Bimanual therapy and constraint-induced movement therapy are equally effective in improving hand function in children with congenital hemiplegia

Abstract

Question: Does constraint-induced movement therapy (CIMT) improve hand function in children with congenital hemiplegia compared to bimanual therapy?

Design: Randomised trial with concealed allocation and blinded outcome assessment.

Setting: 6 CIMT and bimanual therapy day camps were conducted at a University in the United States.

Participants: Children with congenital hemiplegia aged 3.5 to 10 years, with basic movement and grasp in their paretic hand, and who attended mainstream school. Health problems not associated with cerebral palsy, severe hypertonia, and recent surgery or botulinum toxin therapy were exclusion criteria. Randomisation of 44 participants allocated 22 to the CIMT group and 22 to the bimanual therapy group. The groups were matched for age and hand function.

Interventions: Both groups received 90 hours of therapy, delivered in day-camps with 2-5 children in each group. Participants completed 6 hours of therapy a day for 15 consecutive weekdays. Treatment was delivered by physiotherapists, occupational therapists, and students enrolled in health related courses. Participants worked individually and in groups. The CIMT group had their less affected hand restrained in a sling and performed age appropriate fine and gross motor unimanual activities The bimanual therapy group engaged in age appropriate fine and gross motor bimanual activities.

Outcome measures: The primary outcomes were the Jebsen-Taylor Test of Hand Function (JTTHF) to assess unimanual capacity and the Assisting Hand Assessment (AHA) to assess bimanual performance. Secondary outcome measures were Goal Attainment Scale, Quality of Upper Extremity Skills Test (QUEST), and physical activity (percentage time each hand was used during the AHA assessment). Assessments were completed before treatment, 2 days after treatment, and 1 and 6 months after treatment.

Results: 42 participants completed the study. At the end of the 15-day intervention period, the groups did not significantly differ on the primary outcome measures and on two secondary outcome measures (QUEST, physical activity). There were significant within group changes for both groups on each primary outcome (mean change score JTTHF -137 s, 95% CI -174 to -99; mean change score AHA -0.49 logits, 95% CI 0.25 to 0.73) which were maintained at the 6 month follow-up. There were also significant within group changes for both groups for the QUEST and physical activity assessments. The bimanual therapy group made greater progress than the CIMT group on their Goal Attainment Scale scores (mean difference between groups 8.1 T-score, 95% CI 0.7 to 15.5).

Conclusion: CIMT and bimanual therapy resulted in similar improvements in hand function among young children with congenital hemiplegia. The bimanual therapy group made better progress on established goals. [Mean difference between groups calculated by the CAP Editor].