Evidence-Based Practice Report: Cerebral Palsy Interventions

This report critically evaluates three evidence-based practices for the treatment of cerebral palsy (CP). The first article reviewed focuses on intensive upper limb therapy approaches, comparing constraint-induced movement therapy and bimanual training, highlighting their effectiveness in improving upper limb function, particularly in school-aged children. The second article discusses evidence-based diagnosis, healthcare, and rehabilitation for children with CP, emphasizing the importance of standardized motor assessments and recommending interventions such as child-active rehabilitation, behavioral interventions, and contracture management. The third article examines the effectiveness of virtual reality rehabilitation, demonstrating its positive impact on balance, upper extremity skills, and motor skills, suggesting its potential to enhance daily living activities. The report interprets these findings to suggest that occupational therapists can effectively utilize bimanual arm training, constraint-induced movement therapy, contracture management, and virtual reality rehabilitation to improve the quality of life for individuals with CP. These interventions are shown to improve motor skills, enhance physical, social, and cognitive abilities, and provide patients with a sense of accomplishment.

Running head: EVIDENCE BASED PRACTICE
Evidence based practice- Cerebral Palsy
Name of the Student
Name of the University
Author Note

1EVIDENCE BASED PRACTICE
Cerebral palsy (CP) refers to the incidence of neurological disorders, caused due to non-
progressive injury of the brain injury or malformations of the brain among children. It is usually
manifested by the loss of motor functions, cognitive impairment, poor coordination, weak and
stiff muscles, tremors and difficulty in swallowing, speaking and other sensations. CP can be of
different types and completely hinder the ability of the patient to perform daily tasks and live
independently. Thus, occupational therapy is practiced in order to reduce muscle stiffness,
spasticity, improve muscle tone, and enhance coordination and balance among the patients.
Evidence-based practice refers to integration of clinical expertise with best available research
and patient values while making decisions related to patient care. This report will critically
evaluate 3 evidence-based practices on cerebral palsy. It will interpret the results to suggest the
intervention that should be followed by occupational therapists.
Article 1
Title- The State of the Evidence for Intensive Upper Limb Therapy Approaches for
Children with Unilateral Cerebral Palsy
Summary- This article aimed to review the scientific rationale that underpinned these
treatments that will assist in improving the upper limb outcomes of the patients. The review
compared 8 studies that focused on constraint-induced movement therapy, 1 on hand-arm
bimanual training, and 2 on hybrid therapy with control groups that received less therapy. It
revealed that constraint-induced movement therapy was mainly used as an intervention among
students who were aged between 2-16 years. The comparison showed that the intervention
demonstrated significant and clinically beneficial effects on older children. However, no
significant differences were observed in terms of health gains between different methods of
restraint. The review showed that Short-length, high-duration therapies were carried out for a
period of 2-4 weeks and the frequency ranged from 2-7 sessions per week. It suggested that the
constraint-induced therapy was applied primarily on school-aged children, and this led to
individualization of the program. The findings further suggested that there was a gain in upper
limb function on application of this therapy. On directly comparing, the home-based approach
showed greater gains among the sample at a time period of 3 months, post-intervention. Thus, it
established that constraint-induced movement therapy was far superior to the usual care practices
in terms of improving quality and efficiency of impaired upper limb movement (Sakzewski,
Gordon & Eliasson, 2014).
Data showed that use of non-removable devices such as castings resulted in larger
intensity of unstructured training, in addition to creating a burden on the child. Several adverse
events and discomfort among children were reported, related to the use of wearing a restraint by
the studies that had been evaluated. Further, the review provided evidences that HABIT
improved the quality and amount of impairment in upper limb during bimanual tasks. In addition
to retaining the intensive constraint induced practice, it engaged the child to a greater extent in
bimanual activities. Direct comparison between the 2 approaches showed less significant
differences between them in upper limb outcome improvement.
Interpretation- Thus, it can be interpreted that although there was lack of knowledge
related to the feasibility of the therapy in different environmental contexts, bimanual training and
constraint-induced movement therapy result in significant improvements in spatio-temporal
coordination. They increase goal identification by the caregivers and work best for children

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suffering from unilateral cerebral palsy. The intensive practices using the affected hands will
promote arm functioning and help in reducing the functionally disabling symptoms.
Article 2
Title- Evidence-Based Diagnosis, Health Care, and Rehabilitation for Children With
Cerebral Palsy
Summary- This study was based on an informal social-media survey that solicited the
views of parents, who had children suffering from cerebral palsy on working in collaboration
with neurologists. Systematic reviews formed the best-available evidence and were used to
design knowledge translation products. The survey results revealed that parents faced difficulties
in locating neurologist who specialized in cerebral palsy. Evidences suggested that standardized
motor assessment, Hammersmith infant evaluation, and neuroimaging were the best diagnostic
practices. The recommended evidence based interventions were child-active rehabilitation
approaches, health and secondary prevention approaches and compensatory and environmental
adaptation approaches. The findings suggested that behavioral interventions, positive behavior
support, and positive parenting are some of the compensatory environmental approaches that
help carers to improve adaptive behavior among children. Further, the evidences supported the
use of cognitive behavior therapy, contracture management, robotic training, functional skill
management, and spasticity management as effective interventions for children who suffered
from either diplegic or quadriplegic bilateral cerebral palsy (Novak, 2014).
Moreover, effective rehabilitation interventions included learning-based approaches for
improving the gains of motor and functional skills. They supported the use of constraint-induced
movement therapy, bimanual therapy, goal directed training programs and occupational therapy
on use of botulinum toxin for promoting the health and limb strength of cerebral palsy children.
The findings further suggested that electric stimulation of muscles using a skin electrode will
help in inducing passive muscle contraction and will lead to muscle strengthening and motor
activation. The findings were also in support of the effectiveness of functional skill performances
by the use of context focused therapy that had a compensatory and environmental approach.
Interpretation- Thus, it can be interpreted from the above research study that contracture
management can be an effective therapy as joint contractures are observed among children
suffering from spastic cerebral palsy and leads to loss of joint movement due to permanent
shortening of muscles. Joint stretching and mobilization will help in maintaining elasticity of the
joints and will also reduce the severity of the contractures. Furthermore, the intervention of
constraint-induced movement therapy and bimanual training will also help children with cerebral
palsy to learn how to use both their hands to complete their daily activities.
Article 3
Title- Effectiveness of virtual reality rehabilitation for children and adolescents with
cerebral palsy: an updated evidence-based systematic review
Summary- This systematic review focused on comprehensive literature search and tried to
find the effectiveness of virtual reality rehabilitation on the treatment of cerebral palsy. A total of
31 articles were included in the review. They comprised of 5 single-subject designs, 7 case
studies, 11 pre-test and post-test designs and 8 RCTs. The results revealed that an improvement

3EVIDENCE BASED PRACTICE
in balance outcome was observed on application of the virtual reality rehabilitation technique.
There was also an increase observed in the Berg Balance Scale. On combining the intervention
with neuro-developmental treatment, an improvement was also observed in the Wii-based group.
Upper extremity skill improvements were demonstrated by 12 studies (including 1 RCT).
Evidences suggested a 9-13% improvement in arm functioning among two children on
application of bilateral arm training. Further, the increase in gross motor function measure was
supported by several studies. Evidences also demonstrated an improvement in shoulder flexion
and abduction among the recruited participants.
An improvement of lower extremity functions and gait parameters were observed by 2
out of the 4 non-randomized trials that had been included in the study. The outcomes and
effectiveness of virtual therapy on enhancement of motor skills were evaluated by 21 studies
(including 4 RCT). 3 RCTs showed a positive effect on motor skills. Furthermore, significant
evidences were found. Another study found improvement in trunk-to-pelvis coupling, in
combination with virtual therapy. The daily activities were found to improve among the
participants. In addition, neuroplastic changes were found associated with improvement in self-
feeding, reaching and dressing activities. The enrolled children exhibited straighter, smoother
and faster reaches on application of the intervention. Thus, the evidences suggested that virtual
reality therapy was capable of maximizing the arm functioning among children while performing
activities that are related to daily living (Ravi, Kumar & Singhi, 2017).
Interpretation- Thus, it can be interpreted that virtual reality rehabilitation intervention
will help children with cerebral palsy achieve the highest level of independence and will show
significant improvements in daily activities. It uses a plethora of technologies that include input
devices, displays and VR platforms that target the specific disabilities and impairments among
the patients and tailors them to their specific abilities. This rehabilitation program will reduce the
child’s awareness of the traumatic symptoms and will increase motivation, which will finally
improve their motor and cognitive skills. Thus, this intervention can be used by occupational
therapists to treat cerebral palsy patients.
To summarise, it can be stated that occupational therapy is an essential part of the
treatment of people who suffer from CP. It emphasizes on the daily life of those patients and
promotes their abilities to perform daily tasks in a way that will improve their quality of life.
This will also assist them in independent living. It can be conclude from the aforementioned
evidence based studies that bimanual arm training, constraint-induced movement therapy,
contracture management and virtual reality rehabilitation have shown significant improvements
among children and adolescent suffering from CP. They have shown skill recovery, fine motor
skill improvements, and enhancement of physical, social or cognitive abilities. The evidences
have also supported their role in boosting self-esteem, confidence, increasing independence, and
providing them with a sense of accomplishment. Thus, an occupational therapist can use these
techniques in real-time in order to improve the quality of life of cerebral palsy patients.

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References
Novak, I. (2014). Evidence-based diagnosis, health care, and rehabilitation for children with
cerebral palsy. Journal of child neurology, 29(8), 1141-1156. Retrieved from:
https://www.aacpdm.org/UserFiles/file/IC172.pdf
Ravi, D. K., Kumar, N., & Singhi, P. (2017). Effectiveness of virtual reality rehabilitation for
children and adolescents with cerebral palsy: an updated evidence-based systematic
review. Physiotherapy, 103(3), 245-258. Retrieved from:
file:///C:/Users/user/AppData/Local/Temp/1873217_247596947_1870881_1600614969_
10.1016j.ph-1.pd
Sakzewski, L., Gordon, A., & Eliasson, A. C. (2014). The state of the evidence for intensive
upper limb therapy approaches for children with unilateral cerebral palsy. Journal of child
neurology, 29(8), 1077-1090. Retrieved from:
file:///C:/Users/user/AppData/Local/Temp/1873216_1856242192_1870883_1405368748
_sakzewski20.pdf