At-home and in-group delivery of constraint-induced movement therapy in children with hemiparesis: A systematic review

Feasibility of family-directed home-based bimanual intensive therapy combined with modified constraint induced movement therapy (h-BITmCI) in very low and low bimanual functional level: A brief report

OBJECTIVE

To examine the feasibility of a home-based hybrid Bimanual-Intensive-Therapy combined with modified Constraint-Induced-Movement-Therapy (h-BITmCI) in children with spastic unilateral cerebral palsy (SUCP) with low and very low bimanual functional level.

METHODS

A single-group of 10 children aged 5-8 years old, performed the hybrid home Bimanual-Intensive-Therapy (BIT, 80 hours) combined with modified Constraint-Induced-Movement-Therapy (mCIMT, 20 hours): h-BITmCI. Thus, Bimanual Functional Performance (BFP), Quality of Life (QoL) and expectations from families were measured through the Assisting Hand Assessment, (AHA), Pediatric Quality of Life Inventory, for Cerebral Palsy, (PedsQL^TM v. 3.0, CP) and a specific questionnaire for families for baseline period (week 0), during the treatment phase (week 4 and week 8) and after the intervention (week 10). Repeated measures ANOVA analysis (with post hoc test correction) was used for the BFP and QoL, with a confidence interval (CI) of 95% and with p value <.008 considered statistically significant.

RESULTS

Ten children completed the study with an average of 77-hours-BIT and 17-hours-mCIMT. None of the participants dropped out of the study during the follow-up process, and the parents' expectations were fulfilled, indicating high caregiver compliance. During the first 80 hours of BIT, a mean increase of 3.7 AHA units was obtained for the BFP (p = 1.00) and 1.64 points in the QoL (p = 1.00). Clinically relevant changes were observed in the last two weeks (20 hours mCIMT) with a mean increase of 10.6 AHA units in BFP and 6.29 points in QoL (p < .001).

CONCLUSIONS

h-BITmCI protocol is feasible to be performed at home with the family's involvement, obtaining the greatest improvements after 100 hours of both therapies. Thus, mCIMT would be a relevant condition to increase the affected upper limb functionality, rather than the dosage used to obtain clinically relevant changes.

[Effectiveness of constraint-induced movement therapy in upper extremity rehabilitation in patients with cerebral palsy: A systematic review]

BACKGROUND AND OBJECTIVE

In hemiplegic cerebral palsy, learned non-use may appear. This phenomenon can be reversed by constraint-induced movement therapy in the healthy side. The aim of this article was to review the evidence of the effectiveness of this therapy on upper extremity functioning, the performance of activities of daily living and quality of life.

PATIENTS AND METHODS

We performed a systematic review between January and April 2019 in the PubMed, COCHRANE, PEDro and TRIPDATABASE databases. We included 14 clinical studies describing their characteristics.

RESULTS

Most of the studies found significant improvements compared with control groups. Only one article investigated quality of life.

CONCLUSIONS

Constraint-induced movement therapy seems to have positive effects in the motor rehabilitation of the upper extremity in patients with hemiplegic cerebral palsy. Further studies are needed to assess the individual factors of greatest influence in rehabilitation.

Methodological Considerations to Investigate Dosage Parameters of Intensive Upper Limb Rehabilitation in Children with Unilateral Spastic Cerebral Palsy: A Scoping Review of RCTs

PURPOSES

To identify and synthesize RCTs on the isolated effect of dosage parameters of upper limb Intensive Motor Rehabilitation Treatments (IMRT) of children with Unilateral Spastic Cerebral Palsy (USCP); to identify the most frequent methodological weaknesses.

METHODS

Searches were conducted until September 2018 in gray and published literature databases and supplemented by exploring the identified studies' references. Inclusion criteria applied: RCT; children aged 1.5 to 19 years with USCP; upper limb IMRT differing only from ≥1/4 dosage parameters between groups. Literature analyses conducted: qualitative and descriptive.

RESULTS

We identified 461 studies. Seventeen were included: three presented a rehabilitation dosage distinction between groups in Frequency-Time, four in Intensity-Progressivity, three in Intensity-Restraint, two in Intensity-Environment and five presented ≥3 distinctions above.

CONCLUSIONS

Inconsistencies were noted between USCP lifelong issues, and the short follow-ups and lack of participation assessments. Confounding factors and misstatements in Intent To Treat (ITT) analyses were identified. A meta-analysis was considered irrelevant.

ABBREVIATIONS

USCP, CP: Unilateral Spastic Cerebral Palsy, Cerebral Palsy; RCT: Randomized Controlled Trial; IMRT: Intensive Motor Rehabilitation Treatment.

Why Do Clinical Practice Guidelines Get Stuck during Implementation and What Can Be Done: A Case Study in Pediatric Rehabilitation

Aims: The purpose of this study was to obtain the perspectives of occupational and physical therapists working in pediatric rehabilitation about the factors that influence implementation of clinical practice guidelines (CPG) using the case of constraint induced movement therapy (CIMT). We aimed to identify factors that hinder implementation of CPGs and strategies for overcoming barriers when widespread implementation is stalled.Methods: Qualitative case study methodology was bounded within the parameters of CIMT implementation in pediatric rehabilitation in one jurisdiction. Twenty-one occupational and physical therapists participated in one of three focus groups. Data were analyzed using an inductive qualitative approach.Results: Participants viewed CPGs as useful, and emphasized the importance of consistency between guidelines and relevance to practice context. Therapists considered the "art and science" in clinical decision-making. Barriers and facilitators to CPG implementation were identified at the client, clinician, intervention location and systemic level. Potential solutions to help "unstick" guideline implementation were consistent with theories of collective knowledge exchange and mindlines.Conclusion: The presence of CPGs does not ensure evidence uptake; understanding of local barriers is required. This case study highlights the value of a collective knowledge exchange approach and attention to the social structures of knowledge development and evidence use.