TITLE: Constraint Induced Movement Therapy for … · Constraint Induced Movement Therapy for Children 2 The summary of findings was prepared from the abstracts of the relevant information

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TITLE: Constraint Induced Movement Therapy for Children: Update of Clinical Effectiveness and Guidelines

DATE: 16 June 2016

RESEARCH QUESTIONS

1. What is the clinical effectiveness of constraint induced movement therapy for children with

unilateral upper extremity impairment?

2. What are the evidence-based guidelines regarding the use of constraint induced movement therapy for children with unilateral upper extremity impairment?

3. What are the evidence-based guidelines regarding the optimal non-technology or non-drug based therapy for treatment of children with unilateral upper extremity impairment?

KEY FINDINGS

Five systematic reviews, 25 randomized controlled trials, and three evidence-based guidelines were identified regarding the use of constraint induced movement therapy for children with unilateral upper extremity impairment. METHODS

A limited literature search was conducted on key resources including Ovid Medline, PubMed, The Cochrane Library, University of York Centre for Reviews and Dissemination (CRD) databases, ECRI Institute, Canadian and major international health technology agencies, as well as a focused Internet search. No filters were applied to limit retrieval by publication type for research questions 1 and 2. For question 3, methodological filters were used to limit retrieval to systematic reviews, health technology assessments, meta-analyses and guidelines. Where possible, retrieval was limited to the human population. The search was also limited to English language documents published between January 1, 2010 and May 30, 2016. Internet links were provided, where available.

Constraint Induced Movement Therapy for Children 2

The summary of findings was prepared from the abstracts of the relevant information. Please note that data contained in abstracts may not always be an accurate reflection of the data contained within the full article. SELECTION CRITERIA

One reviewer screened citations and selected studies based on the inclusion criteria presented in Table 1.

Table 1: Selection Criteria Population Pediatric patients with unilateral upper extremity impairment, including, but

not limited to cerebral palsy and pediatric stroke patients

Intervention Q1 and 2: Constraint Induced Movement Therapy (CIMT) Q3: CIMT, bimanual training, occupational or physical therapy, observational training, mirror therapy, casting

Excluding robotic or technology based therapies and drug or procedural therapies such as Botulinum toxin or blockades

Comparator Q1: Bimanual training, occupational or physical therapy, observational training, mirror therapy, casting;

Usual care; Q1 to 3: No comparator required

Outcomes Q1: Clinical effectiveness (e.g., upper extremity functional outcomes [e.g., hand function, functional skills, movement quality and efficiency, unimanual

capacity, bimanual performance], self-determined goal achievement, patient satisfaction, quality of life); Q2: Evidence-based guidelines regarding the use of CIMT including

appropriate indications as well as how it should be administered and by whom; Q3: Evidence-based guidelines regarding the use of non-technology, non-

drug-based therapy including which therapy is the most appropriate, who should be treated, how therapy should be administered and by whom

Study Designs Health technology assessments, systematic reviews, meta-analyses, randomized controlled trials, non-randomized studies, evidence-based

guidelines

RESULTS

Rapid Response reports are organized so that the higher quality evidence is presented first. Therefore, health technology assessment reports, systematic reviews, and meta-analyses are presented first. These are followed by randomized controlled trials (RCTs), non-randomized studies, and evidence-based guidelines. Five systematic reviews, 25 RCTs, and three evidence-based guidelines were identified regarding the use of constraint induced movement therapy (CIMT) for children with unilateral upper extremity impairment. No relevant health technology assessments were identified. Due to the large number of relevant studies identified, non-randomized studies have been included in the appendix with other references of potential interest.


OVERALL SUMMARY OF FINDINGS

Five systematic reviews1-5 and 25 RCTs6-30 were identified regarding the clinical effectiveness of CIMT for children with unilateral upper extremity impairment. The results of these studies generally indicate that CIMT was as, or more, effective than bimanual or conventional therapies.

The findings of these studies are summarized in Table 2.

Three evidence-based guidelines31-33 were identified. One guideline31 addresses the use of pediatric modified CIMT plus bimanual training (BMT) for children with unilateral upper extremity impairment; and two guidelines32,33 address optimal non-technology or non-drug based therapy, including CIMT, for treatment of children with unilateral upper extremity impairment.

The modified CIMT guideline from the Cincinnati Childrens Hospital31 provides three suggested treatment protocols. Treatment should be undertaken by a physiotherapist or occupational therapist trained in CIMT and BMT and the treatment protocol should be decided upon in

consultation with the primary caregivers of the child.31

For children with, or at risk for, cerebral palsy (CP) the guideline from the American Occupational Therapy Association32 recommends:

Use of constraint-induced movement therapy to improve motor performance in young

children with CP. Use of neurodevelopmental treatment for young children with CP to improve motor

performance.

Child-focused and context-focused intervention were equally likely to improve motor performance.

The guideline from National Institute for Health and Clinical Excellence33 addressing

management of spasticity and co-existing motor disorders and their early musculoskeletal

complications recommends a number of specific strategies including postural management strategies and active-use therapy, such as CIMT.33

Table 2: Summary of Included Studies

First Author, Year

Patient Population

Intervention and Comparator

Results and Authors Conclusions

Systematic Reviews Chen, 2014

1

27 RCTs

Children with CP CIMT vs conventional therapy

CIMT showed an overall beneficial effect when compared to conventional therapy.

The authors concluded CIMT was an effective intervention to improve arm function in children with CP.

Sakzewski,

20142

42 RCTs

evaluating 113 interventions

Children with

unilateral CP

Non-surgical upper

limb therapies

CIMT resulted in modest to strong

treatment effects when compared with usual care or equal doses of bimanual OT.

Tinderholt,

20143

Young children

with CP

Intensive motor

function and functional skills

Hand function and functional skills

outcomes from CIMT were examined in 6 SRs. The authors indicated that the



First Author, Year

Patient Population



38 controlled studies

training results supported the existing evidence of CIMT.

Dong, 20134

Number of studies not

reported

Children with

unilateral CP

CIMT vs BMT CIMT and BMT both resulted in similar

improvements in overall performance and in bimanual and unimanual function of the affected arm.

Novak, 20135

166 articles

evaluating 64 interventions

Children with CP All interventions for CP

The authors graded the interventions from do it to do not do it. CIMT was rated as a do it therapy.

Randomized Controlled Trials Kirton, 2016

6 Children with

perinatal stroke hemiparesis

(n = 45)

Two weeks of daily

rTMS, CIMT, both, or neither added to intensive therapy

The addition of rTMS, CIMT, or both

resulted in a doubled chance of clinically significant improvement. QoL scores were improved.

Zafer, 20167 Children with

hemiplegic CP

(n = 20)

CIMT vs BMT Participants in the CIMT group had significantly greater improvement in functional status.

Gelkop, 20158 Children with

hemiplegic CP in an educational

setting (n = 12)

mCIMT vs HABIT Children in both treatment groups showed similar significant functional improvement. This improvement was maintained in both

groups at six month follow-up.

Xu, 20159 Children with

hemiplegic CP (n = 68)

CIMT vs

CIMT + electrical stimulation vs traditional OT

Functional outcomes (muscle recruitment

and coordination) of the wrist were more improved in the CIMT + electrical stimulation group.

Abdel-Kafy,

201410

Children with

congenital hemiparesis

(n = 30)

Child-friendly CIMT

vs conventional non-structured therapy group (control)

Upper extremity performance was more

greatly improved in the CIMT group as compared to the control group. This improvement was maintained at three

months follow-up.

Chen, 201411

Children with unilateral CP

(n = 47)

CIMT vs TR The authors reported larger effects in favour of CIMT on motor performance, daily function, and some aspects of

reaching control than in the TR group.

Chen, 201412


(n = 45)

Home-based CIMT vs TR (including unimanual and

bimanual training)

The CIMT group had significantly shorter reaction time and normalized movement time. The treatment group also showed

significantly greater improvement than the traditional group on measurement scales.

Choudhary, 2013

13

Children with hemiplegic CP

(n = 31)

mCIMT + conventional therapy

vs conventional therapy alone

The mCIMT group showed significant improvement in the affected upper limb vs

the control group. The functional improvement was maintained at eight weeks following treatment.



First Author, Year

Patient Population



Deppe, 201314


(n = 47)

mCIMT vs intensive BMT

There was a significantly greater improvement in isolated motor functions

in the affected arm in the mCIMT group. The authors determined that children with more severe disability improved more

than those with less severe disability.

Kingels, 201315


(n = 51)

mCIMT vs mCIMT + IT

There were significant between group differences observed in the Assisting Hand Assessment in favour of the mCIMT

+ IT group. The authors suggested that younger children benefited from both approaches and older children benefited

most from the combined intervention.

de Brito, 201216


(n = 16)

CIMT vs HABIT Functional measures were significantly improved in both treatment groups.

Rostami, 201217

Children with spastic hemparetic CP

(n = 32)

VR vs mCIMT vs mCIMT + VR

Significantly greater improvements in amount of limb use, quality of movement, and speed and dexterity were observed in

the mCIMT + VR group. These improvements were maintained at 3 months follow-up.

Sakzewski,

201218

Children with

congenital hemiplegia

(n = 44)

CIMT vs BMT Significant within group improvements

were observed in both intervention groups; however, the two groups did not differ significantly from each other in

physical activity or skills scales.

Sakzewski, 2012

19


(n = 63)

CIMT vs BMT No changes in social or emotional well-being were reported in either group. Children and parents from both groups

reported a significant improvement in their or their child's feelings about functioning

Xu, 201220

Children with


CIMT vs

CIMT + electrical stimulation vs OT

All three groups showed significant

improvements in range of motion, grip strength, and upper extremity functional test scores. The CIMT + electrical

stimulation group showed significantly greater improvements when compared to the other interventions.

Al-Oraibi, 201121

Children with

unilateral CP (n = 20)

CIMT vs NDT There was a significant improvement in

hand function in the CIMT group when compared with the NDT group.

Eliasson, 201122

Young children

with unilateral CP (n = 25)

Eco-CIMT vs

usual care

The authors determined there was a

significant treatment effect when Eco-CIMT was compared with the control.

Faccin, 201123

Children with

hemiplegic CP

mCIMT vs BMT vs

standard treatment

Paretic hand function was significantly

improved in both the mCIMT and BMT



First Author, Year

Patient Population



(n = 105)

groups and not in the standard treatment group.

Gordon, 201124

Children with


CIMT vs HABIT Both treatment groups showed similar

improvement in scale scores. Goal Attainment Scale scores were more improved in the HABIT group.

Lin, 201125

Children with CP

(n = 21)

CIMT vs

home-based control intervention

Significantly better results were observed

in grasping control, motor efficacy, and unilateral functional performance in the CIMT group. The results were maintained

at six month follow-up.

Sakzewski, 2011

26 Children with congenital hemiplegia

(n = 64)

CIMT vs BMT

Significant changes in the Canadian Occupational Performance Measure were observed in both groups at 3 weeks and

were maintained at 26 weeks. Minimal difference was reported between the two interventions.

Sakzewski,

201127

Children with

congenital hemiplegia

(n = 63)

CIMT vs BMT Unimanual capacity was significantly

greater in the CIMT group. There were no other significant differences reported after the interventions.

Taub, 201128

Children with congenital hemiparesis

(n = 20)

CIMT vs usual care Children in the CIMT group first exhibited emergence of more new classes of motor patterns and skills and had significantly

improved use of the more effected arm.

Wallen, 201129


(n = 50)

mCIMT vs intensive OT

No clinically or statistically significant differences in outcomes between groups

were identified. The authors concluded that mCIMT was not more effective than intensive OT.

de Brito, 201030

Children with CP

(n = 16)

CIMT vs usual care Functional skills and independence

following the intervention were significantly greater in the CIMT group.

BMT = bimanual therapy; CIMT = constraint-induced movement therapy; CP = cerebral palsy; HABIT = hand-arm bimanual intensive therapy; IT = intensive therapy; mCIMT = modif ied constraint-induced movement therapy; NDT = neurodevelopmental treatment; OT = occupational therapy; QoL = quality of life; rTMS = repetitive transcranial magnetic stimulation; SR = systematic

review ; TR = traditional rehabilitation; VR = virtual reality


REFERENCES SUMMARIZED

Health Technology Assessments

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Guidelines and Recommendations

31. Pediatric modified Constraint Induced Movement Therapy (mCIMT/BIT) Team CCHMC.

Evidence-based care guideline for pediatric constraint induced movement therapy [Internet]. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2014 Dec. 21 p. [cited 2016 Jun 15]. (Evidence-based care guideline). Available from: www.cincinnatichildrens.org/WorkArea/DownloadAsset.aspx?id=87897

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through 5 years. Bethesda (MD): American Occupational Therapy Association, Inc. (AOTA); 2013. See: Interventions for children with or at risk for cerebral palsy

33. National Collaborating Centre for Women's and Children's Health. Spasticity in children

and young people with non-progressive brain disorders. Management of spasticity and co-existing motor disorders and their early musculoskeletal complications. London (UK): National Institute for Health and Clinical Excellence (NICE); 2012 Jul. 54 p. (NICE clinical guideline; no. 145). https://www.nice.org.uk/guidance/cg145/resources/spasticity-in-under-19s-management-35109572514757 See: Specific Strategies

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PREPARED BY:

Canadian Agency for Drugs and Technologies in Health Tel: 1-866-898-8439 www.cadth.ca

http://www.cadth.ca/


APPENDIX FURTHER INFORMATION:

Previous CADTH Reports

34. Constraint-induced movement therapy for children: clinical effectiveness and clinical

practice guidelines [Internet]. Ottawa: CADTH; 2010 Oct 29. [cited 2016 Jun 15]. (Rapid response report: reference list). Available from: https://www.cadth.ca/sites/default/files/pdf/J0485_Constraint-Induced_Movement_Therapy_for_Children_final.pdf

Clinical Practice Guidelines Methodology Not Specified

35. Sunny Hill and BC Centre for Ability Pediatric Constraint Induced Movement Therapy

(CIMT) Guidelines Adaptation Working Group. BC pediatric constraint induced movement therapy (CIMT) guideline [Internet]. Vancouver (BC): Sunny HIll Health Centre for Children; 2012. [cited 2016 Jun 15]. (Evidence-based care guideline). Available from: http://www.childdevelopment.ca/Libraries/CIMT/CIMT_guideline_September_13_2012.sflb.ashx

Randomized Controlled Trials CIMT versus CIMT

Dosing 36. Case-Smith J, DeLuca SC, Stevenson R, Ramey SL. Multicenter randomized controlled

trial of pediatric constraint-induced movement therapy: 6-month follow-up. Am J Occup Ther. 2012 Jan;66(1):15-23. PubMed: PM22389937

37. DeLuca SC, Case-Smith J, Stevenson R, Ramey SL. Constraint-induced movement

therapy (CIMT) for young children with cerebral palsy: effects of therapeutic dosage. J Pediatr Rehabil Med. 2012;5(2):133-42. PubMed: PM22699104

Treatment Setting 38. Rostami HR, Malamiri RA. Effect of treatment environment on modified constraint-induced

movement therapy results in children with spastic hemiplegic cerebral palsy: a randomized controlled trial. Disabil Rehabil. 2012;34(1):40-4. PubMed: PM21851293

Non-Randomized Studies

39. Chen HC, Kang LJ, Chen CL, Lin KC, Chen FC, Wu KP. Younger children with cerebral

palsy respond better than older ones to therapist-based constraint-induced therapy at home on functional outcomes and motor control. Phys Occup Ther Pediatr. 2016 May;36(2):171-85. PubMed: PM26643052

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40. Komar A, Ashley K, Hanna K, Lavallee J, Woodhouse J, Bernstein J, et al. Retrospective analysis of an ongoing group-based modified constraint-induced movement therapy program for children with acquired brain Injury. Phys Occup Ther Pediatr. 2016 May;36(2):186-203. PubMed: PM26565125

41. Miller L, Ziviani J, Ware RS, Boyd RN. Does context matter? Mastery motivation and

therapy engagement of children with cerebral palsy. Phys Occup Ther Pediatr. 2016 May;36(2):155-70. PubMed: PM26565438

42. Psychouli P, Kennedy CR. Modified constraint-induced movement therapy as a home-

based intervention for children with cerebral palsy. 2016;Pediatr Phys Ther. 28(2):154-60. PubMed: PM26808960

43. DeLuca SC, Ramey SL, Trucks MR, Wallace DA. Multiple treatments of pediatric

constraint-induced movement therapy (pCIMT): a clinical cohort study. Am J Occup Ther. 2015 Nov;69(6):6906180010p1-9. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4643376/ PubMed: PM26565094

44. Eliasson AC, Holmefur M. The influence of early modified constraint-induced movement therapy training on the longitudinal development of hand function in children with unilateral cerebral palsy. Dev Med Child Neurol. 2015 Jan;57(1):89-94. PubMed: PM25236758

45. Geerdink Y, Aarts P, van der Burg J, Steenbergen B, Geurts A. Intensive upper limb

intervention with self-management training is feasible and promising for older children and adolescents with unilateral cerebral palsy. Res Dev Disabil. 2015 Aug;43-44:97-105. PubMed: PM26164301

46. Nordstrand L, Holmefur M, Kits A, Eliasson AC. Improvements in bimanual hand function after baby-CIMT in two-year old children with unilateral cerebral palsy: A retrospective study. Res Dev Disabil. 2015 Jun;41-42:86-93. PubMed: PM26100242

47. Sakzewski L, Provan K, Ziviani J, Boyd RN. Comparison of dosage of intensive upper limb therapy for children with unilateral cerebral palsy: how big should the therapy pill be? Res Dev Disabil. 2015 Feb;37:9-16. PubMed: PM25460215

48. Thompson AM, Chow S, Vey C, Lloyd M. Constraint-induced movement therapy in children aged 5 to 9 years with cerebral palsy: a day camp model. Pediatr Phys Ther. 2015;27(1):72-80. PubMed: PM25521268

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=26565125&dopt=abstracthttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=26565438&dopt=abstracthttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=26808960&dopt=abstracthttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC4643376/http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=26565094&dopt=abstracthttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=25236758&dopt=abstracthttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=26164301&dopt=abstracthttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=26100242&dopt=abstracthttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=25460215&dopt=abstracthttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=25521268&dopt=abstract


49. Kwon JY, Chang WH, Chang HJ, Yi SH, Kim MY, Kim EH, et al. Changes in diffusion tensor tractographic findings associated with constraint-induced movement therapy in young children with cerebral palsy. Clin Neurophysiol. 2014 Dec;125(12):2397-403. PubMed: PM24746686

50. Lowes LP, Mayhan M, Orr T, Batterson N, Tonneman JA, Meyer A, et al. Pilot study of the

efficacy of constraint-induced movement therapy for infants and toddlers with cerebral palsy. Phys Occup Ther Pediatr. 2014 Feb;34(1):4-21. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4162395 PubMed: PM23848499

51. McConnell K, Johnston L, Kerr C. Efficacy and acceptability of reduced intensity

constraint-induced movement therapy for children aged 9-11 years with hemiplegic cerebral palsy: a pilot study. Phys Occup Ther Pediatr. 2014 Aug;34(3):245-59. PubMed: PM24341455

52. Cimolin V, Beretta E, Piccinini L, Turconi AC, Locatelli F, Galli M, et al. Constraint-induced

movement therapy for children with hemiplegia after traumatic brain injury: a quantitative study. J Head Trauma Rehabil. 2012 May;27(3):177-87. PubMed: PM21522025

53. Reidy TG, Naber E, Viguers E, Allison K, Brady K, Carney J, et al. Outcomes of a clinic-

based pediatric constraint-induced movement therapy program. Phys Occup Ther Pediatr. 2012 Nov;32(4):355-67. PubMed: PM22731797

54. Sakzewski L, Ziviani J, Abbott DF, Macdonell RA, Jackson GD, Boyd RN. Equivalent

retention of gains at 1 year after training with constraint-induced or bimanual therapy in children with unilateral cerebral palsy. Neurorehabil Neural Repair. 2011 Sep;25(7):664-71. PubMed: PM21427273

55. Gillick BT, Koppes A. Gross motor outcomes in children with hemiparesis involved in a

modified constraint-induced therapy program. J Pediatr Rehabil Med. 2010;3(3):171-5. PubMed: PM21791848

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