1. THEIMPACTOFUNIMANUALANDBIMANUALINTENSIVE
TRAINING ON DAILY LIVING IN CHILDREN WITH
HEMIPLEGIC CEREBRAL PALSY
Irfan Iftekhar

2. 1
THE IMPACT OF UNIMANUAL AND BIMANUAL INTENSIVE TRAINING ON
DAILY LIVING IN CHILDREN WITH HEMIPLEGIC CEREBRAL PALSY
by
Irfan Iftekhar

3. 2
THE IMPACT OF UNIMANUAL AND BIMANUAL INTENSIVE TRAINING
ON DAILY LIVING IN CHILDREN WITH HEMIPLEGIC CEREBRAL PALSY
Abstract
Use of Constraint Induced Movement Therapy (CIMT) as an intervention for hemiparesis has
demonstrated favorable results in recent literature. CIMT is a common neurological intervention
which has been used to treat individuals who have experienced unilateral hemiparesis, or
weakness of one arm due to some sort of neurological condition or trauma. CIMT incorporates
constraint of the unaffected arm while performing repetitive practice of motor function activities
with the affected arm. HABIT is a task oriented training that that involves the use of both arms
to complete bimanual tasks. There is no constraint use which addresses the limitation of CIMT
regarding constraint use acting as a barrier to the development of bimanual coordination. The
results of this study indicate that both HABIT and CIMT are effective in inducing lasting and
meaningful changes in children with spastic hemiplegic CP.
Keywords: Bimanual training, spastic hemiplegic cerebral palsy, constraint-induced movement
therapy, child-therapist alliance, child-therapist interaction, motor intervention, restraint,
physical
Dissertation Advisor: Your name:

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Acknowledgments

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ABBREVIATION

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1. Introduction
Congenital hemiplegia is a type of unilateral cerebral palsy (CP) which is most common. In this
the body's one side is significantly impaired in movement and sensation, especially in the upper
extremities, which may cause difficulty with daily activities. Various management approaches
have been developed to promote the active movement of the affected arm for children with
hemiplegia. A distinction is made between Cerebral palsy when the onset is before, during, or
soon after birth, which is referred to as congenital CP, and when the onset is later in childhood,
which is referred to as acquired CP. Many forms of CP have been described, including diplegic,
ataxic and quadraparetic; however, one of the most common types, and the one addressed in this
study, is congenital hemiparetic cerebral palsy (HCP). According to Himmelman et al. (2010),
hemiparesis occurs in approximately 33% of all individuals diagnosed with CP. HCP is an
incomplete paralysis affecting one side of the body and can vary in its degree from person to
person (DeLuca, Echols, Law, & Ramey, 2002). Common manifestations of HCP are weakness,
lack of control of the affected limb(s) and sensory-perceptual deficits (Cerebral Palsy Source,
2005). In addition to sensory-motor deficits, CP is also associated with problems with learning
and language, epilepsy, and hearing and vision impairment (Krageloh-Mann & Horber, 2007;
Geytenbeek, 2011).
The impairments in motor control seen in an individual with Hemiplegic Cerebral Palsy (HCP)
have been well documented and are attributed to deficits in motor planning, movement initiation,
sequencing, coordination, anticipatory control, sensory information and sensory-motor
integration (Cascio, 2010; Gordon, Charles, & Duff, 1999; Gordon, Charles, & Steenbergen,
2006; Gordon & Duff, 1999; Mutsaarts et al., 2006; Steenbergen, Verrel, & Gordon, 2007).

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Children with hemiplegic CP experience difficulties in such tasks like self-caring tasks, playing
and other activities A study by Sigurdardottir (2010) of the population of all 4-6 year olds with
CP in Iceland from 1989 to 2004 found a significant level of impairment in speech, expressive
language and verbal cognition. The population of children (N=152) was evaluated by a team
including a pediatrician, neuropsychologist and a speech and language therapist. They found that
16% of children were nonverbal communicators and that 16% of children had severe dysarthria.
These results are concurrent with the findings in a review of speech and language therapy that
20% of children with CP cannot produce intelligible speech and up to 50% have less severe
speech and communication impairments (Pennington, Goldhart & Marshall, 2005). Bottcher,
Flachs, and Uldall (2010) found impaired executive functioning and slower performance on
timed tasks using standardized neuropsychological measures in children with spastic CP. The
symptom which is most prominent of spastic hemiplegic CP is Spasticity, motor disorder
characterized by exaggerated tendon jerks, resulting from hyperexcitability of the stretch reflex,
as one component of the upper-motor neuron syndrome” (Lance,1980). In children the most
visible unilateral defects are loss of fragility of strength, range of motion, malfunctioning touch
sense, which ultimately lead to weakness in grip and manipulation of objects. In another study
conducted earlier results suggest that for a carefully selected subgroup of children with
hemiplegic CP, HABIT appears to be efficacious in improving bimanual hand use.
Constraint-induced movement therapy (CIT) works on the premise that the brain can reorganize
itself after sustaining damage to the motor area, and that these processes are facilitated through
the two treatment principles: (1) extensive upper-limb training, and (2) constraining the
unaffected limb. The intervention encourages brain reorganization to increase its motor capacities
(Kim et al., 2004) and the cortical space devoted to the affected upper limb (Liepert et al., 2000).

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According to the WHO-ICF, disability must be considered in the context of body structures and
functions, environmental factors, activity and participation (WHO, 2001). These factors, in
addition to the personal factors and characteristics of each individual, interact with one another
and contribute to the overall health condition and function of that individual. The activity of the
child refers to what he or she is able to do, and participation refers to what the child actually
does outside of the therapeutic setting (WHO, 2001). The goal of any implemented intervention
is to increase the activity of the child, such that participation may improve. By improving the
child’s ability to perform upper limb tasks in a lasting way, modified CIMT is promoting
functional changes that permit children with hemiplegic CP to increase their participation in
various tasks outside of therapy.
The following disposition outlines the structure of the thesis:
Chapter Title Content
1 Introduction
This section has the purpose to give an introduction to the
subject in matter. Further, the first chapter contains the
background and problem discussion that will introduce
previous and contemporary research within the field CMIT
and HABIT. The chapter will proceed with a problem
specification resulting in the purpose of the study.
2 Background
The background first introduces the reader to the typical
characteristics of CIMT and HABIT. Thereafter a
description of the effectiveness of these interventions to
improve occupation performance of children having
hemiplegic cerebral palsy (CP)

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3 Methodology
This section will provide the reader with an understanding for
the course of action taken by the author of the thesis in order to
achieve a result of relevance. First, quantitative research
methods will be presented followed by a theory of how
methods were chosen. Secondly, the case study and finally, the
methods of how to collect and analyze the data will be
discussed ending with discussing the validity and reliability of
the results.
4 Data Extraction
Here the data extraction process will be defined.
5 Analysis
This section has the intention to connect presented theory with
findings. The focus is on the research questions in order to
answer the purpose of the thesis and they will work as headings
to provide a structure. Lastly, an analysis with an evaluation
will be conducted.
6 Conclusion
In this section we will present the final conclusions which
answer the purpose. Further, the analysis resulted in a number
of suggestions which will be presented as a course of action.
7 Discussion and
Limitations
This chapter discusses the outcome of the thesis. It presents
some limitations of the study which are important to be aware
of in order to get the correct interpretation of the result. The
chapter continues with some criticism of the chosen method
and how it could have affected the result. Furthermore, some
areas for further studies are presented.
8 Recommendations This chapter will present recommendations and suggestions for
future studies

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2. Background
The efficacy of (CIMT) is considered based on two independent but linked mechanisms (Taub et al.,
2006a): (1) practice based counterconditioning of learned nonuse, and (2) use-dependent plastic brain
reorganization. No cure exists for HCP; however, studies show that the effects of the condition and of
learned nonuse can be minimized through therapy. Of particular interest to the author are the benefit
of Constraint-Induced Movement Therapy (CIMT) for improving function of the afflicted limb and its
possible benefits to motor and cognitive deficits, alike.
Current evidence suggests that both constraint induced movement therapy and intensive bimanual
training are effective in improving upper limb activity limitations. Child friendly versions of Constraint
Induced Movement therapy are more effective at increasing use of the impaired limb accompanied by
increased neuroplastic changes in the primary motor cortex (Boyd et al. 2012).
While CIMT has been more effective at increasing use of the impaired limb, only intensive bimanual
training will improve bimanual co-ordination (Sakzewski et al. 2012). Activity based intervention to
requires short intensive bursts of mCIMT followed by either a block or distributed model of activity
based bimanual training (COMB IT, Boyd et. al. 2013). The dose of training provided in an intensive
block is critical with strong evidence of neuroplasticity with at least 60 hours of mCIMT, whereas 30
hours is not sufficient to drive neuroplastic changes in children with unilateral CP (Boyd et al. 2012}.
The next important step is to overcome barriers to implementation of more intensive activity based
training with use of groups and targeted home based programs (Sakzewski et al. 2013). Based on
current evidence for upper limb training in children with unilateral CP and in the absence of clinical
practice guidelines, four evidence criteria are proposed: Therapy should (i) be goal directed and goal
attainment measured objectively pre and post intervention; (ii) use contemporary motor learning
approach; (iii) achieve an adequate dose; (iv) measure upper limb outcomes objectively pre and post

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intervention (Sakzewski et al. 2013). The challenge for clinicians is to implement higher doses of
training with limited resources and poor access for remote and isolated families.
Many children with cerebral palsy (CP) have the capability to walk or to achieve some amount of
functional mobility in their lower limbs either with or without devices or other external assistance. The
role of physical therapy is to help children with CP and their families achieve their mobility goals to
the extent possible, given the child's capabilities, environment and available resources, with the
ultimate goal to enable them to participate as fully as possible in their home and community.
The underlying principles stem from the current dynamic systems model of motor control and
principles of motor learning, which suggests that movement patterns emerge as a result of the
interaction between the person's abilities, the environment and the task (Mathiowetz and Haugen 1994,
Smith and Wrisberg 2000, Law et al 1996, CAOT 2002). The dynamic System theory postulates that
development occurs from children's ability to construct solutions to motor problems, that development
is driven by the child's characteristics and capacity to explore the situation. This means, that the
children are not using any wrong or right movements when performing activities. The principles of
motor learning focus on the understanding of how the children learn new tasks.
The activity-based approach can be utilized differently depending on what is intended to treat. There
is a difference in the organization of treatment in the case of wanting to learn certain tasks or activities
and when the intention is to be more skilled in general. When a specific activity has to be learned, an
analysis must be made of the task, the environment and the person's capacity. The influence of the
environment and structure of the task needs to be analyzed before investigating the personal
components. Adaptations of environment and activity are typically easier to carry out than changing a
child's capacity. By adapting the environment or activity first, the intervention also supports the child's
self-esteem and problem-solving skills. Adaptation of an environment and of tasks can facilitate the

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performance and. learning procedure. Such adaptation may include the use of technical aids or
simplification of the activity in question, depending on the child's wishes and ability to perform the
activity. Adaptations and simplifications are usually made in the early learning phase to achieve
success. An activity includes several tasks, performed in a certain order. Any task is built up from a
sequence of movements. The sequences need to be executed in a certain order, forming a successful
strategy for the task. Each sequence also needs to have a certain quality of skilled performance. The
order in which the sequences are conducted and the quality of the individual's movements will
influence the result (Gentile 1987). If the goal is increased motor skills in general, Constraint Induced
Movement therapy ( CIMT) can serve as a good model. It has been used for children unilateral CP
with different ages.
2. Purpose of Study
This study was aimed towards examining the efficacy of intensive upper extremity training, CIMT
and HABIT, when provided exclusively in an elementary school setting by child’s therapist. By means
of modifying the schedule of the children’s typical therapy and providing a very specific technique,
the study attempted to make a comparison of a baseline period of routine care with a period of intensive
therapy by same therapists in the school setting. Another aim of the study was to compare the efficacy
of CIMT versus HABIT in this setting.
3. Rationale
The rationale for carrying out this study lies in the well documented findings in the literature. The
primary objective of this trial is to evaluate will give me a better view through research of the impact
of both HABIT and CIMT rehabilitation interventions in children with CP. It is hoped that this study
would shed light on the efficacy of both these interventions and thus would be of value to practicing
therapists.

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4. Literature Review
It is difficult to accept at face value the results of trials or any rehabilitation programmes even if their
conduct is diligently performed and scientifically sound when the measures generating the results are
psychometrically poor.
Some Studies in Clinical Settings like one by DeLuca et al. (2006) who conducted a study aimed at
testing the efficacy of CIMT in a randomized, controlled, crossover trial. The authors recruited 18
participants, ranging from 7-96months of age (mean age = 3 years, 6 months); CIMT was administered
for 6 hours per day for 21 consecutive days. In this study, the children wore a bi-valved cast for the
duration of the experiment (24 hours per day), removing it only once each week to check for any
problems (DeLuca et al., 2006). The authors reported significant motor improvement as indicated by
standardized motor assessments at the post-intervention assessment; these improvements were
maintained at the 3-week follow-up (DeLuca et al., 2006). As expected, individuals in the control
group did not experience a similar improvement; however, once they were crossed over and received
CIMT, they similarly experienced a significant improvement in motor function (DeLuca et al., 2006).
In one study specifically attempted to determine the effects of the environment on the outcome of
CIMT interventions (Rostami & Malamiri, 2012). The authors investigated the effects of modified
CIMT in 14 children aged 4-8.5 years (mean age = 6 years, 2 months); their primary objective was to
determine if a home-based intervention would be more beneficial than a clinic-based intervention for
children with hemiplegic CP (Rostami & Malamiri, 2012).
Children were randomized into either a home-based CIMT group or a clinic-based intervention; the
restraining splint was worn by all participants for the majority of waking hours, being removed only

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for bathing and short periods of rest for both groups. Though the restraint was worn nearly full-time
throughout the intervention, modified CIMT was only administered for 1.5 hours, 3 times per week,
for a total of 10 sessions. It was found that both groups improved following the intervention; however,
only the home group showed continued improvement at the 3- month follow-up session on all
measures. Overall, the home group’s improvement was better than that of the clinic group, and the
authors suggested that the application of CIMT in natural settings should be investigated further
(Rostami & Malamiri, 2012).
The studies performed in a clinical setting have used wide age ranges and a variety of intervening
techniques; these studies have consistently demonstrated that CIMT is effective in inducing lasting
functional improvements in children with spastic hemiplegic CP. It appears that the importance of
transferring the shaping and practice of the unaffected limb to more natural settings is gaining attention
in the field, as an increasing number of studies appear to be implementing home exercise programs
and/or deliberately performing the interventions in settings outside of the laboratory. There have been
Alternate Settings studies to perform the CIMT intervention in setting like the home, day camps. Al-
Oraibi & Eliasson (2011) performed a randomized controlled trial using a home-based model to
compare CIMT and NDT in 14 children with spastic hemiplegic CP aged 2-9 years CIMT was
administered for 2 hours per day, 6 days per week; the NDT group had 1-2 hours of therapy per week.
Standardized tests of motor performance were administered before the intervention, immediately
following the intervention, and 2.5 months following the intervention’s end (Al-Oraibi & Eliasson,
2011). At the post-assessment session, it was found that the NDT group showed almost no
improvements; the CIMT group improved significantly more than the NDT group on all measures,
and the observed improvements persisted at the 2.5 month follow-up. Another group of authors studied
the effects of CIMT in a 4-year old child with hemiplegic CP using a home-based model (Brekke,
Ehler, Furze, & Goulet, 2004). The unaffected limb was restrained for an average of 2.5 hours a day,
for a total of 4 weeks; standardized motor assessments were performed prior to, immediately

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following, and 3 months following the intervention. In this model, caregivers administered CIMT at
home and encouraged practice of the affected limb on a daily basis (Brekke et al., 2004). Following
the intervention, marked improvements were observed in the child’s functional ability to use the
affected limb. The results of the studies by Al-Oraibi & Eliasson (2011) and Brekke et al. (2004)
demonstrate the usefulness of CIMT in a home-based setting, even with small sample sizes (and one
single subject design); the authors suggest that CIMT can be implemented in various environments
with very few extra costs for families and health organizations.
Several randomized controlled trials with larger sample sizes have also been performed in a home
setting; Chen et al. (2012) performed one such CIMT intervention. Participants were 47 children aged
6-12 years with spastic hemiplegic CP (mean age = 8 years, 9 months); 24 children were assigned to
the CIMT group, and 23 children were assigned to the usual care group. The intervention lasted 4
weeks, and involved individualized therapist-based training at home for 3.5-4 hours per day, 2 days
per week (Chen et al., 2012). It was found that the CIMT group improved more than the usual care
group on the grasping sub-sections of the tests of motor performance; the CIMT group also improved
more in hand use and quality of hand use (Chen et al., 2012). Finally, the CIMT group improved more
than the usual care group on some, but not all, aspects of reaching control (Chen et al., 2012). Hsin et
al. (2012) also performed a randomized controlled trial using CIMT in a home-based intervention for
22 children aged 6-8 years with spastic hemiplegic CP (mean age = 6 years, 11 months). CIMT was
administered for 3.5-4hours per day, twice weekly for 4 weeks; assessments were performed pre, post,
and 3 months following the intervention (Hsin et al., 2012).

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Methodology
Current evidence of efficacy for activity based therapies has implications for the delivery of optimal
intervention for children with cerebral palsy, CP, across continents. These interventions primarily

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tested in western settings need to be tailored for implementation across multiple settings, cultures and
economic circumstances in a global perspective. Personnel with appropriate training and expertise are
needed to deliver to families in the home setting and communities to provide an enriched environment
for persons with CP.With a global shortage of appropriately trained personnel, strategies to implement
higher intensities of evidence based rehabilitation to drive neuroplasticity may include both group
delivered activity based practice and web based rehabilitation.
The dynamic System theory postulates that development occurs from children's ability to construct
solutions to motor problems, that development is driven by the child's characteristics and capacity to
explore the situation. This means, that the children are not using any wrong or right movements when
performing activities. The principles of motor learning focus on the understanding of how the children
learn new tasks, the key elements are the different learning steps and how feedback can be given.
Another key component is training at just the right level and the importance of repetition as is widely
accepted to be of major importance.
Methodology
(i) State of the evidence: Upper limb interventions for Unilateral Cerebral Palsy
Children with unilateral cerebral palsy (UCP) present with impaired upper-limb function impacting
independence, participation and quality of life, and require effective rehabilitation. A recent
meta-analysis has systematically reviewed the efficacy of non-surgical upper-limb therapies for
children with UCP (Sakzewski et al. 2009, 2013). Forty-two randomized controlled or comparison
trials evaluating 14 upper-limb therapy approaches (n=1454 subjects) investigated intramuscular
upper limb (UL) Botulinum Toxin A, combined with therapy (BoNT-A, 11 studies; n=322 subjects);
constraint induced movement therapy (CIMT, 3 studies; n=56); modified CIMT (mCIMT, 15 studies;
n=578); combined CIMT and bimanual training (Hybrid, 2 studies; n=35); neurodevelopmental

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treatment (NDT, 2 studies; n=122); forced use therapy (FU, 2 studies; n=54); Hand Arm Bimanual
Intensive Training (HABIT 1 study; n=20); mirror therapy (1 study; n=10); OT home programs (1
study; n=35); context focused therapy (1 study; n=128), action observation (AO,1 study; n=15); lycra
splints (1 study; n=16); OT and acupuncture (1 study; n=75). Twelve studies were of very high
methodological quality (≥8 PEDro Scale), 14 were low (< 6 PEDro Scale). There was weak evidence
for NDT to improve UL movement quality and fine motor skills (Standardized Mean Difference SMD
0.15-0.30).There was modest to strong treatment effects for mCIMT to improve quality and efficiency
of movement of the impaired UL compared to usual care of a lesser dose (SMD 0.30-1.95).
There were weak treatment effects of mCIMT compared to an equal dose of HABIT or bimanual goal
directed OT, as both approaches yielded similar outcomes (SMD -0.13-0.11). There was moderate to
strong evidence that intramuscular BoNT-A provides a supplementary effect to OT to improve
unimanual and individualized achievement (SMD 0.92, 95%CI: 0.57 -1.27).Newer interventions such
as action observation training and mirror therapy should be viewed as experimental. In conclusion
there were moderate to strong evidence supporting intensive activity-based goal directed interventions
(e.g., mCIMT, bimanual training) to improve quality and efficiency of UL movement and
individualized goals compared to usual care. There was little evidence to support current "block"
models of therapy alone as the dose and unlikely to be sufficient to deliver long term changes in UL
function. There was strong evidence that goal-directed occupational therapy home programs are
effective and could supplement hands on direct therapy to achieve increased dose of intervention.
(ii) Implications for a range of resource settings
Current evidence suggests that both constraint induced movement therapy and intensive bimanual
training are effective in improving upper limb activity limitations. Child friendly versions of Constraint
Induced Movement therapy (mCIMT) are more effective at increasing use of the impaired limb

19. 18
(unimanual capacity) accompanied by increased neuroplastic changes in the primary motor cortex
(Boyd et al. 2012). While mCIMT has been more effective at increasing use of the impaired limb, only
intensive bimanual training will improve bimanual co-ordination (Sakzewski et al. 2012). Activity
based intervention to require short intensive bursts of mCIMT followed by either a block or distributed
model of activity based bimanual training (COMBIT, Boyd et. al. 2013). The dose of training provided
in an intensive block is critical with strong evidence of neuroplasticity with at least 60 hours of
mCIMT, whereas 30 hours is not sufficient to drive neuroplastic changes in children with unilateral
CP (Boydet al. 2012}. The next important step is to overcome barriers to implementation of more
intensive activity based training with use of groups and targeted home based programs (Sakzewski et
al. 2013).
Based on current evidence for upper limb training in children with unilateral CP and in the absence of
clinical practice guidelines, four evidence criteria are proposed: Therapy should (i) be goal directed
and goal attainment measured objectively pre and post intervention; (ii) use contemporary motor
learning approach; (iii) achieve an adequate dose; (iv) measure upper limb outcomes objectively pre
and post intervention (Sakzewski et al. 2013). The challenge for clinicians is to implement higher doses
of training with limited resources and poor access for remote and isolated families.
(iii) Web basedrehabilitation
The development of web based rehabilitation provides opportunities for higher intensities of training.
Virtual reality is becoming increasingly popular as a rehabilitation tool for children and adolescents
with CP or Acquired Brain Injury, ABI. New technology has been developed in a program called Mitii
is a novel web-based, virtual rehabilitation program for children and adolescents with CP or an ABI.
Physiotherapists, Occupational Therapists and Psychologists act as virtual trainers to deliver an
individualized and incremented therapy program. Mitii is delivered remotely using an internet

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connected computer and either a Kinect or standard web-camera. Mitii has the potential to deliver an
intensive therapy program in a cost effective manner to children in rural and remote areas. The efficacy
of Mitti is has been tested in two large randomized clinical trials for children with unilateral CP;
MiTTi-CP, n=98, and for children with Acquired brain injury; n=60. Design, incrementation and
delivery of a multimodal training rehabilitation program over the web has highlighted the executive
dysfunction across broad domains of children with UCP (Bodimede et al. 2013) and the need to focus
on motor learning strategies in rehabilitation.
Methodology-2
After a comprehensive search of previous studies dating from January 1990 to December 2014 using
the following databases: CINAHL, EMBASE, MEDLINE, AMED, Cochrane Library, OTseeker,
Cochrane Central Register of Controlled Trials (CENTRAL), and Physiotherapy Evidence Database
(PEDro). The search used Medical Subject Headings and text words:
Hemiplegia or Cerebral palsy and Infant, or Child or Adolescent and Occupational
therapy or Movement therapy or Physical therapy or Splinting or Botulinum toxin or
Strength training or Virtual reality or CIMT therapy and Upper limb or Arm or Hand and
Randomized controlled trial or Random sampling or Double and single blind method
Studies selected for analysis had to meet the following credentials:
1. Full publication in a peer-reviewed journal
2. Published in English language
3. Randomized controlled trials
Only child participants aged 0 to 18 years with congenital hemiplegia with spasticity affecting -
UL function.
-UL function improvement intervention and participation were nonsurgical

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-Systematic reviews metaanalysis and randomized or quasi-randomized, controlled trials
included
Participants of the study did not include a subset of
- Children with hemiplegia;
- Outcomes reported were impairment only
- Studies were not published in English
The studies were not included if:
There was nonrandomized trials or were with no control group, i.e., children who were given standard
care and no intervention.
Study Participants
All studies have Children congenital hemiplegia. A greater sample consisting many children with CP
also had a subset of children with hemiplegia. One of the studies only focused on children with
hemiplegia and two subects with varying CP distribution. The range of age of the children varied from
one and half year to sixteen years.
Types of Intervention
Four broad categories of intervention were identified: NDT, and forced-use therapy, HABIT, and
intramuscular BoNT-A injections to the UL with or without therapy. The Intervention categories were
broad, the NDT, forced use therapy, HABIT and injections of BoNT-A to the UL. Evaluation of
BoNT-A injections to the UL was made through two systematic reviews, one of which has 2 RCTs,
the other 3 RCTs. 1 RCT and 1 quasi-RCT was identified by a systematic review of CIMT in 49
subjects. This review also includes the evaluation of OTidentified 2 RCTs of NDT through systematic
review, further review of the systematic reviews also identified same 2 RCTs after evaluation of UL
casting but was unable to find UL splinting in any RCTs. The score 5 on the PEDro scale is considered
to be moderate to high quality of all trials (Table 1). Median score 1 was reported in one study on

22. 21
nonstandardized assessments, while summary statistics was reported by 1. Table 3 shows the RCTs
quality scores.
Data Extraction
A summary of the population and methodology for all trials is shown in Table 1, while Table 2 shows
the systematic reviews. PEDro, Physiotherapy Evidence Database, was used to evaluate the trials'
methodologic quality. The scale has 11 criteria, each scored as 0 or 1, whereas a total of 11 points
resulted. The Interrater reliability of the PEDro scale is adequate. Those Studies which have scores of
≥5 were considered as having adequate internal validity so they in the meta-analysis, were added.
Methods of and characteristics of study -RCTs
Study Design Diagnosis Age Treatment n Control n
Leanne Sakzewski et al RCT CP 5 to
16 y
Intense NDT 19 Intensive
NDT
18
Marina de Brito et al RCT CP 3 to 8
y
Regular NDT 17 Regular
NDT
18
Roslyn Boyd et al RCT-
crossover
CP 5 to
16 y
Intense NDT 26 Intensive
NDT
24
Nava Gelkop et al RCT-
crossover
CP 17
mo to
7 y
Intense NDT 26 Regular OT 24
Gordon et al SB RCT Hemi CP 3.5 to
10 y
HABIT 10 Regular
therapy
10
Hemi indicates hemiplegia; DB, double-blind; SB, single-blind; PT, physiotherapy; FU, forced use.
a 2CP indicates two other subtypes of CP other than hemiplegia. (1 triplegia, 1 quadriplex.)
Systematic Reviews' Characteristics and Methods

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Review InterventionPopulation Included Studies Meta-
analysis
Clinical Inference
Leanne Sakzewski
et al
UL
intervention
CP RCTs (n = 4), non-
RCTs (n = 44)
Best evidence for OT
and small treatment
effects; growing evidence
for BoNT-A to improve
UL function
Marina de Brito et
al
NDT Neurological
diagnosis
(0–18 y)
RCTs (n = 17) Reported benefits of
NDT
Significant group
variability across
studies and use of
different outcome
measures measures
Wasiak et al4 BoNT-A CP (0–19 y) RCTs (n = 2)
Roslyn Boyd et al
Nava Gelkop et al
OT
UL and
lower-limb
CP (<19 y)
CP
Efficacy studies
(RCTs, pre-post or
time series)
Systematic reviews
(n = 5)
Reflecting variability of
interventions, outcome
measures, and
methodologic quality of
included studies
casting and splinting
evidence for effect of
UL function
BoNT-A
CIMT,
forced-use
therapy
Hemiplegia (0–
19 y)
RCTs, controlled
clinical trials
Significant treatment
effect in single
Gordon et al CP (n = 3) trial and positive
concluded with evidence
CIMT should remain in
clinical trials
Data Synthesis

24. 23
For the management of data and its analysis RevMan 5.0 was put to use summary was made of the
outcomes and consistent measurement scales, by using means, effect sizes, ESs, and 95% confidence
intervals, CIs, for each of the study. ESs 0.2 was taken as small, while 0.4 to 0.6 as moderate and large
was 0.8. Standardized mean differences (SMDs) with 95% CIs were calculated; for meta-analysis and
for comparison mean differences (SMDs) with 95% CIs were calculated. In the case of pool treatment
effects, a fixed effect model was used. By I2 statistic the Heterogeneity was evaluated.
Results
Systematic reviews-6, and RCTs of therapeutic UL interventions confirmed the criteria of inclusion,
while one systematic review and seven trials were excluded (for reasons Fig.1).
For quality of UL movement the NDT meta-analysis gave medium treatment effect, besides little effect
to enhance acquisition of fine motor skills. Various age groups were targeted by all studies, hence
different results that those children with older age might have better response to intensive NDT
including casting than the younger ones. But irrespective of the type and intensity directed in achieving
goals the UL training might be good for the child and the family with significant changes in the
performance of the child.

25. 24
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