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A R T I C L E
Constraint-Induced Movement
Therapy in Children Aged 5 to 9
Years With Cerebral Palsy: A Day
Camp Model
Ashley M.E. Thompson, MHSc; Serena Chow, MScOT; Cathy Vey, BScOT; Meghann Lloyd, PhD
Carleton University (Ms Thompson), Ottawa, Ontario, Canada; University of Ontario Institute of Technology (Dr Lloyd),
Oshawa, Ontario, Canada; Grandview Childrens Centre (Ms Chow and Ms Vey), Oshawa, Ontario, Canada.
Purpose: To examine the effectiveness of a modified form of constraint-induced movement therapy (mCIMT)
in the context of a day camp model in 6 children aged 5-9 years with spastic hemiplegic cerebral palsy.
Methods: Before, 1 week after, and 3 months after 9 consecutive days of mCIMT, participants were assessed
using the Quality of Upper Extremity Skills Test (QUEST) and assessments of range of motion and grip strength.
Caregiver perceptions were assessed using the Pediatric Evaluation of Disability Inventory (PEDI) and a parent
questionnaire. Results: Significant improvements were observed on the grasps and protective extension
subsections of the QUEST after the intervention. Increased social function was also observed as measured
by the PEDI. All improvements were maintained at the 3-month follow-up assessment. Analysis of individual
participants yielded additional information on clinically significant improvements as a result of the mCIMT
intervention. Conclusions: The day camp model of mCIMT was effective in inducing lasting and meaningful
changes in the children with hemiplegic cerebral palsy. (Pediatr Phys Ther 2015;27:7280) Key words: cerebral
palsy/hemiplegia, child, evaluation of disability, motor skills, upper limb
INTRODUCTION AND PURPOSE
Cerebral palsy (CP) encompasses a group of movement and posture disorders caused by a nonprogressive
but permanent abnormality in the fetal or infant brain.1
The development of the brain is interrupted by an interfering event that damages or otherwise influences the
expected patterns of maturation; the result may be a lesion
0898-5669/2701-0072
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Wilkins and Section on Pediatrics of the American Physical Therapy
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Correspondence: Ashley M.E. Thompson, MHSc, Carleton University, 1125 Colonel By Dr, Ottawa, ON K1S 5B6, Canada (Ashley.Thompson3@carleton.ca).
Grant Support: This study was supported by grants from the Grandview
Childrens Centre Foundation, Oshawa, Ontario, Canada.
At the time this article was written Ashley Thompson was a student at the
University of Ontario Institute of Technology, Master of Health Sciences,
Oshawa, Ontario, Canada.
The authors declare no conflict of interest.
DOI: 10.1097/PEP.0000000000000111
72
Thompson et al
Copyright 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins and the Section on Pediatrics of the American Physical Therapy
Association. Unauthorized reproduction of this article is prohibited.
Copyright 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins and the Section on Pediatrics of the American Physical Therapy
Association. Unauthorized reproduction of this article is prohibited.
74
Thompson et al
Copyright 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins and the Section on Pediatrics of the American Physical Therapy
Association. Unauthorized reproduction of this article is prohibited.
Copyright 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins and the Section on Pediatrics of the American Physical Therapy
Association. Unauthorized reproduction of this article is prohibited.
TABLE 1
Participant Information
MACS
level (I-V)
GMFCS
level (I-V)
MAS at Elbow
Joint
Pre-, Post-, and
3-mo Follow-up
Assessment (0-4)
Previously
Attended
Camp
Age, yr
Sex
Affected
Side
1
2
3
6
6
9
Male
Male
Male
Right
Right
Right
I
II
II
I
I
II
1, 2, 2
NT, 2, 1
2, 1, 1
Yes (2011)
Yes (2011)
No
4
5
6
5
5
6
Male
Female
Female
Right
Left
Right
II
I
II
II
I
I
3, 3, 2
0, 0, 0
0, 0, 0
No
Yes (2011)
No
Participant
Additional
Impairments
None
None
Learning disabilities; sensory
integration disorder; social
isolation; difficulty transitioning
from preferred activities to less
preferred; angry (sometimes
physical with outbursts; impulse
control difficulties)
Learning disabilities
None
Febrile seizures; difficulty keeping
up with other children in
physical activities
Abbreviations: GMFCS, Gross Motor Function Classification System; MACS, Manual Abilities Classification System; MAS, Modified Ashworth Scale; NT,
not tested.
TABLE 2
QUEST Scores by Participant and by Section
Participant
QUEST Section
Total score
Dissociated movements
Grasps
Weight bearing
Protective extension
Session
Preassessment
Postassessment
3-mo follow-up assessment
Preassessment
Postassessment
3-mo follow-up assessment
Preassessment
Postassessment
3-mo follow-up assessment
Preassessment
Postassessment
3-mo follow-up assessment
Preassessment
Postassessment
3-mo follow-up assessment
72.97
72.44
71.97
70.31
62.50
56.25
69.57
78.26
82.61
92.00
74.00
74.00
60.00
75.00
75.00
81.98
89.94
84.56
75.00
82.81
76.56
69.57
78.95
73.68
100.00
98.00
88.00
83.33
100.00
100.00
69.80
68.27
79.85
70.31
67.19
78.13
60.87
65.22
82.61
98.00
74.00
92.00
50.00
66.67
66.67
61.79
49.27
46.87
54.84
53.23
51.56
56.52
52.17
47.37
74.00
50.00
0.00a
0.00
41.67
41.67
92.01
95.65
94.66
93.75
100.00
95.31
82.61
82.61
100.00
100.00
100.00
100.00
91.67
100.00
83.33
91.62
97.35
99.22
92.19
93.75
96.88
82.61
95.65
100.00
100.00
100.00
100.00
91.67
100.00
100.00
Thompson et al
Caregiver Reports
On the PEDI, caregivers responses indicated a significant improvement in social function skills after the intervention (Z = 2.201; P = .028; observed power > 0.999;
Cohens d = 2.55). No significant changes were observed
in any of the other categories of the PEDI.
On the CTC questionnaire, no significant changes
were observed in the caregiver responses over time or on
the satisfaction section of the questionnaire over time. In
each individual category of the CTC questionnaire, however, at least 3 of the 6 caregivers satisfaction responses
increased between the initial assessment and the 3-month
follow-up; the only exception to this was in the frequency
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cally significant improvements in grasping ability that persist months later.29,30 More efficient grasping capabilities
would allow children to perform more efficiently a variety
of functional tasks, including self-care tasks such as feeding and dressing, and might allow increased participation
in other activities such as play.
Trends toward improvement in the protective extension sub-section of the QUEST occurred regardless of
GMFCS or MACS level. As activities performed at the camp
did not specifically address protective extension skills an
increase in the spontaneous use of the affected limb could
have reasonably contributed to improved protective extension scores. Children with CP often experience impairments in balance42 ; these impairments can lead to falls,
further supporting the relevance of the current finding of
improved protective extension skills.
The improvements observed on the QUEST
are consistent with previous research, demonstrating improvements on standardized tests of motor
performance16,17,19-21,23,30,43 ; however, those studies
found varying degrees of improvement on various motor
assessments.16-18,27,29 Ultimately, individual differences
may affect the improvements observed on standardized
tests of motor performance.
Like our findings, previous studies have consistently
shown that grip strength and active range of motion in
the unaffected limb are not hindered after CIMT.15,21,23,31
Previous studies have also reported nonsignificant results
for change in grip strength in the affected limb after a CIMT
intervention.33,44,45
Caregiver Reports
Fig. 3. Median grasps scores on the Quality of Upper Extremity Skills Test with standard deviation. Participant 4s scores are
excluded from analysis.
of use subsection, where only 2 of the 6 caregivers reported increased satisfaction. In the spontaneity of use
subsection, 5 of the 6 caregivers reported increased satisfaction after the intervention.
DISCUSSION
The results from the current study support findings
of prior clinical studies demonstrating mCIMT to be effective in children with hemiplegia.20,22,23 The results further
support previous research demonstrating that mCIMT can
be successfully applied outside a clinical setting, yielding
positive outcomes for youth.15,17,24-26
Motor Outcomes
The finding of improvement in the grasps area of
the QUEST supports previous research findings of statistiPediatric Physical Therapy
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Thompson et al
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Association. Unauthorized reproduction of this article is prohibited.
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