EFFECT OF MODIFIED CONSTRAINT INDUCED MOVEMENT THERAPY …

Research Article

Corresponding Author:Anil Pawar, Assistant Professor, Department of Zoology, D.A.V. College for Girls, Yamunanagar (Haryana); Mobile:919467604205; Email: [email protected]

Received: 16.6.2014 Revised: 11.7.2014 Accepted: 29.7.2014

Int J Cur Res Rev | Vol 6 • Issue 17 • September 2014 29

EFFECT OF MODIFIED CONSTRAINT INDUCED MOVEMENT THERAPY ON HAND FUNCTION OF HEMIPLEGIC CEREBRAL PALSY

Pranali Thakkar

Sigma Institute of Physiotherapy, Bakrol, Vadodara, Gujarat, India.

ABSTRACTIntroduction: From the last few years constraint induced movement therapy (CIMT), as an intervention, has received a great deal of attention for children with Hemiplegic cerebral palsy (CP). To date, evidence on this treatment has been very poor and limited so additional research required. For various reasons, traditional form of therapy was neither considered feasible nor do child and family friendly for that we had use a modified form of CIMTObjective: To determine the effectiveness of modified CIMT on hand function of hemiplegic CP children characterized by re-straining the unaffected hand with short glove up to wrist. Methodology: 10 children (age: 2 to 8 years) from pediatric physiotherapy clinics from Vadodara and Ahmedabad with hemi-plegic CP were included in the study. Modified constraint was applied to unaffected hand. The intervention was given for 3 hrs/day including 30 minutes of therapy time and home program which could split into different sessions of no less than 30 minutes duration for consecutive 4 weeks. Pre and Post outcome measure by using QUEST (Quality of upper extremity skill test) and PMAL (pediatric motor activity log) were taken.Result: Significant difference between Pre and Post values of all components of PMAL and QUEST (P < 0.05) showing the ef-fectiveness of mCIMT in improving hand function and in ADL activities.Conclusion: mCIMT yields statistically as well as clinically significant improvements in both motor function and functional use of the affected upper extremity in children between the ages of 2 and 8 years with hemiplegic CP.

Key Words: Hemiplegic CP, Modified CIMT, Hand function

Corresponding Author:Pranali Thakkar, Sigma Institute of Physiotherapy, Bakrol, Vadodara, Gujarat, India, E-mail: [email protected]

Received: 27.05.2014 Revised: 25.06.2014 Accepted: 21.07.2014

INTRODUCTION

Hemiplegia accounts for 35% (1 in 1300) of the chil-dren with CP and upper limb (UL) involvement is usu-ally more pronounced than the lower limb.1 if hemiplegic stroke occurs in-utero, or any time between birth and two years of age, it is considered hemiplegic CP.

The most common cause of hemiplegic CP is a CVA (Cer-ebro vascular accidents) commonly known as a stroke. Children with hemiplegia have unilateral involvement of upper and lower extremities opposite to the side of cerebral injury, often characterized as muscle weakness and spasticity.2These factors may decrease movement efficiency3, especially in the use of the upper extremity, which can also limit performance in functional activi-ties at home and school.2, 4, 5They often learn to perform many tasks exclusively with their non-involve dextrem-

ity. This results in failure to use the involved extremity (i.e. developmental disuse). The impairment of the hand is often the result of damage to the motor cortex and cortico spinal pathways responsible for the fine motor control of the fingers and hand.4

Constraint induced movement therapy (CIMT) is a rela-tively new intervention derived from the basic sciences.6In 1995, however, it was suggested that a promising new therapy for adults with hemiparesis consequent to stroke, known as Constraint-Induced Movement therapy,6-9

The CIMT protocol stems directly from basic research with monkeys.6, 10CIMT has been adopted as a method of teaching a child to use his/ her affected upper limb through use of a restraint on the non-affected limb and massed practice of movements of the affected limb.11

IJCRR


Thakkar et. al.: Effect of modified constraint induced movement therapy on hand function of hemiplegic cerebral palsy

The elements of CIMT are:

1) Constraint of the unaffected arm to encourage the use of the affected hand,

2) Practice of the affected arm and 3) Use of intensive techniques to train the affected

arm.12

A Cochrane review concluded that there was emerging evidence supporting CIMT for children with hemiple-gia.13

Therapy accompanied in CIMT is constraint given for 6 hours per day. For various reasons, traditional form of therapy was neither considered feasible nor do child and family friendly for that we had use a modified form of CIMT

A number of variations are used in mCIMT. Modified CIMT (mCIMT) involve the application of a restraint with less than three hours per day11 and Type of con-straint use can be different

Modification of this approach for children with CP has followed, but until recently efficacy was limited to case reports and small prospective studies.4,13-15

Need for this study was to overcome these methodologi-cal problems and design a trial that can give evidence on modified CIMT (Modified constraint) effect.

This study presents the methodological choice (with less duration and short comfortable glove to the unaf-fected side for 3hrs per day) and to see the effectiveness of Modified CIMT (as a restraint glove combined with an intensive rehabilitation and home program) on hand function of hemiplegic CP children.

MATERIAL AND METHODS

Ethical approval: Study was approved by Ethical com-mittee of Sumandeep Vidyapeeth University and From pediatric physiotherapy centers of Vadodara and ahem-dabad, from where Participants met with inclusion cri-teria for the study was found and approval letters were taken from that physiotherapy centers. Permission for outcome measure scale (QUEST and PMAL) was taken by e-mail from author.

Research Design: Single group pretest posttest de-sign.

Source of data: Pediatric Physiotherapy clinics of Va-dodara and Ahmedabad

Sampling method: Convenient sampling

Sample size: 10Patients

Inclusion Criteria• Participantswithdiagnosisof spastichemiplegic

cerebral palsy as diagnosed and reported in the medical history by a Physician

• Agebetween2to8years• Active movement of the shoulder, elbow, wrist,

digits and thumb of the affected upper limb, such that the: child is able to reach forward to an el-evated position In front with mid-range shoulder flexion16,17

• Ability to extend wrist >20° and fingers at themetacarpophalangealjoints>10°fromfullflex-ion16,17

• Able toattendthetasksandfollowsimplecom-mands

• Muscletone(i.e.1-2,modifiedAshworthscale)• Parentswhoarewillingtocommitforanintensive

therapy program and agree to cease all other up-per limb therapeutic interventions for the 4 weeks period of the trial.

Exclusion Criteria• Knowncaseofseizureandonanti–epilepticdrugs• Visualproblemsinterferingwithtreatment• Any surgery on the paretic handwithin past 1

year • Botulinum toxin therapy in the upper extremity

within the past 6 month

Sample Recruitment

Targeted Population: Hemiplegic CP

Accesible Population: Physiotherapy clinics of Vadodara and Ahmedabad

Subjects Met with inclusion criteria from 4 clinics

N = 11

Total Sample size

N =10

Drop out N=1 (due to uncomfortable with glove parents wants to discontinue)

ProcedureParents and Children (who were understandable) were explained about the study. Informed consent were ob-tained from parents prior to study.

Modified Constraint Induced Movement Therapy (mCIMT):

Int J Cur Res Rev | Vol 6 • Issue 17 • September 201431


Subjects participated in the study were provided to wear a fairly comfortable glove by Principal Investigator, as a modified restraint up to wrist is used which covers fin-gers, thumb and hand to avoid hand function of unaf-fected side. The subjects can however use the hand for support or for breaking a fall. (Figure: 1)

The intervention was given for 3 hours/day including therapy time and home program which they can split into different sessions of no less than 30 minutes dura-tion for consecutive 4 weeks (week days). 3 hours was decided according to children play time when maximum use of hand was needed.

According to assessment, treatment plan based on uni-manual activities were given.

Treatment protocol

• Reach out activities (forward, Lateral and back-ward reach-figure:3-5)

• Graspingandreleasingactivities(usingdifferentsize of cubes and different shape things e.g. Pen-cil, eraser, toys, glass etc.)

• Finemotormovements(figure:7-10)• Protectivefunctionexercise• Resistedexe.Forimprovingstrength• Handweightbearingexercise(forward,lateral,

backward )• FunctionalADLandplayactivities(figure:6)• Goalorientedactivities

Activities were facilitated by using simple verbal com-mands, encouragement, toys, demonstration and assis-tance was given when needed.

Family members and / care givers were explained to un-dertake an intensive home program for 3 hours per day. Families were provided with specific goals after each ses-sion.

Logbook (Work diary) - was given to primary care giver for collecting details of child activity during that 3 hour time period.

Outcome measureThe motor outcome was measured by using,

PMAL (Pediatric motor activity scale)18,19(How often and how well) and

QUEST (Quality of Upper Extremity Skill Test) 20(dissoci-ated movement, grasp, protective extension, and weight-bearing)

Prior to treatment and after 4 week of treatment

Materialsused in the study• Restraint(aglove)(Figure:1)• DifferentToys(figure:2)

• WorkDiary• QUESTandPMALScoresheet• ChairandTable• Mat

Statistical Analysis:Data analysis was done by using SPSS 17 for windows, for both outcome measures PMAL and QUEST by statisti-

Figure 1: Modified Constraint (Glove) Treatment activities

Figure 2: Different toys used

Figure 3: Forward reach out



cian. Mean difference scores and Standard deviation for each variable were done. Wilcoxon signed rank test(as qualitative data) was used for data analysis. A signifi-cance level of 0.05 was set for all data analysis.

RESULT

Children in the studywereagedbetween2 to8years(the mean age was 5.25 years). There were of (60%) boys and (40%) girls, and equal numbers with the left

or right arm affected. (Table 1, 2&3)(Graph 1&2)

ResultofPMALinwhichpvalue(p<0.05)showingsig-nificant difference between Pre and post value of amount of use, quality of use and average score showing in (Ta-ble: 4, Graph: 3)

Result of QUEST in which p value (p<0.05) showingsignificance difference between pre and post values for dissociated movements,grasp, protective extension and weight-bearing but mean difference less in protective ex-tension and weight bearing showing in (Table: 5 , Graph : 4 )

Figure 4: Lateral reach out

Figure 5: Backward reach out

Figure 6: Play activity for co-ordination

Figure 7: Fine motor activity -1





DISCUSSION

This study was planned to see the effectiveness of Modi-fied CIMT that is on hand function of hemiplegic CP children.In the QUEST there was significant improve-ment seen in overall 4 domains but less improvement in weightbearingandprotectiveExtension. .Results fromthis study are consistent with other studies in showing a significant improvement in upper limb function after mCIMT in children.13,14,21 In this study most families did


Graph 1: Gender

Graph 2: Affected side

Graph 3: Mean differences between Pre and Post values Of How Often, How well and average Score

Graph 4: Mean differences between Pre and Post values For Dissociated movement, Grasp, Weight bearing, Protective Ex-tension and Total scor

Table 1: Age

Variable Minimum Maximum Mean SD

Age 2 8 5.25 ±1.82

Table 2: Gender

Variable Male Female

Gender 60% 40%

Table 3: Affected side

Variable Right Left

Affected side 5 5

Table 4: Mean, SD and p-value for PMAL scorePMAL

Variable Pre Post p-value

z-value

Mean SD Mean SD

How Often 1.36 ± 0.83 1.77 ± 0.88 0.005 - 2.809

How Well 1.56 ± 0.91 1.83 ± 0.95 0.005 - 2.810

Average 1.46 ± 0.86 1.80 ± 0.91 0.005 - 2.809



not find it easy to complete even modified CIMT. Some children disliked wearing the glove and some have com-plaint of uneasiness due to close glove.

Studies in adults following stroke have provided evi-dence of adaptation in the brain following CIMT.22, 23 Since the potential for central nervous system plasticity in young children is increased relative to adults, 24-26 it is postulated that this approach might prove to be especial-ly effective in children.27 In one study found that bilat-eral cortical activation was increased following mCIMT including higher levels of activity in the contralateral sensorimotor cortex. This suggests that with mCIMT, cor-tical reorganization occurs as new pathways between the damaged and healthy cortical hemisphere are made and control of the affected UE moves towards coming from the contralateral (lesion) hemisphere rather than solely from the ipsilateral hemisphere.27Secondly, The motor learning literature suggests that CIMT employs massed practice to increase the tendency of patients to use their more impaired limb, and thereby induces a use-depend-ent functional reorganization of brain structures.28

Taub’s study involved restraining children in casts for 24 hours per day for 1 month, with and without structured practice. Our study, as well as Eliasson’s, succeeded in being ‘child friendly’ by reducing the number of hours that children were restrained while still improving mo-tor performance in the involved hand and embedding practice in play activities with intensive rehabilitation programme.8Although in one study they have concluded that Improvement in hand function is not captured by any one measure. The effectiveness of this intervention is promising but may be dependent on the age, severity of the impairment, cognitive abilities and behavior.29 Clini-cally Overall, this intervention improvein hand function of involved upper extremity in a selected group of chil-dren with hemiplegic CP.In this study no side effects of restraint was found.

Limitation of the study• Small sample size

• No comparison with control group so can’t com-ment on that modified CIMT is more better than the conventional therapy

• No Long term follow up

Further recommendation• Long-term follow-up for amount of time required

for stable performance following this type of train-ing

• Multiple intervention episodes of Pediatric mCIMT with a larger sample of children with Hemiplegic CP and to see whether functional changes relate to cortical reorganization and, if so whether changes vary as a function of age

CONCLUSION

In conclusion, the planning and implementation of this multisite study on the efficacy of modified CIMT in hemi-plegic CP children shows that interventions are safe, ef-fective and worthwhile. Modified constraint induced movement therapy yields clinically as well as statistically significant improvements in both motor function and functional use of the affected upper extremity in chil-drenbetweentheagesof2and8yearswithhemiplegiccerebral palsy.In this study we found that modified CIMT is a feasible and tolerable intervention for children with hemiplegic CP children. The results obtained seem par-ticularly important for the current rehabilitation practice e for hemiplegic CP with modified CIMT.

ACKNOWLEDGEMENT

Author would like to express sincere gratitude to Dr. A. Jagatheesan, Dr. Mandar, Dr. Lata A. Parmar, Dr. Pallavi Barochiya, Dr. Savji A. Nakum, Dr. Piyusha, Dr. Diwakar, MansiParikh,RupalShah,Shivam,Nirali,Mitalifortheirdirect and indirect contribution in the work.

Author acknowledges the immense help received from the scholars whose articles are cited and included in ref-

Table 5: Mean, SD and p-value for QUEST score

Variable Pre Post P value z-value

Mean SD Mean SD

Dissociated Movement 75.00 ±9.83 82.65 ±8.93 0.005 - 2.807

Grasp 54.27 ±17.58 62.21 ±19.34 0.008 - 2.668

Weight Bearing 73.27 14.83 79.07 ±11.23 0.027 - 2.207

Protective Extension 36.92 ±10.46 44.16 ±10.83 0.026 - 2.226

Total 59.86 ±10.84 67.01 ±10.12 0.005 - 2.803



erences of this manuscript. She is also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.

ABBREVIATIONCP : Cerebral PalsyCIMT : Constraint Induced Movement TherapymCIMT : modified Constraint Induced Movement TherapyUE : Upper ExtremityQUEST : Quality of Upper Extremity Skill TestPMAL : Pediatric Motor Activity Log scale CVA : Cerebrovascular accidentHO : How Often HW : How Well

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EFFECT OF MODIFIED CONSTRAINT INDUCED MOVEMENT THERAPY …