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Modified constraint-induced therapy for children with hemiplegic cerebral palsy: a randomized trial
Margaret Wallen1, Jenny Ziviani, Olivia Naylor
1Occupational Therapy Department, The Children's Hospital at Westmead, Sydney, NSW, Australia. margarew@chw.edu.au
Insights
Modified constraint-induced therapy (mCIT) showed no significant improvement over intensive occupational therapy for children with hemiplegic cerebral palsy (CP). Both therapies were equally effective in improving daily living activities and upper limb function.
Area of Science:
- Pediatric Rehabilitation
- Neurology
- Occupational Therapy
Background:
- Conventional constraint-induced therapies are intensive for children with cerebral palsy (CP).
- Family-centered modified constraint-induced therapy (mCIT) may improve feasibility and acceptance.
- Rigorous evaluation via randomized trials is necessary for family-centered approaches.
Purpose of the Study:
- To compare the effectiveness of mCIT versus intensive occupational therapy.
- To assess outcomes in activities of daily living (ADL) and upper limb function.
- To evaluate outcomes in children with hemiplegic CP.
Main Methods:
- Assessor-blinded pragmatic randomized trial with 50 children (19 mo-7 y 10 mo) with hemiplegic CP.
- Two 8-week interventions: intensive occupational therapy (n=25) or mCIT (n=25).
- Primary outcome: Canadian Occupational Performance Measure (COPM); secondary outcomes included Goal Attainment Scaling and Assisting Hand Assessment.
Main Results:
- No statistically significant or clinically important differences between mCIT and intensive occupational therapy for primary or secondary outcomes.
- Mean difference in COPM: 0.3 (95% CI -0.8 to 1.4; p=0.61).
- Minor adverse events related to therapy acceptance were reported in both groups.
Conclusions:
- Modified constraint-induced therapy is not more effective than intensive occupational therapy for children with hemiplegic CP.
- Current evidence does not support mCIT over standard intensive occupational therapy for improving ADL or upper limb function.
- Further research may explore alternative modifications or outcome measures for constraint-based therapies in pediatric CP.
Aim:
Conventional constraint-based therapies are intensive and demanding to implement, particularly for children. Modified forms of constraint-based therapies that are family-centred may be more acceptable and feasible for families of children with cerebral palsy (CP)-but require rigorous evaluation using randomized trials. The aim of this study was to determine the effects of modified constraint-induced therapy compared with intensive occupational therapy on activities of daily living and upper limb outcomes in children with hemiplegic CP.
Method:
In this assessor-blinded pragmatic randomized trial, 50 children (27 males, 23 females; age range 19 mo-7 y 10 mo) with hemiplegic CP were randomized using a concealed allocation procedure to one of two 8-week interventions: intensive occupational therapy (n = 25), or modified constraint-induced therapy (n = 25). Manual Ability Classification System (MACS) levels of the participants were, level I n = 2, II n = 37, III n = 8, and level IV n = 1; Gross Motor Function Classification System (GMFCS) levels were, level I n = 33, level II n = 15, and level III n = 1. Participants were recruited through three specialist CP centres in Australia and randomized between January 2008 and April 2010. Children randomized to modified constraint-induced therapy wore a mitt on the unaffected hand for 2 hours each day, during which time the children participated in targeted therapy. The primary outcome was the Canadian Occupational Performance Measure (COPM--measured on a 10-point scale) at completion of therapy. Other outcome measures were Goal Attainment Scaling, Assisting Hand Assessment, Pediatric Motor Activity Log, Modified Ashworth Scale, Modified Tardieu Scale, and a parent questionnaire. Assessments were carried out at 10 weeks and 6 months following randomization.
Results:
All participants were included in the analysis. Between-group differences for all outcomes were neither clinically important nor statistically significant. The mean difference in COPM was 0.3 (95% confidence interval [CI] -0.8 to 1.4; p=0.61) and mean difference in COPM satisfaction was 0.1 (95% CI -1.1 to 1.2; p=0.90). Minor adverse events were reported by five of the 25 participants in the modified constraint-induced therapy group and by one of the 25 in the intensive occupational therapy group. All adverse events were related to participants' lack of acceptance of therapy.
Interpretation:
Modified constraint-induced therapy is no more effective than intensive occupational therapy for improving completion of activities of daily living or upper limb function in children with hemiplegic CP.
