CRITICALLY APPRAISED PAPER (CAP) Yu, J., Kang, H., & Jung, J. (2012). Effects of modified constraint-induced movement therapy on hand dexterity, grip strength and activities of daily living of children with cerebral palsy: A randomized control trial. Journal of Physical Therapy Science, 24(10), 1029 1031. http://dx.doi.org/10.1589/jpts.24.1029 CLINICAL BOTTOM LINE: This is a quantitative Level I randomized control trial that reviews the effects of constraintinduced movement therapy (CIMT) in children with cerebral palsy (CP). More specifically, it seeks to determine the influence of modified constraint-induced movement therapy (mcimt) on hand function, including hand dexterity, grip strength, and activities of daily living (ADLs) of children with hemiplegic CP. A sample of 20 children with hemiplegic CP, an average age of 9.4 years old, was selected from S. Hospital in South Korea. Both the treatment and control groups were given traditional rehabilitation therapy in 30-minute sessions semi-weekly, while children in the treatment group also received a mcimt session by two physical therapists who incorporated activities to facilitate children s ability to grasp, seize, hold, and handle a variety of objects with the more affected arm. Results indicated clinically significant improvements in hand dexterity and grip strength of the affected side, as well as improvements in ADL performance with significant differences in the mcimt and control groups. Despite meaningful results, the study is limited by possible sample and intervention biases such as possible co-intervention, timing of intervention, and various therapists. Without considering possible biases, it is difficult to determine if improvements are a direct result from the mcimt or if they were due to an alternate confounding variable. Despite these limitations, the outcomes were significant and supported the use of mcimt. Previous research in addition to this study support occupational therapists consideration of mcimt as an intervention strategy to help improve overall functioning and aid the eventual independence of children with hemiplegic CP. RESEARCH OBJECTIVE(S) List study objectives. Determine the influence of modified constraint-induced movement therapy (mcimt) on hand function of children with hemiplegic cerebral palsy (p. 1029). Determine the influence of mcimt on activities of daily living (ADLs) of children with hemiplegic CP (p. 1029). 1
DESIGN TYPE AND LEVEL OF EVIDENCE: Limitations (appropriateness of study design): Was the study design type appropriate for the knowledge level about? Yes Level I: Randomized controlled trial SAMPLE SELECTION How were subjects recruited and selected to participate? Please describe. The 20 participants were selected from S. Hospital in South Korea in 2011. The author did not report anything further about the selection process. Participants were randomized using a table of random sampling numbers and separated from each other for single blind analysis. Inclusion Criteria Inclusion criteria included voluntary movement that was not limited when the non-affected side was restrained; no difficulties in performing passive range of motion (ROM) exercises; some active ROM on the affected side, including voluntary wrist extension of 10 or more and voluntary finger extension of 10 or more on all fingers; and ability to follow therapist instructions. Exclusion Criteria Exclusion criteria included participation in mcimt-related treatment in the previous 2 years and cognitive deficits that inhibited the child s ability to follow therapists instructions. SAMPLE CHARACTERISTICS N = (Number of participants taking part in the study) % Dropouts 20% of participants dropped out of the study. Although it was not explicitly stated that any participants dropped out, it was stated in the methods section that 24 children participated in this study. However, data were only collected on 20 children. Based on the article, it is unclear as to what occurred with the other 4 children who were said to be included initially. #/ (%) Male 13 (65%) #/ (%) Female 7 (35%) 20 Ethnicity NR Disease/disability diagnosis Children with hemiplegic CP 2
INTERVENTION(S) AND CONTROL GROUPS Group 1: Control group (traditional rehabilitation therapy) Brief description of the intervention How many participants in the group? Where did the intervention take place? Who delivered? This group received traditional rehabilitation therapy. Specific information regarding the type of treatment provided is not reported. 10 children participated in this group: 6 boys and 4 girls. Interventions were provided at S. Hospital in South Korea. Researchers do not provide any further details regarding where in the hospital therapy occurred. 2 expert physical therapists How often? Participants received traditional rehabilitation therapy for 30 minutes, twice a week. For how long? 10 weeks Group 2: Intervention group (mcimt) Brief description of the intervention How many participants in the group? Where did the intervention take place? Who delivered? Participants received traditional rehabilitation therapy and mcimt. In the mcimt, the child s non-affected arm was restrained with a string and a splint made of a light material. In the restraint, the arm was positioned in 90 degrees of elbow flexion, 20 degrees wrist extension, and 20 degrees of finger flexion. While in this position, participants completed 13 different activities, including transferring a small object with a spoon, performing button closures, manipulating clothespins, ring tossing, playing card games, keyboard strokes, grab-bars-meet-the-balloon, building a stuffed animal, playing with water pistols, building with blocks, and playing with toys with the affected arm and hand. The activities chosen encouraged children to grasp, seize, hold, and handle a variety of objects with different sizes and weights. 10 children participated in this group: 7 boys and 3 girls. Interventions were provided at S. Hospital in South Korea. Researchers do not provide any further details regarding where in the hospital therapy occurred. 2 expert physical therapists How often? Participants received traditional rehabilitation therapy for 30 minutes, twice a week and mcimt for 60 minutes. The author did not report how often mcimt sessions were. For how long? 10 weeks Intervention Biases: Check yes, no, or NR and explain, if needed. 3
Contamination: Co-intervention: NR Timing: Site: Comment: Although both treatments occurred at the S. Hospital, intervention and control groups were separated to reduce contamination. Researchers asked participants not to discuss their protocol with members of the alternate group. Comment: Researchers did not report potential co-intervention the children may have received in addition to traditional rehab therapy and the mcimt. Comment: One group received treatment in the morning and the other received treatment in the afternoon. This may have influenced the participants energy levels and overall participation in interventions. Comment: Intervention took place at S. Hospital for all participants. Use of different therapists to provide intervention: Comment: The study does not specify whether the therapists implementing the interventions were providing the same traditional rehabilitation therapy to each group. Additionally, one therapist could have been more motivating or more favorable. MEASURES AND OUTCOMES Complete for each measure relevant to occupational therapy: Measure 1: Name/type of The box and block test (BBT) measure used: What outcome was measured? reliable? valid? When is the measure used? Hand dexterity: Measures arm dexterity and hand manipulation ability. This tool involves testing the number of wood blocks a patient is able to grasp and transport to another spot with the affected hand. This was used twice during the study, once to evaluate ADLs before receiving treatment and again at the end of 10 weeks. 4
Measure 2: Name/type of measure used: What outcome was measured? reliable? valid? When is the measure used? Measure 3: Name/type of measure used: What outcome was measured? reliable? valid? When is the measure used? Hand dynamometer Grip strength This was used twice during the study, once to evaluate ADLs before receiving treatment and again at the end of 10 weeks. Wee-Functional Independence Measure (weefim) ADL independence level This was used twice during the study, once to evaluate ADLs before receiving treatment and again at the end of 10 weeks. Measurement Biases Were the evaluators blind to treatment status? Check yes, no, or NR, and if no, explain. Comment: The researchers provided the treatment and were involved in all areas of data collection and analysis. Recall or memory bias. Check yes, no, or NR, and if yes, explain. Comment: Others (list and explain): NR RESULTS List key findings based on study objectives Include statistical significance where appropriate (p<0.05) Include effect size if reported 5
Descriptive statistics were used to analyze subject characteristics. Researchers utilized SPSS v. 12.0 to calculate mean and standard deviation. Inferential statistics were calculated with an independent t test to measure difference in hand function and ADL scores between the two groups. A statistically significant p value of <0.05 was used for all data analysis. Analysis revealed that when compared to the control group, participants in the intervention group had statistically significant improvements in hand dexterity and grip strength of the affected side as well as improvements in ADL performance. Was this study adequately powered (large enough to show a difference)? Check yes, no, or NR, and if no, explain. Comment: 20 participants is not a large enough sample size to make a generalizable conclusion of the population being studied. Were appropriate analytic methods used? Check yes, no, or NR, and if no, explain. Were statistics appropriately reported (in written or table format)? Check yes or no, and if no, explain. Was the percent/number of subjects/participants who dropped out of the study reported? Limitations: What are the overall study limitations? The overall study limitations include the small number of participants, and possible cointervention, timing, and therapists biases. Foremost, the results of this study cannot be generalized to all children with CP due to the small sample size. Although researchers screened participants for prior CIMT experience, there was no mention of current additional therapy participants may be receiving during the time of the study. Time of day may have influenced the participants energy levels and involvement in the treatment sessions, as one group of participants received treatment in the morning and the other in the afternoon. The author did not state whether therapists were the same across both groups. Therefore, it is unclear whether results were exclusively due to the mcimt intervention. Further research is necessary addressing each of these biases to verify efficacy and long-term effects of mcimt. CONCLUSIONS State the authors conclusions related to the research objectives. 6
Compared to the control group s traditional therapeutic treatment, all statistical analyses showed improvements in hand dexterity and grip strength of the affected side as well as improvements in ADL performance in children with cerebral palsy. Despite meaningful results, researchers concluded that the results of this study cannot be generalized to all children with CP due to the small sample size, so further research is needed in this area. Considering the number and characteristics of participants and the limitations influencing the mcimt training period, comprehensive research and testing should be performed. Although more research is needed in this area, initial results support the use of mcimt as a treatment option when working with children who have been diagnosed with hemiplegic CP. This intervention has implications in a broad range of clinical settings. It also would be valuable to develop other measures and protocols that would increase a child s interest in mcimt training activities that could be applicable to a specific age range, culture, and individual interests. This work is based on the evidence-based literature review completed by Jacqueline Stanton, OTS; Alexsandria Morales, OTS; Joshua Muchnick, OTS; and Megan K. Foti, DOT, MS, OTR, Faculty Advisor, Richard Stockton College of New Jersey. CAP Worksheet adapted from Critical Review Form-Quantitative Studies. Copyright 1998, by M. Law, D. Stewart, N. Pollack, L. Letts, J. Bosch, & M. Westmorland, McMaster University. Used with permission. For personal or educational use only. All other uses require permission from AOTA. Contact: www.copyright.com 7