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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 12  |  Issue : 2  |  Page : 93-97

Feasibility of application of constraint-induced movement therapy in a child with hemiplegic cerebral palsy: A single-case study


1 Department of Pediatric Neurophysiotherapy, Shree B.G.Patel College of Physiotherapy, Anand, Gujarat, India
2 Department of Physiotherapy, SOAHS, Manipal Academy of Higher Education, Manipal, Karnataka, India

Date of Submission01-Feb-2018
Date of Acceptance28-Sep-2018
Date of Web Publication17-Dec-2018

Correspondence Address:
Dr. Darshanaben J Tadvi
Shree B G Patel College of Physiotherapy, Opp. GPO, J.P.Road, Anand - 388 001, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/PJIAP.PJIAP_1_18

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  Abstract 

Children suffering from hemiplegic cerebral palsy (CP) develop developmental disregard (DD). In addition, they fail to comprehend the consequences of nonuse. The utility of affected upper limb is jeopardized. Current evidence supports the use of constraint-induced movement therapy (CIMT) for upper limb function in individuals with hemiplegia. This single-case study attempts to identify feasibility of application of pediatric CIMT on a child with hemiplegic CP. The aim of this study is to identify the benefits and feasibility of application of CIMT for improving quality of the upper limb movement in a child with hemiplegic CP. A 2½-year-old girl with hemiplegic CP visited the outpatient department (OPD) with the problem of lack of use of the right upper limb for activities and play along with the poorer quality of the upper limb movement. Disregard index was calculated to identify the presence of DD. CIMT was chosen as the child had above minimal ability to open fingers and extend the wrist. A 2-week intervention was designed based on the goal-oriented, ability-specific, child-specific practice of functional tasks. A rigid tape was used to provide constraint. The child was motivated to play with the affected hand for 2 h in the OPD and 2 h at home. Tasks of incremental difficulty were utilized as shaping method. The improvement in the quality of movement was measured using quality of upper extremity skilled test (QUEST) and Assisting Hand Assessment (AHA). The score on QUEST improved from 66.35 to 72.1, AHA improved from 66 to 73, and the disregard index score improved from 42.75 to 26.3 in 2 weeks. The treatment was adjusted to accommodate the behavior of the child.

Keywords: Cerebral palsy, constraint-induced movement therapy, feasibility


How to cite this article:
Tadvi DJ, Rajagopalan V. Feasibility of application of constraint-induced movement therapy in a child with hemiplegic cerebral palsy: A single-case study. Physiother - J Indian Assoc Physiother 2018;12:93-7

How to cite this URL:
Tadvi DJ, Rajagopalan V. Feasibility of application of constraint-induced movement therapy in a child with hemiplegic cerebral palsy: A single-case study. Physiother - J Indian Assoc Physiother [serial online] 2018 [cited 2019 Jan 15];12:93-7. Available from: http://www.pjiap.org/text.asp?2018/12/2/93/247603


  Introduction Top


The incidence of cerebral palsy (CP) is 2–2.5/1000 live births in India which is similar to the western country.[1] One-third of the children with CP has unilateral motor impairments or hemiplegic CP, predominantly involving one upper and lower limb on the same side of the body. Children with hemiplegic CP use their most affected arm and handless frequently and less skillfully than their nonaffected arm and hand. Nonuse of affected hand limits their independence in daily life.[2]

Reduced capacity (the ability to execute meaningful tasks in daily life) related to the brain damage is not the only reason for the reduced spontaneous use of their affected upper limb in daily life, i.e., performance but these children also suffer from an asymmetrical development due to the lack of use of the affected upper limb (WHO, 2001). This phenomenon is called as “developmental disregard (DD).” DD can be defined as a failure to employ the potential motor functions and capabilities of the affected limb and hand for the spontaneous use in everyday life.[3],[4] DD affects the performance of daily life activities involving the affected arm. Therefore, children with CP compensate their use of affected limb with the unaffected limb during the daily life activities.[5] The lack of spontaneous affected arm use is due to behavioral mechanisms rather than the structural damage.

Emerging evidence recommend the use of pediatric constraint-induced movement therapy (CIMT) for upper limb rehabilitation in children with hemiplegic CP to improve upper extremity function in them.[6],[7],[8] CIMT involves massed practice and shaping; wherein, the child has to actively practice the use of the upper limb while performing daily activity or play in hemiplegic CP children for many hours in a day.[9],[10],[11],[12],[13]

However, translating evidence into practice requires evaluation of its feasibility within the Indian cultural context. Hence, we have examined the feasibility and benefits of CIMT in a toddler with hemiplegic CP. Specifically, how well does the child accept CIMT and what factors facilitate acceptance of the treatment and also to know the amount of increase of the spontaneous use of paretic upper extremity during play at home following the treatment sessions?


  Methodology Top


Study design

This is a single-case study of a 2½-year-old baby girl with hemiplegic CP.

Patient information

On inquiring birth history, the mother had a full-term planned cesarean delivery with normal birth weight. The child had a positive history of hyperbilirubinemia on the 2nd day of birth which was cured by medical treatment within a week. At the age of 9 months, her mother discovered that she was not using her right hand much in reaching and grasping toys compared to the left hand and was not able to sit without support. The pediatrician diagnosed her problem as a right hemiplegic CP and referred for physical therapy.

Her physical therapy started at the 10 months of age at the outpatient physical therapy department. She was able to perform gross motor function according to her age except for optimal affected arm function. At the age of 2½-year, her parent's major concern was that she was not using her right hand to play and other activities compare to the left hand as the child developed nonuse of affected arm. She neglected the affected (right) arm during play, and the quality of movement of the right upper extremity was not normal.

The functional level of child was determined by Gross Motor Function Classification System (GMFCS) five-level classification system. The child has GMFCS level I which means that the child has good mobility without the need of assistive mobility device. On objective assessment of the child, we identified that the primary cause of lack of the right upper limb use was DD. Her physical impairments, weakness, spasticity, sensory deficits, and joint ranges were negligible. We discovered while observing that the child during play or activity that the child uses her affected hand while she encountered the big or heavy object like volleyball. Her DD score was 42.75. On behavioral examination in the clinic, she was cranky and easily distractive child. She loved to be appreciated for her small achievements and liked outdoor play rather inside clinical setup.

Clinical assessment was taken before and after 2 weeks of treatment. The effective use of paretic arm and quality of movement was measured using Assisting Hand Assessment (AHA) and Quality of Upper Extremity Skilled test (QUEST) scores. AHA scale measures how effectively child with unilateral disability use their affected hand in bimanual tasks.[14] The performance is scored in 22 items on a four-point rating scale. The total score ranges from 22 to 88 points. QUEST scale measures the quality of arm and hand movement. QUEST includes 34 items from the four domains of dissociated movement, grasp, weight bearing, and protective extension, and QUEST score ranges from 50 to 100.[15]

Change in DD was assessed using DD index (DDI) supplemented by mother's interview and therapist report from each session. We used Pediatric Motor Activity Log (PMAL) along with QUEST scores to determine DD. PMAL measures the amount and quality of arm use in real life and includes How Often scale and How Well scale to rate a total of 22 items with six-point scale. How Often scale illustrates score of how often your child uses affected hand to perform each of 22 activities, whereas How Well scale illustrates score of how well your child uses the affected arm for that 22 activities.[15]

The DDI scores were calculated using the following formula:

(DD = QUEST score – [PMAL score/5 × 100]).[15]

Intervention procedures

CIMT was given for 6 days a week for 2 weeks. The total treatment duration was 4 h a day. Two hours of treatment was provided by trained physical therapist and 2 h of home program. The treatment was designed by considering the child's interests, behavior, acceptability, and environmental factors.

The list of activities given to the child is as follows: hand activities provided were picking and placing different shapes of toys such as small cubes with cartoon pictures, long, flat, and rectangular-shaped toy train track, small elliptical-shaped fishes of a variety of colors, and cylindrical small bars of different colors. Arm activities provided were throwing the ball (tennis ball), hitting a ball with the two types of racket light weighted (plastic racket) and heavier racket, eating chocolate or small beans, giving a high five with the right hand to therapist's or parents' hand, writing on the board with chalk followed by rubbing with a duster, lifting different weight objects from one place and putting to another spot, stair climbing with wall support taken by her right hand, and pushing a slider door [Figure 1].
Figure 1: (a) Grasping different objects constraint given by tape. (b) Opening and closing door play. (c) Plucking flower game constraint - holding hand by mother/therapist. (d) Writing on board with chalk. (e) Game of throwing object

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The exercises were continued at home with her toys, and her mother was trained to facilitate the use of the affected hand while playing along and additionally activities provided during therapy session were also attempted at home. We conducted problem-solving sessions on the 2nd and 9th day of treatment to identify and rectify the problems encountered in the home environment. Modified constraining methods such as manual constraint by mother or therapist and bandage with micro tape were utilized. The intervention was provided for 2 weeks.

Measurement of outcomes

There was an improvement in the grasp, release, fine motor adjustment, and pace items in AHA. QUEST included four components (dissociated movements, grasp, weight bearing, and protective extension). Two components of QUEST (weight bearing and protective extension) were not tested as child's lacked understanding about the task. The score on QUEST improved from 66.35 to 72.1, AHA improved from 66 to 73, and the disregard index score improved from 42.75 to 26.3 in 2 weeks. The positive change in disregard index score occurred with the improvement in QUEST score and PMAL score of How Often scale and How Well scale as well.

The child was highly motivated toward activities and playing outside clinical setups such as classroom and outdoor activities, and her attention to those activities was relatively sustained better than activities inside the department. Mother reported her spontaneous use of affected hand while play and activity at home. She revealed that her spontaneous use had increased selectively with toys which were small in size and had a cylindrical and square or rectangle in shape.


  Discussion Top


The case study helped us to identify the feasibility of CIMT application in the child with hemiplegic CP. The results suggest treatment difference produced effects more than minimal clinically significant difference. In 2 weeks, 12 sessions, the score on AHA improved from 66 to 73. QUEST included four components (dissociated movements, grasp, weight bearing, and protective extension). Two components of QUEST (weight bearing and protective extension) were not tested as child's lack of understanding about the task. The score on QUEST improved from 66.35 to 72.1. Smallest detectable difference of QUEST and AHA was 4.89 score units and AHA was <4 raw score, respectively.

However, the application of CIMT could not be the same for all children. Its application could require patient-centric modification to derive activities and type of constraint before the commencement of CIMT. The confounding factors of treatment acceptance were interest of child, behavior of child, and parent's acceptability of CIMT. In the beginning sessions, the child was refusing constraint leading to cranky behavior. Therefore, mother was also skeptical about the child's acceptance of treatment. Eventually, the treatment was well accepted by child and mother when it was integrated as play and counseling to mother.

Despite these specific shortcomings, CIMT was feasible to be applied within pediatric rehabilitation. However, the parent needs to accept and be trained to apply the intervention. They should be trained in the selection of the activities appropriate for the ability and how to progress. In addition, when to stop the intervention and when to restart should be specifically communicated to them. Constraining the arm was not well tolerated, and hence, we had to be persistent during treatment sessions to manually prevent the less affected arm from being used.

We discovered that movement quality of affected upper extremity was compromised due to the lack of forearm supination and wrist extension movement. Thus, further attention is needed for improving the quality of movement. While grasping and picking up cubes from the base child had used trunk flexion rather elbow extension and wrist extension. The ability to release objects was better for contoured and solid objects (cube or chalk) than soft or foam object (flower) release which requires wrist and finger extension. There was also evident lack of wrist extension and supination of the forearm in activities such as pushing a door, rubbing with duster on board, and writing on a board with chalk and turning a page of a book. The aim of different types of activity prescription was to increase the opportunity for learning of all movement types of upper extremity necessary for interacting with the environment.

The bimanual training (BIMT) is also an effective intervention for the upper limb use in hemiplegic CP. The functional impact of BIMT in children with hemiplegic CP is similar to the CIMT.[16],[17],[18],[19] The adversity of CIMT on the nonaffected arm could be negligible as treatment duration was shorter (4 h a day), interval training design of 2 h, and also encouraged bimanual activities while play exclusive of treatment time. The combination of these two interventions would yield a better improvement in the functional use of affected upper extremity in children with hemiplegic CP. Perhaps, CIMT increases the capacity of unaffected arm use and its quality of movement while play and for grasping activities.[4],[5] We found the intervention effective and can be translated to practice, but the intervention should be child, parent, ability, and environment specific.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgement

We are grateful to the oxford college of physiotherapy, Bangalore to provide us platform to conduct a study and we thank to patient and parent for their participation in this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Gladstone M. A review of the incidence and prevalence, types and aetiology of childhood cerebral palsy in resource-poor settings. Ann Trop Paediatr 2010;30:181-96.  Back to cited text no. 1
    
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Houwink A, Aarts PB, Geurts AC, Steenbergen B. A neurocognitive perspective on developmental disregard in children with hemiplegic cerebral palsy. Res Dev Disabil 2011;32:2157-63.  Back to cited text no. 3
    
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Radell U, Tillberg E, Mattsson E, Amark P. Participation in age-related activities and influence of cultural factors – Comments from youth and parents of children with postnatal post infectious hemiplegia in Stockholm, Sweden. Disabil Rehabil 2008;30:891-7.  Back to cited text no. 4
    
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Hoare BJ, Wasiak J, Imms C, Carey L. Constraint-induced movement therapy in the treatment of the upper limb in children with hemiplegic cerebral palsy. Cochrane Database Syst Rev 2007;2:CD004149.  Back to cited text no. 5
    
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Hart H. Can constraint therapy be developmentally appropriate and child-friendly? Dev Med Child Neurol 2005;47:363.  Back to cited text no. 9
    
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Charles JR, Gordon AM. A repeated course of constraint-induced movement therapy results in further improvement. Dev Med Child Neurol 2007;49:770-3.  Back to cited text no. 11
    
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Sterr A, Freivogel S, Schmalohr D. Neurobehavioral aspects of recovery: Assessment of the learned nonuse phenomenon in hemiparetic adolescents. Arch Phys Med Rehabil 2002;83:1726-31.  Back to cited text no. 12
    
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Gordon AM, Charles J, Wolf SL. Efficacy of constraint-induced movement therapy on involved upper-extremity use in children with hemiplegic cerebral palsy is not age-dependent. Pediatrics 2006;117:e363-73.  Back to cited text no. 13
    
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Krumlinde-Sundholm L, Holmefur M, Kottorp A, Eliasson AC. The assisting hand assessment: Current evidence of validity, reliability, and responsiveness to change. Dev Med Child Neurol 2007;49:259-64.  Back to cited text no. 14
    
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Sutcliffe TL, Logan WJ, Fehlings DL. Pediatric constraint-induced movement therapy is associated with increased contralateral cortical activity on functional magnetic resonance imaging. J Child Neurol 2009;24:1230-5.  Back to cited text no. 15
    
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Huang HH, Fetters L, Hale J, McBride A. Bound for success: A systematic review of constraint-induced movement therapy in children with cerebral palsy supports improved arm and hand use. Phys Ther 2009;89:1126-41.  Back to cited text no. 16
    
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Klingels K, De Cock P, Molenaers G, Desloovere K, Huenaerts C, Jaspers E, et al. Upper limb motor and sensory impairments in children with hemiplegic cerebral palsy. Can they be measured reliably? Disabil Rehabil 2010;32:409-16.  Back to cited text no. 17
    
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de Brito Brandão M, Gordon AM, Mancini MC. Functional impact of constraint therapy and bimanual training in children with cerebral palsy: A randomized controlled trial. Am J Occup Ther 2012;66:672-81.  Back to cited text no. 18
    
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Dong VA, Tung IH, Siu HW, Fong KN. Studies comparing the efficacy of constraint-induced movement therapy and bimanual training in children with unilateral cerebral palsy: A systematic review. Dev Neurorehabil 2013;16:133-43.  Back to cited text no. 19
    


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