen: 15 articles included in systematic review Authors contacted Quality Assessment and Data Abstraction • Review followed the AACPDM methodology. • Group Designs: – Sackett’s Levels of Evidence – AACPDM Quality Assessment Scale • SSRDs: – SSRD Levels of Evidence – Quality Rigor and Evaluative Criteria • Data Abstraction forms Levels of Evidence-Group Level Intervention (Group) studies I Systematic Review of randomized controlled trials (RCT’s) Large RCT (with narrow confidence intervals) II Smaller RCT’s (with wider confidence intervals) Systematic Reviews of cohort studies “Outcomes research” (very large ecologic studies) III High quality cohort studies (must have concurrect control group) Systematic Reviews of Case Control Studies Case-control Study IV Case Series Poor quality cohort and poor quality case-control study V Expert opinion Bench research Expert opinion based on theory or physiologic research Common sense/ anecdotes Levels of Evidence- Single Subject Design Level Intervention (Single Subject) studies I N-of-1 randomized controlled trial II ABABA design Alternating treatments design Multiple baseline designs (concurrent or non-concurrent; across subjects, settings or behaviors) III ABA design IV AB design (with replication on >1 subject) V AB design (with 1 subject only) Grading the Research Effective Level Quality Score GROUP Charles et al 2006                              Yes II  5/7 Taub et al 2004 Yes II 5/7 Sung et al 2005 Yes II 3/7 Willis et al 2002 Yes II 3/7 Elaisson et al 2005 Yes III 4/7 Bonnier et al 2005 Yes IV 6/7 Gordon et al 2006 Yes IV 5/7 SSRD Deluca et al 2003 Yes II 3/7 Naylor et al 2005 Yes III 4/7 Charles et al 2001 Yes III 3/7 Crocker et al 1997 Yes III 2/7 Pierce et al 2002 Yes III 2/7 Karman et al 2003 Yes IV 3/7 Glover et al 2002 Yes IV 1/7 Quality 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 CIMT for 6hrs/session, 10/12 consec. Days • Therapy: play/shaping/functional tasks • Outcomes: Jebson Taylor Hand Test, Bruininks-Oseretsky[subset 8] (motor proficiency), Caregiver Functional Use Survey, Hand Held Dynamometer, Modified Ashworth Scale Single 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 Review 1) Is there a general benefit? Is there a long term effect? 2) Is there a particular age that is appropriate? 3) Is there improvement in ICF components? 4) Are there any complications? 5) Is one protocol or type of therapy best? 1) Is there a general benefit? Long term effects? • All 15 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 up 2) International Classification of Function • Functioning and disability: – Body Structure/ Function – Activities/ Participation • Contextual Factors – Environmental Factors – Personal Factors ICF: 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 activity were the primary outcomes of interest in our studies. ICF: Body Function/Activity Statistically 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 use of 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 Factors Improvements found in: • care-givers’ perception of amount and quality of use (at post intervention in one study and at 1 & 6 month follow-up in another study). 3) Age Appropriateness Gordon et al., 2006: Studied age-dependence of the effectiveness of CIMT. Children divided into older group (9-13), and younger group (4-8). No difference in outcomes between older and younger children. Age Appropriateness Coordination 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 measure Age Appropriateness • Age specific detrimental effects: – Potentially permanent repercussions for motor skill development in the constrained limb due to corticospinal tract development during the first years of life. 4) Documented Complications • No specific report of complications and/or adverse effects of treatment • Participant withdrawal/dropouts, safety and side effect considerations Documented Complications Withdrawal/dropouts: • 15 studies   5 with dropout reports 3 with reason provided – Eliasson et. 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 Complications Safety and side effect considerations • No long term complications or side effects noted in any of the studies under review – Taub et 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 protocols Documented Complications • The lack of reported side effects does not mean 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 appropriate 5) 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 unclear as to which parameters are most effective in achieving the desired outcomes Conclusions Recommendations • Constraint therapy appears suitable for children of all ages • Various forms of restraint show success • No single protocol is better than another Protocol Summary • Ages 7 mo – 18 yrs • Study Population size 1 – 45 • Avg time wearing constraint 12hrs/day • Avg time in therapy 5 hrs/day • Avg duration of intervention 20 days • Common outcome measures: Jebsen-Taylor test, PMAL, Peabody, Bruininks-Oseretsky Limitations • 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 research Future Research • Comparison of protocols • Long term outcomes greater than 8 months • RCT’s or higher level studies • Structured practice alone compared to a constraint intervention • Critical age of development and use with the very young • Researchers from various areas Bottom Line • All three forms of constraint therapy reviewed appear to promote a positive change in functional use of an affected upper limb in children with hemiplegia. However, further research is required to determine any specific protocol. References 1) Taub E, Uswatte G, Morris DM. Improved motor recovery after stroke and massive cortical reorganization following Constraint-Induced Movement therapy. Phys Med Rehabil Clin N Am. 2003 Feb;14(1 Suppl):S77-91, ix. 2) Ro T, Noser E, Boake C, Johnson R, Gaber M, Speroni A, Bernstein M, De Joya A Scott Burgin W, Zhang L, Taub E, Grotta JC, Levin HS. Functional reorganization and recovery after constraint- induced movement therapy in subacute stroke: case reports. Neurocase. 2006 Feb;12(1):50-60. 3) Taub, E. (1980).  Somatosensory deafferentation research with monkeys; implications for rehabilitation medicine.  In: Behavioural Psychology in Rehabilitation medicine: Clinical Applications.  Baltimore, Maryland, USA: Williams and Wilkens.  371-401. 4) Hakkennes S, Keating JL. Constraint- induced movement therapy following stroke: a systematic review of randomized control trials. Aust J 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 cerebrovascular stroke. Neurorehabilitation and Neural Repair, 17, 137-152. 7) Boyd, R.N., Morris, M.E., Graham, H.K. (2001).  Management of upper 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, Wolery M. 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, Lavinder G, 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) DeLuca S, Echols K, Ramey S, Taub E. 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 hemiparetic cerebral palsy: A randomized controlled crossover trial. Dissertation Abstracts International: Section B: The Sciences & Engineering, 2002, 63, 5-B, 2619. US. 14) Eliasson A, KrumlindeSundholm L, 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, Mateer C, Yoell C, 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) Karman N, Maryles J, Baker R, Simpser E, Berger-Gross P. Constraint-induced movement therapy for hemiplegic children with acquired brain injuries. Journal of 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, Eliasson A, KrumlindeSundholm L. 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, Gershkoff A, 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, Ryu J, Pyun S, Yoo S, Song W, Park M. Efficacy of forced-use therapy in hemiplegic cerebral palsy. Archives of Physical Medicine and Rehabilitation, 2005, 86, 2195-2198. 22) Taub E, Ramey S, DeLuca S, 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, Morello A, Davie A, Rice J, Bennett J. Forced use treatment of childhood hemiparesis. Pediatrics, 2002, 110, 1 I, 94-96. 24) O’ Donnell M, Darrah J, Adams R, Butler C, Damiano D, Roxborough L. AACPDM Methodology for Developing Systematic Reviews of Treatment Interventions. 2004. Thank You Lori Roxborough Lousia Pulfrey Susan Harris Audience 


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