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Forced Use Treatment of Childhood Hemiparesis

John K. Willis, MD^*, Ann Morello, LOTR, Anita Davie, PT, Janet C. Rice, PhD^|| and James T. Bennett, MD^¶

^* Department of Psychiatry and Neurology, Tulane University School of Medicine, New Orleans, Louisiana
Tulane Occupational Therapy, New Orleans, Louisiana
Tulane Physical Therapy, New Orleans, Louisiana
^|| Tulane Biostatistics and Epidemiology, New Orleans, Louisiana
^¶ Tulane Orthopaedic Surgery, New Orleans, Louisiana

	ABSTRACT

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Objective. Forced use, or constraint-induced, movement therapy has shown some efficacy in the rehabilitation of adults with chronic hemiparesis as a result of stroke. We used restraint of the unimpaired arm to ascertain whether this would improve function of the paretic arm in children with chronic (>1 year) hemiparesis.

Methods. Twelve hemiparetic treatment children (age 1–8 years) received a plaster cast on the unimpaired arm for 1 month; 13 hemiparetic control children did not. Peabody Developmental Motor Scales (PDMS) were performed on all treatment and control children immediately before and after casting and again 6 months later when controls crossed over to receive casts. Thus, PDMS were performed at entry, then 1 month, 6 months, and 7 months after entry. Any noted change in functional ability was also elicited by parental report. The frequency of visits to physical and occupational therapy was recorded.

Results. The 12 treatment (casted) children improved 12.6 PDMS points after 1 month of casting; the 13 control children improved 2.5 points. Improved PDMS scores persisted 6 months later when 7 treatment children returned. Similar results were obtained in the crossover when 10 control children received casts. Parental report corroborated improvement in casted children (22 of 22 parents) and its persistence at follow-up (21 of 22 parents). Receiving ongoing physical/occupational therapy did not seem to account for these results: control children received more (2.1 visits/wk) than treatment children (1.4 visits/wk).

Conclusions. Forced use can be an effective rehabilitation technique in children with chronic hemiparesis.

Key Words: hemiplegia • cerebral palsy • rehabilitation

Abbreviations: PDMS, Peabody Developmental Motor Scales • ANOVA, analysis of variance

	INTRODUCTION

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Methods to rehabilitate patients with hemiparesis as a result of stroke and other lesions have been described at least since 1915, when massage, passive movement, and the encouragement of voluntary extension were reported to be useful in adults with long-standing hemiplegia.¹ The observation that monkeys used a deafferentated arm only after restraint of the intact arm prompted the first forced use study: 25 hemiplegic adults showed persistent improvement in upper extremity function after restraint of the intact arm for 2 weeks.² Extensive subsequent work has shown the general applicability of "constraint-induced movement therapy": adults rendered chronically hemiparetic by stroke have consistently shown improved upper extremity function with restraint of the intact arm and intensive training of the paretic arm.^3,4 Plasticity and cerebrocortical reorganization may explain this reversal of "learned nonuse."^2,5–7 A single case report suggests that forced use may be useful in children with hemiparetic cerebral palsy.⁸ Expecting a greater potential in early life for cerebral reorganization and plasticity, the presumed mechanisms to explain out data,^9–11 we performed a controlled forced use study with 25 children who experience chronic hemiparesis.

	METHODS

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After approval by the Tulane University Institutional Review Board and written informed consent from a parent or guardian, we recruited 25 children (ages 1–8 years) with chronic hemiparesis (>1 year) as a result of static brain lesions (13 stroke, 6 cerebral malformation, 2 trauma, 4 unknown). The inclusion criteria were presence of a hemiparesis (documented by neurologic examination by the first author, J.W.) for at least 1 year and age from 1 to 8 years. Children who could not cooperate for testing were to be excluded; this occurred only once. Subjects were randomized into 2 groups, treatment and control. The randomization sequence was TCTCCCTTTCTTCTCTTTCCTCCCC. The randomization placed all treatment subjects from ages 3 to 6 years (3 years: 2 subjects, 4:4, 5:2, 6:4) and most control subjects from ages 1 to 2 years (1 year:2, 2:6, 4:1, 5:1, 7:1, 8:2). Because of the variability, however, the differences between these groups was not significant (see "Results" section).

The paretic arm of all 25 children was assessed at entry into the study with the Peabody Developmental Motor Scales (PDMS); a fine motor quotient was obtained, excluding all bimanual tasks. PDMS were performed by licensed physical and occupation therapists (A.D., A.M.). They were not blinded as to subject group. The PDMS was chosen because of its large normative sample, appropriateness for age, ease of administration, and correlation with the results of related assessments.^12–16

The treatment group (n = 12) then immediately received on the unaffected arm a plaster cast that extended from just below the elbow to the fingertips; this cast was left in place for 1 month and repaired as needed. The controls received no additional intervention. All subjects continued their routine visits to occupational and physical therapy; no effort was made to change their routines. After 1 month, the cast was removed from the treatment group and both groups again were assessed with PDMS.

Six months later, 17 subjects (7 treatment, 10 control) returned, at which time all again received PDMS. The control group then received identical casting of the unaffected arm for 1 month, and the treatment group received no intervention, after which both groups again were assessed with PDMS.

By telephone inquiry, we interviewed the parents of all 22 children who received a cast and asked the following: 1) Did the cast produce improved use of the paretic arm in daily living? 2) Did some improvement persist? A "yes" or "no" answer was obtained for each question.

We ascertained the number of visits per week to physical and occupational therapists for each subject during the time of the protocol. All such visits were stated to last 30 to 60 minutes.

Statistical analysis was performed for a 2-period crossover study. We rejected the hypothesis of no carryover from period 1 to period 2 and analyzed the first phase of the experiment (12 treatment, 13 control) using 2-factor analysis of variance (ANOVA) with repeated measures on the time factor. For analyses involving more than 2 times, we corrected the P values for violation of the sphericity assumption.

	RESULTS

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At entry into the study, the mean PDMS score of the paretic arm for the treatment group (n = 12) was 143.2; after 1 month of casting, the mean PDMS score was 155.8. For the control group (n = 13), the mean PDMS score was 102.2 at entry and 104.7 after 1 month. The group by time interaction was significant (F = 29.17; df = 1, 23; P < .0001; Fig 1).

View larger version (12K): [in this window] [in a new window]   Fig 1. Effect of casting the unimpaired arm for 1 month on mean PDMS score of the impaired arm. , treatment group (casted, n = 12); O, control group (not casted, n = 13). The treatment group improved significantly compared with controls (P < .0001).

We conducted several different analyses to assure ourselves that age effects were not confounded with the treatment effect. These include inclusion of age as a stratifying factor in the ANOVA, exclusion of the children aged 1 or 2 years, and inclusion of age as a covariate in the ANOVA. All 3 approaches yielded similar results that are consistent with the original findings.

For those initial treatment subjects who returned 6 months later to complete the crossover (n = 7 to be controls in the second period), mean PDMS scores were 140.0 precast, 153.9 postcast, 149.4 as controls 6 months later, and 155.9 after 1 month without intervention. The effect of the casting was still present 6 months later.

The apparent regression in the PDMS scores of the treatment group 6 months after casting was not significant: Newman-Keuls post hoc procedures show no significant difference between the second and third means. The apparent gain seen between the third and fourth means likewise is not significant. In addition, the difference between the first and third means is significant (P < .05): performance remains better than that at baseline.

For those initial control subjects who returned for casting 6 months later (n = 10), mean PDMS scores were 111.7 at entry, 114.4 after 1 month without intervention, 112.8 before casting 6 months later, and 124.3 after 1 month wearing a cast on the unaffected arm. There was very little change until after casting (Fig 2). The before-and-after differences for the control group casted during the second period of the study were significant (F = 13.64, df = 1, 9; P = .005).

View larger version (11K): [in this window] [in a new window]   Fig 2. Mean PDMS scores for subjects who completed both periods of study (n = 17). , treatment group, casted in first period (n = 7); O, control group, casted in second period 6 months later (n = 10). There was little change before casting. Casting effects remained 6 months later. Standard errors of individual means in order were as follows: treatment—12.3, 12.4, 12.9, 12.9; control—24.4, 29.8, 29.1, 28.0. The ANOVA removes the factor of variability among subjects, however, and the standard error used in the analysis is 1.78.

Frequency of visits to physical and occupational therapy did not seem to account for the results: the control group had a greater mean number of visits per week, 2.1, compared with the treatment group’s 1.4 visits per week.

There were no medical complications to casting. Several parents withdrew their children from the study and had the casts removed because of their children’s irritability and/or complaints about wearing the cast. Approximately 15% of casts required repair or reapplication before the end of the month.

	DISCUSSION

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Cerebral palsy affects 1.2 in 1000 children; 17% of children who have cerebral palsy and were preterm at birth and 56% who were term experience a hemiparesis.¹⁷ Stroke and other neurologic insults in childhood add to these numbers.

Forced use alone results in improvement in chronically hemiparetic adults after stroke.² The addition of intensive therapy, "constraint-induced movement therapy," produces greater improvement.³ We found improvement in children with chronic hemiparesis employing forced use without other interventions. Although each subject did receive his or her routine physical and occupational therapy, the initial controls received more, suggesting that this did not account for improvement in the treatment group. Cerebrocortical reorganization seems to account for the therapeutic effect in adults who receive constraint-induced movement therapy for chronic hemiparesis.⁷ Our data demonstrate improvement in the function of the hemiparetic upper extremity after 1 month of forced use in children.

	ACKNOWLEDGMENTS

 
We acknowledge the financial and logistic support of Dr Leon Weisberg, Chairman, Division of Neurology, Department of Psychiatry and Neurology, Tulane University School of Medicine, without whom this work could not have been accomplished.

	FOOTNOTES

 
Received for publication Aug 1, 2001; Accepted Jan 22, 2002.

Reprint requests to (J.K.W.) Department of Psychiatry and Neurology, HC82, Tulane University School of Medicine, 1430 Tulane Ave, New Orleans, LA 70112. Email: jwillis{at}tulane.edu

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