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Constraint-induced therapy for a child with hemiplegic cerebral palsy: A case report
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CLINICAL NOTE
Constraint-Induced Therapy for a Child With Hemiplegic Cerebral Palsy: A Case Report Samuel R. Pierce, PT, MS, NCS, Kendall Daly, MS, OTR/L, Kara G. Gallagher, MS, OTR/L, Arthur M. Gershkoff, MD, Susan W. Schaumburg, MSPT ABSTRACT. Pierce SR, Daly K, Gallagher KG, Gershkoff AM, Schaumburg SW. Constraint-induced therapy for a child with hemiplegic cerebral palsy: a case report. Arch Phys Med Rehabil 2002;83:1462-3. A 12-year-old boy with hemiplegic cerebral palsy (CP) presented with decreased function in his left upper extremity. He was treated with a 3-week protocol of constraint-induced therapy (CIT) consisting of six 2-hour sessions of physical and occupational therapy, plus home practice. Improvements in upper-extremity function were found in the mean and median time for completion of the Wolf Motor Function Test immediately posttreatment and at 8-month follow-up. Also, improvements in functional use of the arm were documented with the Assessment of Motor and Process Skills and by patient selfreport of use of the upper extremity at home. The results suggest that CIT may be useful in the treatment of upperextremity dysfunction in hemiplegic CP. Larger, experimentally controlled investigations of the efficacy of CIT and the mechanism of recovery in patients with CP are warranted. The effects of the duration and intensity of CIT protocols need additional study to increase its clinical application. Key Words: Arm; Case report; Cerebral palsy; Rehabilitation. © 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation HILDREN WITH CEREBRAL PALSY (CP) often have decreased strength, sensation, and coordination in their C involved upper extremity. One promising treatment strategy 1
for these children is constraint-induced therapy (CIT). CIT training programs typically consist of supervised practice in which the child uses the hemiplegic upper extremity while wearing a restraining device on the uninvolved extremity during activities.2-4 The efficacy of CIT has been documented in multiple investigations in adults with hemiplegia secondary to stroke and traumatic brain injury.2-4 However, there have been few studies of CIT’s effectiveness in children with CP. Crocker et al5 reported improved upper-extremity movement in a child with CP after CIT, and Charles et al6 found improvements in hand function in 2 of 3 children with CP who participated in a CIT protocol. Currently, the clinical application of CIT may be
From the Departments of Physical Therapy (Pierce, Schaumburg) and of Occupational Therapy (Daly, Gallagher), and the Stroke and Neurological Disease Program (Gershkoff), MossRehab Hospital; and Jefferson Medical College (Gershkoff), Philadelphia, PA. Supported by Albert Einstein Society Innovative Grant Program, Albert Einstein Medical Center, Philadelphia, PA. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors(s) or upon any organization with which the author(s) is/are associated. Reprint requests Samuel Pierce, PT, Dept of Research, Shriners Hospital for Children, 3551 N Broad St, Philadelphia, PA, 19140, e-mail: [email protected]. 0003-9993/02/8310-7256$35.00/0 doi:10.1053/apmr.2002.34832
Arch Phys Med Rehabil Vol 83, October 2002
limited by the high intensity of the program, which may not match staffing and reimbursement realities in today’s health care environment. To date, there have been no reported investigations of CIT that implemented a treatment schedule typical of outpatient settings. In this case, we report on the use of CIT in a child with hemiplegic CP who was treated in a traditional outpatient setting. CASE DESCRIPTION The patient was a 12-year-old boy who was referred to physical (PT) and occupational therapy (OT) secondary to decreased use of his left upper extremity because of hemiplegic CP. He was an active child who played sports but had difficulty using his left hand. His goals from initial evaluation were “to use my left hand to hold a cup, to catch a baseball, and to carry schoolbooks.” Our evaluation showed no evidence of fixed contractures, and strength was generally 2⫹/5 for all muscle groups. Grasp and release were slow and often unsuccessful when he grasped small objects. The patient was independent in all functional activities and had normal cognition. CIT was the primary intervention in the patient’s treatment. Two 1-hour sessions of PT and two 1-hour sessions of OT were completed weekly for 3 weeks. The patient wore a restraining mitt throughout the therapy sessions to prevent use of the uninvolved upper extremity, except when bimanual activities were attempted. PT focused on practice with the left upper arm through exercise, play activities, and fine motor activities. OT focused on neuromuscular reeducation of the left upper extremity and incorporating it into functional tasks. The patient was instructed in donning and doffing the restraining mitt, which he wore at home as much as possible, except during personal hygiene activities. A home-exercise-program, consisting of functional and play activities, was to be performed while wearing the mitt. His mother was instructed to encourage his use of the mitt at home during appropriate activities. Treatment outcomes were assessed at baseline, postintervention, and at 8-month follow-up. Table 1 shows the timed components, as measured by a digital stopwatch, of the Wolf Motor Function Test7 (WMFT) at baseline, postintervention, and follow-up assessments. To date, the reliability of the WMFT has been established for adults with hemiplegia7 but not for children. Improvements in the timed component of the WMFT were found in 13 of 15 activities when baseline assessments were compared with the postintervention assessment. The mean time to complete each task improved by 37.5%, whereas the median time improved by 33.9% for these sessions. Grip strength, as measured by a hand-held dynamometer, improved from 2.5 to 7.4psi. Improvements in activities of daily living functions were found between baseline and postintervention assessments in 8 of 16 motor skills and 5 of 20 process skills on the Assessment of Motor Process Skills.8 Immediately posttreatment, the patient reported increased use of the left upper extremity at home during functional activities such as using the television remote control and lifting heavier items. He reported using the restraining device at home an average of 1 hour a day. When comparing the postintervention
APPLICATION OF CIT IN A CHILD WITH CP, Pierce Table 1: Components of WMFT Results (in seconds) to Complete at Baseline, Postintervention, and 8-Month Follow-up Baseline
Forearm to table Forearm to box Hand to table Hand to box Extend elbow Extend elbow with weight Reach and retrieve Lift can Lift paperclip Flip cards Stack checkers Turn key Fold towel Lift pencil Lift basket Mean score Median score
Postintervention
Follow-Up
.72 .87 1 .87 1
.65 .84 .62 .6 .41
.65 .84 .34 .68 .25
1.12 .94 3.84 120 25.06 57.81 13.97 10.1 23.53 35.31 19.74 3.84
.63 .53 2.68 120 26.38 9.88 9.09 6.56 2.54 3.75 12.34 2.54
.46 1.03 10.38 50.94 29.85 6.31 4.34 5.16 1.44 NA 8.05 1.24
Abbreviation: NA, not available.
and follow-up assessments, additional improvements were seen, as shown by further decreases in mean (34.8%) and median (51.2%) WMFT times. Grip strength slightly decreased from 7.4 to 6.6psi from postintervention to follow-up. At follow-up, the patient reported that he continued to use his left upper arm more frequently than before treatment. DISCUSSION The results in this case confirm the effectiveness of CIT in the treatment of upper-extremity dysfunction in children with CP. Larger, experimentally controlled investigations of CIT with children with CP are warranted. The mechanism behind the improvements in our patient is unknown, but studies of CIT with adults with hemiplegia suggest that plastic changes in the central nervous system may be involved.9 Future studies of CIT with children with CP could incorporate functional magnetic resonance imaging to further investigate recovery mechanism in this population. Also, the effects of treatment schedule and amount of practice with the hemiplegic extremity needs to be examined to determine the optimal treatment program for clinic-based CIT. Taub et al10 suggested that the amount of practice completed in a CIT program, which is typically 5 days a week for 7 hours a day for 2 weeks, is the most crucial factor facilitating recovery
1463
of the hemiplegic upper extremity. However, this intensity of treatment may not be feasible in the current managed care environment. A more home-based program would foster growth in the clinical application of CIT. The effectiveness of our CIT program may have been limited by the patient’s minimal daily practice at home. Further research is needed to determine the factors that improve adherence with a homebased CIT program. CONCLUSION The application of CIT with children with CP has only recently been investigated. This case study suggests that CIT may be effective in improving upper-extremity impairments and function in this population. Additional experimentally controlled investigations are warranted to determine the efficacy of CIT and the mechanism of recovery in children with CP. Also, the effect of treatment schedule on CIT’s efficacy should be studied to determine the optimal structure for CIT programs. References 1. Gordon AM, Duff SV. Relation between clinical measures and fine manipulative control in children with hemiplegic cerebral palsy. Dev Med Child Neurol 1999;41:586-91. 2. van der Lee JH, Wagenaar RC, Lankhorst GJ, Vogelaar TW, Deville WL, Bouter LM. Forced use of the upper extremity in chronic stroke patients: results from a single-blind randomized clinical trial. Stroke 1999;30:2369-75. 3. Miltner WH, Bauder H, Sommer M, Dettmers C, Taub E. Effects of constraint-induced movement therapy on chronic stroke patients: a replication. Stroke 1999:30:586-92. 4. Dromerick AW, Edwards DF, Hahn M. Does the application of constraint-induced movement therapy during acute rehabilitation reduce arm impairment after stroke? Stroke 2000;31:2984-8. 5. Crocker M, MacKay-Lyons M, McDonnell E. Forced use of the upper extremity in cerebral palsy: a single case design. Am J Occup Ther 1997;51:824-33. 6. Charles J, Lavinder G, Gordon AM. Effects of constraint-induced therapy on hand function in children with hemiplegic cerebral palsy. Pediatr Phys Ther 2001;13:68-76. 7. Morris DM, Uswatte G, Crago JE, Cook EW, Taub E. The reliability of the Wolf Motor Function Test for assessing upper extremity function after stroke. Arch Phys Med Rehabil 2001;82: 750-5. 8. Kirkley KN, Fisher AG. Alternate forms of reliability of the assessment of motor process and skills. J Outcome Meas 1999;3: 53-70. 9. Liepert J, Bauder H, Wolfgang HR, Miltner WH, Taub E, Weiller C. Treatment-induced cortical reorganization after stroke in humans. Stroke 2000;31:1210-6. 10. Taub E, Uswatte G, Pidikiti R. Constraint-induced movement therapy: a new family of techniques with broad application to physical rehabilitation—a clinical review. J Rehabil Res Dev 1999;36:237-51.
Arch Phys Med Rehabil Vol 83, October 2002
CLINICAL NOTE
Constraint-Induced Therapy for a Child With Hemiplegic Cerebral Palsy: A Case Report Samuel R. Pierce, PT, MS, NCS, Kendall Daly, MS, OTR/L, Kara G. Gallagher, MS, OTR/L, Arthur M. Gershkoff, MD, Susan W. Schaumburg, MSPT ABSTRACT. Pierce SR, Daly K, Gallagher KG, Gershkoff AM, Schaumburg SW. Constraint-induced therapy for a child with hemiplegic cerebral palsy: a case report. Arch Phys Med Rehabil 2002;83:1462-3. A 12-year-old boy with hemiplegic cerebral palsy (CP) presented with decreased function in his left upper extremity. He was treated with a 3-week protocol of constraint-induced therapy (CIT) consisting of six 2-hour sessions of physical and occupational therapy, plus home practice. Improvements in upper-extremity function were found in the mean and median time for completion of the Wolf Motor Function Test immediately posttreatment and at 8-month follow-up. Also, improvements in functional use of the arm were documented with the Assessment of Motor and Process Skills and by patient selfreport of use of the upper extremity at home. The results suggest that CIT may be useful in the treatment of upperextremity dysfunction in hemiplegic CP. Larger, experimentally controlled investigations of the efficacy of CIT and the mechanism of recovery in patients with CP are warranted. The effects of the duration and intensity of CIT protocols need additional study to increase its clinical application. Key Words: Arm; Case report; Cerebral palsy; Rehabilitation. © 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation HILDREN WITH CEREBRAL PALSY (CP) often have decreased strength, sensation, and coordination in their C involved upper extremity. One promising treatment strategy 1
for these children is constraint-induced therapy (CIT). CIT training programs typically consist of supervised practice in which the child uses the hemiplegic upper extremity while wearing a restraining device on the uninvolved extremity during activities.2-4 The efficacy of CIT has been documented in multiple investigations in adults with hemiplegia secondary to stroke and traumatic brain injury.2-4 However, there have been few studies of CIT’s effectiveness in children with CP. Crocker et al5 reported improved upper-extremity movement in a child with CP after CIT, and Charles et al6 found improvements in hand function in 2 of 3 children with CP who participated in a CIT protocol. Currently, the clinical application of CIT may be
From the Departments of Physical Therapy (Pierce, Schaumburg) and of Occupational Therapy (Daly, Gallagher), and the Stroke and Neurological Disease Program (Gershkoff), MossRehab Hospital; and Jefferson Medical College (Gershkoff), Philadelphia, PA. Supported by Albert Einstein Society Innovative Grant Program, Albert Einstein Medical Center, Philadelphia, PA. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors(s) or upon any organization with which the author(s) is/are associated. Reprint requests Samuel Pierce, PT, Dept of Research, Shriners Hospital for Children, 3551 N Broad St, Philadelphia, PA, 19140, e-mail: [email protected]. 0003-9993/02/8310-7256$35.00/0 doi:10.1053/apmr.2002.34832
Arch Phys Med Rehabil Vol 83, October 2002
limited by the high intensity of the program, which may not match staffing and reimbursement realities in today’s health care environment. To date, there have been no reported investigations of CIT that implemented a treatment schedule typical of outpatient settings. In this case, we report on the use of CIT in a child with hemiplegic CP who was treated in a traditional outpatient setting. CASE DESCRIPTION The patient was a 12-year-old boy who was referred to physical (PT) and occupational therapy (OT) secondary to decreased use of his left upper extremity because of hemiplegic CP. He was an active child who played sports but had difficulty using his left hand. His goals from initial evaluation were “to use my left hand to hold a cup, to catch a baseball, and to carry schoolbooks.” Our evaluation showed no evidence of fixed contractures, and strength was generally 2⫹/5 for all muscle groups. Grasp and release were slow and often unsuccessful when he grasped small objects. The patient was independent in all functional activities and had normal cognition. CIT was the primary intervention in the patient’s treatment. Two 1-hour sessions of PT and two 1-hour sessions of OT were completed weekly for 3 weeks. The patient wore a restraining mitt throughout the therapy sessions to prevent use of the uninvolved upper extremity, except when bimanual activities were attempted. PT focused on practice with the left upper arm through exercise, play activities, and fine motor activities. OT focused on neuromuscular reeducation of the left upper extremity and incorporating it into functional tasks. The patient was instructed in donning and doffing the restraining mitt, which he wore at home as much as possible, except during personal hygiene activities. A home-exercise-program, consisting of functional and play activities, was to be performed while wearing the mitt. His mother was instructed to encourage his use of the mitt at home during appropriate activities. Treatment outcomes were assessed at baseline, postintervention, and at 8-month follow-up. Table 1 shows the timed components, as measured by a digital stopwatch, of the Wolf Motor Function Test7 (WMFT) at baseline, postintervention, and follow-up assessments. To date, the reliability of the WMFT has been established for adults with hemiplegia7 but not for children. Improvements in the timed component of the WMFT were found in 13 of 15 activities when baseline assessments were compared with the postintervention assessment. The mean time to complete each task improved by 37.5%, whereas the median time improved by 33.9% for these sessions. Grip strength, as measured by a hand-held dynamometer, improved from 2.5 to 7.4psi. Improvements in activities of daily living functions were found between baseline and postintervention assessments in 8 of 16 motor skills and 5 of 20 process skills on the Assessment of Motor Process Skills.8 Immediately posttreatment, the patient reported increased use of the left upper extremity at home during functional activities such as using the television remote control and lifting heavier items. He reported using the restraining device at home an average of 1 hour a day. When comparing the postintervention
APPLICATION OF CIT IN A CHILD WITH CP, Pierce Table 1: Components of WMFT Results (in seconds) to Complete at Baseline, Postintervention, and 8-Month Follow-up Baseline
Forearm to table Forearm to box Hand to table Hand to box Extend elbow Extend elbow with weight Reach and retrieve Lift can Lift paperclip Flip cards Stack checkers Turn key Fold towel Lift pencil Lift basket Mean score Median score
Postintervention
Follow-Up
.72 .87 1 .87 1
.65 .84 .62 .6 .41
.65 .84 .34 .68 .25
1.12 .94 3.84 120 25.06 57.81 13.97 10.1 23.53 35.31 19.74 3.84
.63 .53 2.68 120 26.38 9.88 9.09 6.56 2.54 3.75 12.34 2.54
.46 1.03 10.38 50.94 29.85 6.31 4.34 5.16 1.44 NA 8.05 1.24
Abbreviation: NA, not available.
and follow-up assessments, additional improvements were seen, as shown by further decreases in mean (34.8%) and median (51.2%) WMFT times. Grip strength slightly decreased from 7.4 to 6.6psi from postintervention to follow-up. At follow-up, the patient reported that he continued to use his left upper arm more frequently than before treatment. DISCUSSION The results in this case confirm the effectiveness of CIT in the treatment of upper-extremity dysfunction in children with CP. Larger, experimentally controlled investigations of CIT with children with CP are warranted. The mechanism behind the improvements in our patient is unknown, but studies of CIT with adults with hemiplegia suggest that plastic changes in the central nervous system may be involved.9 Future studies of CIT with children with CP could incorporate functional magnetic resonance imaging to further investigate recovery mechanism in this population. Also, the effects of treatment schedule and amount of practice with the hemiplegic extremity needs to be examined to determine the optimal treatment program for clinic-based CIT. Taub et al10 suggested that the amount of practice completed in a CIT program, which is typically 5 days a week for 7 hours a day for 2 weeks, is the most crucial factor facilitating recovery
1463
of the hemiplegic upper extremity. However, this intensity of treatment may not be feasible in the current managed care environment. A more home-based program would foster growth in the clinical application of CIT. The effectiveness of our CIT program may have been limited by the patient’s minimal daily practice at home. Further research is needed to determine the factors that improve adherence with a homebased CIT program. CONCLUSION The application of CIT with children with CP has only recently been investigated. This case study suggests that CIT may be effective in improving upper-extremity impairments and function in this population. Additional experimentally controlled investigations are warranted to determine the efficacy of CIT and the mechanism of recovery in children with CP. Also, the effect of treatment schedule on CIT’s efficacy should be studied to determine the optimal structure for CIT programs. References 1. Gordon AM, Duff SV. Relation between clinical measures and fine manipulative control in children with hemiplegic cerebral palsy. Dev Med Child Neurol 1999;41:586-91. 2. van der Lee JH, Wagenaar RC, Lankhorst GJ, Vogelaar TW, Deville WL, Bouter LM. Forced use of the upper extremity in chronic stroke patients: results from a single-blind randomized clinical trial. Stroke 1999;30:2369-75. 3. Miltner WH, Bauder H, Sommer M, Dettmers C, Taub E. Effects of constraint-induced movement therapy on chronic stroke patients: a replication. Stroke 1999:30:586-92. 4. Dromerick AW, Edwards DF, Hahn M. Does the application of constraint-induced movement therapy during acute rehabilitation reduce arm impairment after stroke? Stroke 2000;31:2984-8. 5. Crocker M, MacKay-Lyons M, McDonnell E. Forced use of the upper extremity in cerebral palsy: a single case design. Am J Occup Ther 1997;51:824-33. 6. Charles J, Lavinder G, Gordon AM. Effects of constraint-induced therapy on hand function in children with hemiplegic cerebral palsy. Pediatr Phys Ther 2001;13:68-76. 7. Morris DM, Uswatte G, Crago JE, Cook EW, Taub E. The reliability of the Wolf Motor Function Test for assessing upper extremity function after stroke. Arch Phys Med Rehabil 2001;82: 750-5. 8. Kirkley KN, Fisher AG. Alternate forms of reliability of the assessment of motor process and skills. J Outcome Meas 1999;3: 53-70. 9. Liepert J, Bauder H, Wolfgang HR, Miltner WH, Taub E, Weiller C. Treatment-induced cortical reorganization after stroke in humans. Stroke 2000;31:1210-6. 10. Taub E, Uswatte G, Pidikiti R. Constraint-induced movement therapy: a new family of techniques with broad application to physical rehabilitation—a clinical review. J Rehabil Res Dev 1999;36:237-51.
Arch Phys Med Rehabil Vol 83, October 2002