Leanne Sakzewski

Systematic Review and Meta-analysis of Therapeutic Management of Upper-Limb Dysfunction in Children With Congenital Hemiplegia

CONTEXT. Rehabilitation for children with congenital hemiplegia to improve function in the impaired upper limb and enhance participation may be time-consuming and costly. OBJECTIVES. To systematically review the efficacy of nonsurgical upper-limb therapeutic interventions for children with congenital hemiplegia. METHODS. The Cochrane Central Register of Controlled Trials, Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), AMED (Allied and Complementary Medicine), Embase, PsycINFO, and Web of Science were searched up to July 2008. Data sources were randomized or quasi-randomized trials and systematic reviews. RESULTS. Twelve studies and 7 systematic reviews met our criteria. Trials had strong methodologic quality (Physiotherapy Evidence Database [PEDro] scale ≥ 5), and systematic reviews rated strongly (AMSTAR [Assessment of Multiple Systematic Reviews] score ≥ 6). Four interventions were identified: intramuscular botulinum toxin A combined with upper-limb training; constraint-induced movement therapy; hand-arm bimanual intensive training; and neurodevelopmental therapy. Data were pooled for upper-limb, self-care, and individualized outcomes. There were small-to-medium treatment effects favoring intramuscular botulinum toxin A and occupational therapy, neurodevelopmental therapy and casting, constraint-induced movement therapy, and hand-arm bimanual intensive training on upper-limb outcomes. There were large treatment effects favoring intramuscular botulinum toxin A and upper-limb training for individualized outcomes. No studies reported participation outcomes. CONCLUSIONS. No one treatment approach seems to be superior; however, injections of botulinum toxin A provide a supplementary benefit to a variety of upper-limb–training approaches. Additional research is needed to justify more-intensive approaches such as constraint-induced movement therapy and hand-arm bimanual intensive training.

Clinimetric properties of participation measures for 5- to 13-year-old children with cerebral palsy: a systematic review

This study systematically reviewed the validity, reliability, sensitivity to change, and clinical utility of measurements of participation for children with cerebral palsy. Sixteen measures were identified and seven met the inclusion criteria of having 30% content measuring participation, for use with children aged 5 to 13 years with physical disability, and were condition specific. The Childrens Assessment of Participation and Enjoyment (CAPE) assessed participation in leisure and recreation, while the School Function Assessment (SFA) and School Outcome Measure addressed participation in the school environment. The Assessment of Life Habits for Children (LIFE‐H) measured participation in home, school, and community life, and the Children Helping Out: Responsibilities and Expectations assessed childrens participation in household duties. The Canadian Occupational Performance Measure (COPM) and Goal Attainment Scaling (GAS) were individualized tools used to evaluate goal achievement. Results showed most instruments had adequate reliability and validity. The COPM and GAS were the only measures that reported adequate responsiveness to detect clinically significant change. Limited data are currently available to determine the responsiveness of the CAPE, LIFE‐H, and SFA. A combination of assessments is required to capture participation of children in home, school, and community environments.

Randomized trial of constraint-induced movement therapy and bimanual training on activity outcomes for children with congenital hemiplegia

Aim  To determine if constraint‐induced movement therapy (CIMT) is more effective than bimanual training (BIM) in improving upper limb activity outcomes for children with congenital hemiplegia in a matched‐pairs randomized trial.

Efficacy of Upper Limb Therapies for Unilateral Cerebral Palsy: A Meta-analysis

BACKGROUND AND OBJECTIVE: Children with unilateral cerebral palsy present with impaired upper limb (UL) function affecting independence, participation, and quality of life and require effective rehabilitation. This study aims to systematically review the efficacy of nonsurgical upper limb therapies for children with unilateral cerebral palsy. METHODS: Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Embase, the Cochrane Central Register of Controlled Trials, and PubMed were searched to December 2012. Randomized controlled or comparison trials were included. RESULTS: Forty-two studies evaluating 113 UL therapy approaches (N = 1454 subjects) met the inclusion criteria. Moderate to strong effects favoring intramuscular injections of botulinum toxin A and occupational therapy (OT) to improve UL and individualized outcomes compared with OT alone were identified. Constraint-induced movement therapy achieved modest to strong treatment effects on improving movement quality and efficiency of the impaired UL compared with usual care. There were weak treatment effects for most outcomes when constraint therapy was compared with an equal dose (amount) of bimanual OT; both yielded similar improved outcomes. Newer interventions such as action observation training and mirror therapy should be viewed as experimental. CONCLUSIONS: There is modest evidence that intensive activity-based, goal-directed interventions (eg, constraint-induced movement therapy, bimanual training) are more effective than standard care in improving UL and individualized outcomes. There is little evidence to support block therapy alone as the dose of intervention is unlikely to be sufficient to lead to sustained changes in UL outcomes. There is strong evidence that goal-directed OT home programs are effective and could supplement hands-on direct therapy to achieve increased dose of intervention.

Upper limb activity measures for 5- to 16-year-old children with congenital hemiplegia: a systematic review.

Aim  This systematic review aimed to compare the validity, reliability, evaluative validity, and clinical utility of upper limb activity measures for children aged 5 to 16 years with congenital hemiplegia.

INCITE: A randomised trial comparing constraint induced movement therapy and bimanual training in children with congenital hemiplegia

BackgroundCongenital hemiplegia is the most common form of cerebral palsy (CP) accounting for 1 in 1300 live births. These children have limitations in capacity to use the impaired upper limb and bimanual coordination deficits which impact on daily activities and participation in home, school and community life. There are currently two diverse intensive therapy approaches. Traditional therapy has adopted a bimanual approach (BIM training) and recently, constraint induced movement therapy (CIMT) has emerged as a promising unimanual approach. Uncertainty remains about the efficacy of these interventions and characteristics of best responders. This study aims to compare the efficacy of CIMT to BIM training to improve outcomes across the ICF for school children with congenital hemiplegia.Methods/DesignA matched pairs randomised comparison design will be used with children matched by age, gender, side of hemiplegia and level of upper limb function. Based on power calculations a sample size of 52 children (26 matched pairs) will be recruited. Children will be randomised within pairs to receive either CIMT or BIM training. Both interventions will use an intensive activity based day camp model, with groups receiving the same dosage of intervention delivered in the same environment (total 60 hours over 10 days). A novel circus theme will be used to enhance motivation. Groups will be compared at baseline, then at 3, 26 and 52 weeks following intervention. Severity of congenital hemiplegia will be classified according to brain structure (MRI and white matter fibre tracking), cortical excitability using Transcranial Magnetic Stimulation (TMS), functional use of the hand in everyday tasks (Manual Ability Classification System) and Gross Motor Function Classification System (GMFCS). Outcomes will address neurovascular changes (functional MRI, functional connectivity), and brain (re)organisation (TMS), body structure and function (range of motion, spasticity, strength and sensation), activity limitations (upper limb unimanual capacity and bimanual motor coordination), participation restrictions (in home, school and recreation), environmental (barriers and facilitators to participation) and quality of life.DiscussionThis paper outlines the theoretical basis, study hypotheses and outcome measures for a matched pairs randomised trial comparing CIMT and BIM training to improve outcomes across the ICF.Trial RegistrationACTRN12609000912280

The relationship between unimanual capacity and bimanual performance in children with congenital hemiplegia

Aim  This study explores the relationship between unimanual capacity and bimanual performance for children with congenital hemiplegia aged 5 to 16 years. It also examines the relationship between impairments and unimanual capacity and bimanual performance.

Best Responders After Intensive Upper-Limb Training for Children With Unilateral Cerebral Palsy

OBJECTIVE To delineate characteristics of best responders in a randomized trial comparing constraint-induced movement therapy (CIMT) to bimanual training for children with unilateral cerebral palsy. DESIGN Secondary analysis of a single-blind matched-pairs randomized comparison trial. SETTING Community sporting facilities in 2 Australian capital cities. PARTICIPANTS Children (n=64; mean age, 10.2±2.7y; 52% boys), matched for age, sex, side of hemiplegia, and upper-limb function, were randomized within pairs to CIMT or bimanual training. Sixty-one children who completed CIMT (n=31) or bimanual training (n=30) were included in this study. INTERVENTIONS Each intervention was delivered in day camps (total 60h over 10d) using a novel circus theme with goal-directed training. MAIN OUTCOME MEASURES Change between baseline, 3, and 26 weeks on the Melbourne Assessment of Unilateral Upper Limb Function (MUUL>7.4%), Assisting Hand Assessment (AHA>4 raw score points), and Canadian Occupational Performance Measure (COPM>2 points) defined best responders. RESULTS Poorer baseline hand function predicted a best response for unimanual capacity of the impaired upper limb (MUUL) immediately postintervention; however, at 26 weeks the odds of achieving a favorable outcome were 21 times greater for CIMT than bimanual training. A favorable response for bimanual performance (AHA) was predicted by immediate change in Jebsen-Taylor hand function test scores. Age (older), left-sided hemiplegia, and lower-baseline COPM performance scores significantly predicted favorable individualized outcomes. CONCLUSIONS Secondary analysis of a randomized trial directly comparing 2 upper-limb training models, found children with poorer hand function benefited most. Favorable outcomes for bimanual performance were associated with gains in movement efficiency and older children with left-sided hemiplegia achieved more favorable gains in perceived occupational performance.

Participation Outcomes in a Randomized Trial of 2 Models of Upper-Limb Rehabilitation for Children With Congenital Hemiplegia

OBJECTIVE To determine if constraint-induced movement therapy (CIMT) is more effective than bimanual training to improve occupational performance and participation in children with congenital hemiplegia. DESIGN Single-blind randomized comparison trial with evaluations at baseline, 3, and 26 weeks. SETTING Community facilities in 2 Australian states. PARTICIPANTS Referred sample of children (N=64; mean age ± SD, 10.2±2.7y, 52% boys) were matched for age, sex, side of hemiplegia, and upper-limb function and were randomized to CIMT or bimanual training. After random allocation, 100% of CIMT and 94% of the bimanual training group completed the intervention. INTERVENTIONS Each intervention was delivered in day camps (total 60 h over 10d) using a circus theme with goal-directed training. Children receiving CIMT wore a tailor-made glove during the camp. MAIN OUTCOME MEASURES The primary outcome was the Canadian Occupational Performance Measure (COPM). Secondary measures included the Assessment of Life Habits (LIFE-H), Childrens Assessment of Participation and Enjoyment, and School Function Assessment. RESULTS There were no between-group differences at baseline. Both groups made significant changes for COPM performance at 3 weeks (estimated mean difference =2.9; 95% confidence interval [CI], 2.3-3.6; P<.001 for CIMT; estimated mean difference=2.8; 95% CI, 2.2-3.4; P<.001 for bimanual training) that were maintained at 26 weeks. Significant gains were made in the personal care LIFE-H domain following CIMT (estimated mean difference=0.5; 95% CI, 0.1-0.9; P=.01) and bimanual training (estimated mean difference=0.6; 95% CI, 0.2-1.1; P=.006). CONCLUSIONS There were minimal differences between the 2 training approaches. Goal-directed, activity-based, upper-limb training, addressed through either CIMT or bimanual training achieved gains in occupational performance. Changes in participation on specific domains of participation assessments appear to correspond with identified goals.

A balancing act: Children's experience of modified constraint-induced movement therapy

Objective: This qualitative study explored the experiences of children participating in modified constraint-induced movement therapy (CIMT) within a circus-themed day camp. Methods: Individual semi-structured interviews were performed with 32 children (15 girls, 17 boys; mean age 10.1 years) to gain insights into their experience of CIMT. Interviews were audio recorded, transcribed verbatim and independently read by two authors to identify common themes. Results: Three themes emerged from the data: childrens experience of wearing the glove employed in the modified CIMT, their reactions to the camp format and the gains they made during the camp. Conclusion: The results highlighted the need to achieve a balance between the frustration of participating in modified CIMT and what was seen as motivators to sustain involvement. Findings are interpreted in the context of self-determination theory and remind clinicians to ensure interventions consider autonomy, competence and relatedness.