Constraint-induced movement therapy in the treatment of the upper limb in children with hemiplegic cerebral palsy

This therapy involves constraining the non-affected arm to encourage performance of therapeutic tasks with the affected arm, which children normally tend to disregard. Two clinical trials showed positive trends in support of constraint-induced movement therapy (CIMT) and Forced Use, whilst another demonstrated a positive treatment effect favouring modified CIMT as a treatment for children with hemiplegic cerebral palsy. This evidence is based on one small randomised controlled trial with methodological limitations, one trial with ambiguous methodology and reporting and one controlled clinical trial. There is a need for additional high quality research to adequately support the use of this therapy.

Authors' conclusions: 

This systematic review found a significant treatment effect using modified CIMT in a single trial. A positive trend favouring CIMT and Forced Use was also demonstrated. Given the limited evidence, the use of CIMT, modified CIMT and Forced Use should be considered experimental in children with hemiplegic cerebral palsy. Further research using adequately powered RCTs, rigorous methodology and valid and reliable outcome measures is essential to provide higher level support of the effectiveness of CIMT for children with hemiplegic cerebral palsy.

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Background: 

Children with hemiplegic cerebral palsy learn strategies to manage daily tasks (for example play) using one hand and often the affected limb is disregarded or not used. Constraint-induced movement therapy (CIMT) is emerging as a treatment approach for use with children with hemiplegic cerebral palsy. It aims to increase spontaneous use of the affected upper limb and thereby limit the effects of developmental disregard. CIMT is based on two fundamental principles: constraint of the non-affected limb and massed practice of therapeutic tasks with the affected limb.

Objectives: 

The objective of this review was to evaluate the effectiveness of CIMT, modified CIMT or Forced Use in the treatment of the affected upper limb in children with hemiplegic cerebral palsy.

Search strategy: 

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2006, Issue 3), MEDLINE (1966 to August Week 4 2006), CINAHL (1982 to July Week 3 2006), EMBASE (1980 to August 2006), PsychInfo (1985 to August Week 4 2006) and reference lists of all relevant articles.

Selection criteria: 

All randomised controlled trials (RCTs) and controlled clinical trials (CCTs) comparing CIMT, modified CIMT and Forced Use with traditional services such as occupational therapy, physiotherapy or no treatment were selected.

Data collection and analysis: 

Two review authors extracted the data independently using standardised forms. Each trial was assessed for internal validity with differences in ratings resolved by discussion. Data were extracted and entered into Review Manager 4.2 where appropriate.

Main results: 

Three studies met the inclusion criteria. The results of one RCT showed a trend for positive treatment effect favouring CIMT using the Dissociated Movement subscale of the Quality of Upper Extremity Skills Test (QUEST). Other outcome measures, that were without reported psychometric properties, showed significant treatment effects. A CCT demonstrated a significant treatment effect favouring modified CIMT at two and six months using the Assisting Hand Assessment (AHA). Another trial with inaccurate reporting and ambiguous methodology, showed a significant treatment effect at 6 weeks on the self care component of the WeeFIM using a Forced Use protocol. All other measures showed no significant treatment effect.

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