Published online May 18, 2009
PEDIATRICS Vol. 123 No. 6 June 2009, pp. e1111-e1122 (doi:10.1542/peds.2008-3335)
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REVIEW ARTICLE

Systematic Review and Meta-analysis of Therapeutic Management of Upper-Limb Dysfunction in Children With Congenital Hemiplegia

Leanne Sakzewski, BOccThya,b, Jenny Ziviani, PhD, MEd, BA, BAppScOTc and Roslyn Boyd, PhD, MSc(Physiotherapy)a,b

a Queensland Cerebral Palsy and Rehabilitation Research Centre, School of Medicine
c School of Health and Rehabilitation Sciences, University of Queensland, Brisbane, Australia
b Brain Research Institute, Melbourne, Victoria, Australia

CONTEXT. Rehabilitation for children with congenital hemiplegia to improve function in the impaired upper limb and enhance participation may be time-consuming and costly.

OBJECTIVES. To systematically review the efficacy of nonsurgical upper-limb therapeutic interventions for children with congenital hemiplegia.

METHODS. The Cochrane Central Register of Controlled Trials, Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), AMED (Allied and Complementary Medicine), Embase, PsycINFO, and Web of Science were searched up to July 2008. Data sources were randomized or quasi-randomized trials and systematic reviews.

RESULTS. Twelve studies and 7 systematic reviews met our criteria. Trials had strong methodologic quality (Physiotherapy Evidence Database [PEDro] scale ≥ 5), and systematic reviews rated strongly (AMSTAR [Assessment of Multiple Systematic Reviews] score ≥ 6). Four interventions were identified: intramuscular botulinum toxin A combined with upper-limb training; constraint-induced movement therapy; hand-arm bimanual intensive training; and neurodevelopmental therapy. Data were pooled for upper-limb, self-care, and individualized outcomes. There were small-to-medium treatment effects favoring intramuscular botulinum toxin A and occupational therapy, neurodevelopmental therapy and casting, constraint-induced movement therapy, and hand-arm bimanual intensive training on upper-limb outcomes. There were large treatment effects favoring intramuscular botulinum toxin A and upper-limb training for individualized outcomes. No studies reported participation outcomes.

CONCLUSIONS. No one treatment approach seems to be superior; however, injections of botulinum toxin A provide a supplementary benefit to a variety of upper-limb–training approaches. Additional research is needed to justify more-intensive approaches such as constraint-induced movement therapy and hand-arm bimanual intensive training.

Key Words: cerebral palsy • systematic review • meta-analysis • upper-limb rehabilitation

Abbreviations: CP—cerebral palsy • UL—upper limb • OT—occupational therapy • BoNT-A—botulinum toxin A • CIMT—constraint-induced movement therapy • RCT—randomized, controlled trial • HABIT—hand-arm bimanual intensive training • NDT—neurodevelopmental treatment • PEDro—Physiotherapy Evidence Database • AMSTAR—Assessment of Multiple Systematic Reviews • CI—confidence interval • ES—effect size • SMD—standardized mean difference • QUEST—Quality of Upper Extremity Skills Test • PFMS—Peabody Fine Motor Scales • COPM—Canadian Occupational Performance Measure • GAS—Goal Attainment Scale • PEDI—Pediatric Evaluation of Disability Inventory • BOTMP—Bruininks-Oseretsky Test of Motor Proficiency

Accepted Jan 30, 2009.


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