Modified constraint-induced therapy for children with cerebral palsy: A randomised controlled trial

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BACKGROUND: Upper limb dysfunction is one of the most important predictors of participation restriction in children with cerebral palsy. Modified constraint-induced therapy is an intervention designed to improve the function of the affected arm of children with hemiplegic cerebral palsy and maximise their participation in daily activities. This therapy involves constraining the unaffected hand with a mitt and providing concurrent and carefully targeted therapy during the period of constraint. It has been argued that the constraint of the unaffected side encourages the child to use the affected side, providing opportunity for the child to develop muscle control and strength and to reduce learned non-use. Modified constraint-induced therapy is already offered in Australian clinics even though it is an expensive and intensive intervention and there is little evidence of its effectiveness. This randomised controlled trial will evaluate the effects of modified constraint-induced therapy on children’s upper limb function and participation in daily activities. If the intervention is to be widely adopted it must first be shown to be substantially more effective than current best practices in paediatric service provision. HYPOTHESES: Children with spastic hemiplegic cerebral palsy participating in modified constraint-induced therapy will have better upper limb function and will be better able to complete important daily activities than a group receiving standard best practice occupational therapy. STUDY: Randomised controlled trial. Fifty children with spastic hemiplegic cerebral palsy, aged between 18 months and 8 years and meeting specified eligibility criteria will be recruited from The Children’s Hospital at Westmead, The Centre for Cerebral Palsy and The Spastic Centre of NSW. Consenting families will complete a baseline assessment and then be randomised to a modified constraint-induced therapy group or standard best practice occupational therapy group. Therapy (and constraint) will start 1 week later and continue for 8 weeks. Children will be reassessed at 8 weeks and 6 months. Intervention for the experimental group will consist of modified constraint-induced therapy. Constraint will be implemented by a custom-made mitt which prevents grasp and release with the unaffected hand. The mitt will be worn for a minimum of 2 hours per day, 7 days per week for 8 weeks. In addition, adjunct therapy (to improve motor ability of the affected upper limb) will be provided daily by carers whilst the constraint is in place and once per week by an occupational therapist. The adjunct therapy is a critical component of modified constraint-induced therapy. The control group will participate in standard best practice occupational therapy for 8 weeks. The provision of standard practice controls for frequency of provision of occupational therapy. More importantly, it allows us to establish if modified constraint-induced therapy is more effective than current best practice, which should be a pre-requisite for implementation of this therapy.

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