Terapia de movimento induzido por restrição do membro superior de crianças com paralisia cerebral na prática clínica: uma revisão sistemática da literatura

Autoria SCIMAGO INSTITUTIONS RANKINGS

Este estudo se propôs a realizar uma revisão sistemática da literatura para investigar como e com que modificações ou adaptações a terapia de movimento induzido por restrição tem sido empregada na prática clínica para intervenções terapêuticas em crianças com paralisia cerebral. As pesquisas foram conduzidas do portal periódico da CAPES (Agência brasileira de amparo), e dos bancos de dados Pubmed, Bireme, Science Direct, Scielo e PEDro para artigos relevantes publicados entre janeiro de 2010 e maio de 2016. Os artigos obtidos foram avaliados, quantificados e qualificados por dois revisores anônimos usando a Base de Dados em Evidências em Fisioterapia. As pesquisas levaram para a recuperação de 102 artigos, 12 dos quais foram incluídos nesta revisão sistemática. Uma tabela foi criada contendo informações sobre os grupos de estudo, critérios de inclusão, intervenção, frequência de intervenção, dificuldades encontradas, avaliações e resultados. Foi encontrada uma variedade considerável nos modelos de intervenção terapêutica. Os resultados desta revisão demonstram que a terapia de movimento induzido por restrição na prática clínica pediátrica não é empregada na sua forma original. Embora os estudos analisados não tenham uma metodologia comum em relação ao uso deste tipo de terapia, o método foi adaptado com flexibilidade considerável, fornecendo resultados promissores e positivos sobre a intervenção terapêutica do parético membro superior em crianças com paralisia cerebral.

Descritores:
Paralisia Cerebral; Extremidade Superior; Hemiplegia; Imobilização; Movimento

Reference		Item
Reference		Eligibility	1 - Randomized allocation	2 - Allocation concealment	3 - Similar prognosis	4 - Blinding of participants	5 - Blinding of therapists	6 - Blinding of examiners	7 - Outcome measures	8 - Intention to treat	9 - Inter-group comparisons	10 - Variability and precision	Score
1	Aarts PB. et al.(¹⁷)	1	1	0	1	0	0	1	1	0	1	1	6/10
2	Aarts PB. et al.(¹⁸)	1	1	0	1	0	0	1	1	0	1	1	6/10
3	Brandão MB. et al.(¹⁹)	1	1	1	1	0	0	0	1	0	1	1	6/10
4	Brandão MB. et al.(²⁰)	1	1	1	1	0	0	1	1	1	1	1	8/10
5	Chen HC.et al.(²¹)	1	1	1	1	0	0	1	1	0	1	1	7/10
6	Chen CL.et al.(²²)	1	1	0	1	0	0	1	1	0	1	1	6/10
7	Choudhary A. et al.(²³)	1	1	1	1	0	0	1	1	1	1	1	8/10
8	Hsin YJ. et al.(²⁴)	1	1	1	1	0	0	1	1	0	1	1	7/10
9	Sakzewski L et al.(²⁵)	1	1	1	1	0	0	1	1	1	1	1	8/10
10	Sakzewski L et al.(²⁶)	1	1	1	1	0	0	1	0	0	1	1	6/10
11	Case-Smith J. et al.(²⁷)	1	1	0	1	0	0	1	1	0	1	1	6/10
12	Wallen M. et al.(²⁸)	1	1	0	1	0	0	1	1	1	1	1	7/10

Reference	Groups	Inclusion criteria	Intervention	Intervention frequency	Evaluations	Difficulties encountered
Aarts PB et al.(¹⁷)	n = 52 (2 dropouts) CIMT-BIT = 28 Control = 22	2.5 to 8 years CP with unilateral, bilateral or severely asymmetrical impairment MACS I, II or III	Both groups provided with games and functional activities CIMT-BIT: Unimanual activities with affected limb in first 6 weeks with unaffected limb constrained in sling; goal-oriented bimanual activities in last 2 weeks Control: Conventional therapy involving goal-oriented activities with affected limb; training performed at home and school by parents and teachers	CIMT-BIT: 8 weeks x 3 sessions/week x 3 hr = 72 hr (at rehabilitation center) Control: 8 weeks x 2 sessions/week x 1 hour = 12 hr (at rehabilitation center); 8 weeks x 7.5 hr/week = 60 hr (at home)	Primary outcomes: Assisting Hand Assessment (AHA) ABILHAND-KIDS Secondary outcomes: Melbourne Assessment of Unilateral Upper Limb Function (MUUL) Canadian Occupational Performance Measure (COPM) Goal Attainment Scaling (GAS)	Two children withdrawn from control group due to family circumstances after randomization, impeding true intention-to-treat analysis
Aarts PB et al.(¹⁸)	n = 50 CIMT-BIT = 28 Control = 22	2.5 to 8 years CP with unilateral, bilateral or severely asymmetrical impairment MACS I, II or III	Both groups provided with games and functional activities CIMT-BIT: Unimanual activities with affected limb in first 6 weeks with unaffected limb constrained in sling; goal-oriented bimanual activities in last 2 weeks Control: Conventional therapy involving goal-oriented activities with affected limb; training performed at home and school by parents and teachers	CIMT-BIT: 8 weeks x 3 sessions/week x 3 hr = 72 hr (at rehabilitation center) Control: 8 weeks x 2 sessions/week x 1 hour = 12 hr (at rehabilitation center); 8 weeks x 7.5 hr/week = 60 hr (at home)	Determine Developmental Disregard module of Video Observations Aarts and Aarts, (VOAA-DDD) Active and passive range of motion of wrist and elbow (goniometer)	Two children withdrawn from control group due to family circumstances after randomization, impeding true-to-treat analysis
Brandão MB et al.(¹⁹)	n = 16 CIMT = 8 HABIT = 8	3 to 10 years Hemiparesis with difference of at least 50% between limbs on timed motor tasks of Jebsen-Taylor Hand Function Test Wrist extension capacity at least 20°; fingers with 10° of complete flexion Normal cognitive skills	Both groups provided with games, fine and gross motor activities (individual and group activities) CIMT: Unimanual activities involving affected limb with unaffected limb constrained in sling, complemented with unimanual or bimanual practice of activities of daily living and games at home HABIT: Bimanual activities in accordance with appropriate age, complemented with unimanual or bimanual practice of activities of daily living and games at home	CIMT: 15 days x 6 hr./day = 90 hr. (rehabilitation center); 15 days x 1 hr./day = 15 hr. (at home) HABIT: 15 days x 6 hr./day = 90 hr (rehabilitation center); 15 days x 1 hr/day = 15 hr (at home)	Pediatric Evaluation of Disability Inventory (PEDI) Canadian Occupational Performance Measure (COPM)	Not possible to administer COPM directly to children since some participants were too young to understand the content of the questionnaire and provide a reliable result.
Brandão MB et al.(²⁰)	n = 16 (1 dropout) Intervention = 8 Control = 7	4 to 8 years Spastic hemiparetic CP Understand verbal commands Execute proposed activities	Intervention: Unimanual fine motor tasks involving affected limb in first 2 weeks with unaffected limb constrained in sling during therapy and at home (total: 10 h); routine daily bimanual activities during last week Control: Conventional therapy with functional activities, bimanual activities and sensory stimulation	Intervention: 2 weeks x 5 sessions/week x 3 hr = 30 hrs; 1 week x 3 sessions/day x 45 min = 11 hr 15 min Control: 3 weeks x 1 session/week x 45 min = 2 hr 15 min	Jebsen-Taylor Hand Function Test (JTHF) Pediatric Evaluation of Disability Inventory (PEDI)	One child in control group interrupted study due to family problems.
Chen HC et al.(²¹)	n = 48 (3 dropouts) Home CIT = 23 Traditional rehabilitation (TR) = 22	6 to 12 years Spastic unilateral CP Considerable non-use of affected limb Wrist and MCP joints ≥ 10º Absence of excessive muscle tone in affected limb	Both groups received individualized at-home intervention with functional activities Home-Based CIT: Unimanual activities involving affected limb with unaffected limb constrained by elastic band and mitt; encouraged by parents to perform daily functional activities with affected limb TR: Guided unimanual and bimanual activities; encouraged by parents to perform daily functional unilateral and bilateral activities	Home-Based CIT: 4 weeks x 2 sessions/week x 3.5 to 4 hr = 32 hr TR: 4 weeks x 2 sessions/week x 3.5 to 4 hr = 32 hr	Primary outcomes Bruininks-Oseretsky Test of Motor Proficiency (BOTMP) Peabody Developmental Motor Scales, Second Edition (PDMS-2) Secondary outcomes Functional Independence Measure for children (WeeFIM) Kinematic and clinical evaluations	One child in TR group unable to complete follow-up due to family schedule and lack of transportation to post-intervention evaluation One child in each group excluded due to insufficient motor skills to conclude kinematic evaluation of reaching task
Chen CL et al.(²²)	n = 48 (1 dropout) CIMT = 24 Traditional rehabilitation (TR) = 23	6 to 12 years Unilateral spastic CP Considerable non-use of affected limb (score on PMAL “how often” scale less than 2.5) Wrist and MCP joints ≥ 10º Absence of excessive muscle tone in affected limb (≤ 2 on Ashworth scale)	Both groups received individualized intervention with functional activities CIMT: Unimanual activities involving affected limb with unaffected limb constrained by elastic band and mitt; encouraged by parents to perform daily functional activities with affected limb TR: Guided unimanual and bimanual activities; encouraged by parents to perform daily functional unilateral and bilateral activities	CIMT: 4 weeks x 2 sessions/week x 3.5 to 4 hr = 32 hr TR: 4 weeks x 2 sessions/week x 3.5 to 4 hr = 32 hr	Peabody Developmental Motor Scales, Second Edition (PDMS-2) Pediatric Motor Activity Log (PMAL) Kinematic and clinical evaluations	One child in TR group unable to complete follow-up due to family schedule and lack of transportation to post-intervention evaluation
Choudhary A et al.(²³)	n = 31 (1 dropout) CIMT = 15 Control = 15	3 to 8 years Hemiparetic CP with minimum difference between upper limbs of 10 points on QUEST Understand simple commands Sit without support See objects at distance of 1 m	CIMT: Unimanual reaching activities involving paretic limb with unaffected limb wrapped in triangular bandage Control: Conventional therapy with stretching, strengthening, bimanual activities and practice of activities of daily living	CIMT: 10 days distributed over 4 weeks x 2 h/day = 20 hr (at rehabilitation center) Control: 4 weeks x 20 min/day = 10 hr (at home)	Primary outcomes Quality of Upper Extremity Skills Test (QUEST) Secondary outcomes QUEST score Nine-hole pegboard	One patient in CIMT group received 5 supervised intervention sessions, but did not return for scheduled visits afterward.
Hsin YJ et al.(²⁴)	n = 22 CIMT = 11 Control = 11	6 to 8 years Spastic unilateral CP Considerable non-use of affected limb (score on PMAL “how often” scale less than 2.5) Wrist and MCP joints ≥ 10º Absence of excessive muscle tone in affected limb (≤ 2 on Ashworth scale)	Both groups received individualized intervention with functional activities at home CIMT: Unimanual activities involving affected limb with unaffected limb constrained by elastic bandage and mitt; encouraged by parents to perform daily functional activities with affected limb Control: Guided unimanual and bimanual activities; encouraged by parents to perform daily unimanual and bimanual functional activities	CIMT: 4 weeks x 2 sessions/week x 3.5 to 4 hr = 32 hr Control: 4 weeks x 2 sessions/week x 3.5 to 4 hr = 32 hr	Primary outcome Subtest 8 - Bruininks-Oseretsky Test of Motor Proficiency (BOTMP) Secondary outcomes Pediatric Motor Activity Log (PMAL) Cerebral Palsy-Specific Quality of Life (CPQOL)	No difficulties described
Sakzewski L et al.(²⁵)	n = 64 (3 dropouts) CIMT = 31 BIT = 30	5 to 16 years Congenital hemipareiss Understand commands Muscle tone of affected limb grade 1 to 3 on Ashworth scale	Both groups provided with fine and gross motor activities, functional reach activities and balance activities in setting with circus theme CIMT: Unaffected limb constrained by mitt during unilateral activities BIT: Guided bimanual activities	6 hr/day x 10 days = 60 hr (daily camping)	Primary outcomes Melbourne Assessment of Unilateral Upper Limb Function (MUUL) Assisting Hand Assessment (AHA) Canadian Occupational Performance Measure (COPM)	Three children did not complete intervention program.
Sakzewski L et al.(²⁶)	n= 53 (9 dropouts) Hybrid-CIMT = 25 Standard Care = 19	5 to 16 years Unilateral CP Understand commands Muscle tone of affected limb grade 1 to 3 on Ashworth scale	Both groups provided with fine and gross motor activities, functional reach activities and balance activities in setting with circus theme Hybrid-CIMT: Unaffected limb constrained by mitt during unilateral activities; bimanual activities performed in second week Standard Care: Bimanual activities; at-home training with parents	Hybrid-CIMT: 6 hr/day x 10 days = 60 hr (daily camping) Standard Care: 1.5 hr/day x 6 days = 9 hr (daily camping) 12 weeks x 6 sessions/week x 30 min = 36 hr (at home)	Primary outcomes MUUL AHA Secondary outcomes COPM JTTHF Box and Block Test Children’s Hand-use Experience Questionnaire (CHEQ)	Six children withdrew from Standard Care group and 3 withdrew from Hybrid-CIMT One child had seizure due to fever during intervention program.
Case-Smith J et al.(²⁷)	n = 18 3-hr = 9 6-hr = 9	3 to 6 years Unilateral CP	Both groups submitted to intensive intervention in natural environment - functional activities, activities of daily living, reaching and sensory perception First 18 days - Unilateral activities involving affected limb with unaffected limb constrained by cast Last 3 days - bimanual activities	3-hr: 4 weeks x 21 days x 3 hr = 63 hr 6-hr: 4 weeks x 21 days x 6 hr = 126 hr (performed in three different clinical settings)	Assisting Hand Assessment (AHA) Quality of Upper Extremity Skills Test (QUEST) Pediatric Motor Activity Log (PMAL)	One child in 3-hr group and two in 6-hr group did not undergo six-month follow-up evaluation due to scheduling difficulties.
Wallen M et al.(²⁸)	n = 50 CIMT = 25 Intensive occupational therapy (IOT) = 25	1.5 to 8 years Spastic hemiparetic CP 10º wrist and finger extension of affected limb Functional passive range of motion of affected limb Cooperation	Both groups provided with functional and play activities CIMT: Unilateral activities involving affected limb with unaffected limb constrained by mitt IOT: Bimanual activities complemented with at-home program supervised by parents	8 weeks x 7 sessions/week x 2 hr = 112 hr	Primary outcomes Canadian Occupational Performance Measure (COPM) Secondary outcomes Goal Attainment Scaling(GAS) Assisting Hand Assessment (AHA) Pediatric Motor Activity Log (PMAL) Modified Tardieu Scale (MTS) Ashworth	No difficulties described

Reference	Outcomes
Aarts PB et al.(¹⁷)	Improvements on AHA and ABILHAND-KIDS in both groups, with slight diminishment at follow-up; Improvements on Melbourne, COPM and GAS in both groups, with increased improvement at follow-up
Aarts PB et al.(¹⁸)	“Capacity” and “performance” scores on VOAA-DDD increased, whereas “development” score remained stable in CIMT-BT group; No improvement in scores of Control group after intervention, but improvement in “performance” at follow-up; No significant improvements in active or passive range of motion in either group
Brandão MB et al.(¹⁹)	Improvements in “self-care”, “independence” (PEDI), “performance” and “satisfaction” (COPM) in both groups
Brandão MB et al.(²⁰)	No significant improvement on JTHF test in either group; Significant improvements in functional abilities and independence (PEDI) in both groups at post-intervention and follow-up evaluations
Chen HC et al.(²¹)	Improvements on “grasping” subscale (PDMS-2), subtest 8 (BOTMP), “self-care” subscale (WeeFIM), kinematic analyses of reach and grasping in both groups at post-intervention and both follow-up (3 and 6 months) evaluations
Chen CL et al.(²²)	CIMT group demonstrated significant improvement on “grasping” subscale (PDMS-2), quality/quantity of hand use (PMAL), reaction time, normalized movement time and peak velocity in comparison to TR group.
Choudhary A et al.(²³)	CIMT group demonstrated significant improvement in QUEST score and time required to complete nine-hole pegboard test in comparison to Control, with difference persisting at both follow-up evaluations ( 4 and 8 weeks).
Hsin YJ et al.(²⁴)	Improvements on BOTMP subtest 8 in both groups at post-intervention and 3-month follow-up evaluations; Improvement on PMAL in both groups, with CIMT group demonstrating greater quality/quantity of hand use than Control group, persisting at 3-month follow up
Sakzewski L et al.(²⁵)	Older children, those with left-side hemiparesis and those with poorer manual function benefitted more from therapy. Better effect on MUUL in CIMT group than BIT group; More changes in AHA in BIT group than CIMT group
Sakzewski L et al.(²⁶)	Significant improvements in “satisfaction”, “performance” (COPM) and dexterity (BBT and JTTHF) in both groups; Significant gains in AHA in Standard Care group at 26-week follow-up evaluation
Case-Smith J et al.(²⁷)	Significant improvements in AHA, PMAL and movement dissociation (QUEST) in both groups
Wallen M et al.(²⁸)	Significant improvements in post-intervention “satisfaction” and “performance” (COPM) in both groups

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