Lithuanian University of Health Sciences Faculty of Medicine Department of Pediatrics Rehabilitation

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Lithuanian University of Health Sciences

Faculty of Medicine

Department of Pediatrics Rehabilitation

Title of Master’s Thesis:

The efficacy of interventions to increase participation of children with cerebral palsy

Author: Sherine Bahrou

Supervisor:

Ph.D., Assoc. Prof. Audrone Prasauskiene

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SUMMARY

Author name: Sherine Bahrou

Research title: The efficacy of interventions to increase participation of children with cerebral palsy. Aim: To determine the efficacy of interventions aimed at increasing the level of participation in children with cerebral palsy.

Objectives:

1. Identify the extent and range of the existing literature on the efficacy of interventions aimed to increase participation of children with cerebral palsy.

2. Systematically review evidence on the impact of rehabilitation interventions on the participation of children with cerebral palsy.

3. Identify gaps in the research and to delineate the future research needs.

Methodology: The systematic review was conducted in line with the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement (PRISMA). The data sources include Medline (PubMed), along with reference lists of relevant reviews and included articles. Study eligibility criteria were studies that assess the efficacy of interventions to increase participation of children with cerebral palsy.

Results: Eleven studies were included in the review. Hand and arm bimanual therapy and constrain-induced movement therapy had positive impact on social participation, while robot-assisted upper-limb therapy didn’t have effect on participation. Studies investigating effect of physiotherapy interventions show equivocal results. Positive results on participations were seen in studies that combined

physiotherapy with context- based therapies and used goal-oriented approach for treatment planning. Conclusion: Child-focused and context-focused interventions to promote participation of children with CP are equally effective. The goal setting is critical component of successful intervention.

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Santrauka

Autorius: SherineBahrou

Darbo tema: Intervencijų, skirtų cerebrinį paralyžių turinčių vaikų dalyvumui gerinti, efektyvumo apžvalga.

Tikslas: Nustatyti intervencijų, skirtų cerebrinį paralyžių turinčių vaikų dalyvumui gerinti, efektyvumą Uždaviniai:

1. Atrinkti mokslinius straipsnius, kuriuose analizuojamas intervencijų, skirtų cerebrinį paralyžių (CP) turinčių vaikų dalyvumui gerinti, efektyvumas

2. Sistemiškai apžvelgti reabilitacijos intervencijų, skirtų CP turinčių vaikų dalyvumui gerinti, mokslinį pagrįstumą.

3. Įvertinti kokios intervencijos ištirtos nepakankamai, nustatyti kokie papildomi tyrimai reikalingi šioje srityje.

Metodika: Sisteminė apžvalga atlikta vadovaujantis sisteminių apžvalgų ir meta-analizių rengimo rekomendacijomis PRISMA. Atrinkti moksliniai straipsniai iš Medline (PubMed) duomenų bazės, ir į šią apžvalgą įtrauktų straipsnių literatūros sąrašų. Įtraukimo į apžvalgą kriterijai – tyrimai, analizuojantys intervencijų, skirtų CP turinčių vaikų dalyvumui gerinti, efektyvumą.

Rezultatai: Į apžvalgą įtraukti 11 tyrimų. Rankos suvaržymo terapija ir abiejų rankų lavinimas turėjo teigiamą poveikį dalyvumui socialinėse veiklose. Rankos lavinimas robotizuoto treniruoklio pagalba dalyvumui įtakos neturėjo. Studijų, tyrusių kineziterapijos (KT) efektyvumą, duomenys prieštaringi. Teigiamas poveikis dalyvumui rastas studijose, kuriose KT buvo derinama su į aplinkybes nukreiptomis intervencijomis ir kai buvo išsikelti konkretūs terapijos tikslai.

Išvados: Į vaiką orientuotos ir į aplinkybes orientuotos terapijos buvo vienodai efektyvios vaikų su CP dalyvumui. Tikslų išsikėlimas - būtina intervencijų sėkmės sąlyga.

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ACKNOWLEDGMENTS

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CONFLICTS OF INTEREST

The author reports no conflicts of interest.

PERMISSION ISSUED BY THE ETHICS COMMITTEE

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LIST OF ABBREVIATIONS

APCP - Assessment of Preschool Children's Participation BTX – Botox

BMFM - Bimanual Fine Motor

CAPE - Children’s Assessment of Participation and Enjoyment CP - Cerebral Palsy

CT - Computed Tomography

CIMT - Constraint-Induced Movement Therapy

GMFCS - Gross Motor Function Classification System HAS - Habitual Activity Survey

HABIT-ILE - Hand and Arm Bimanual Intensive Therapy Including Lower Extremity

ICF-CY - International Classification of Functioning, Disability and Health-Children and Youth ICF - International Classification of Functioning, Disability, and Health

ID - Intellectual Disability

LAQ - Lifestyle Assessment Questionnaire MRI- Magnetic Resonance Imaging

MACS – Manual ability Classification System

PEM-CY - Participation and Environment Measure for Children and Youth PRE - Progressive resistance exercise

PODCI - Pediatric Outcomes Data Collection Instrument

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RAT - Robot-Assisted Therapy

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CHAPTER 1: INTRODUCTION

Cerebral palsy (CP): “a group of permanent disorders that affect the development of movement and posture, and cause activity limitation, that attributed to nonprogressive disturbances that occurred in the developing fetal or infant brain. The disorders of motor system of cerebral palsy are often accompanied by disturbances of sensation, perception, cognition, communication, and behavior, by epilepsy, and by

secondary musculoskeletal problem”. [1]

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CHAPTER 2: AIMS AND OBJECTIVES

Aim: To determine the efficacy of interventions aimed at increasing the level of participation in children with cerebral palsy.

Objectives:

1. Identify the extent and range of the existing literature on the efficacy of interventions aimed to increase participation of children with cerebral palsy.

2. Systematically review evidence on the impact of rehabilitation interventions on the participation of children with cerebral palsy.

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CHAPTER 3: LITERATURE REVIEW

3.1 Definition, prevalence, types, and etiology of cerebral palsy

Cerebral palsy (CP): “describes a group of permanent disorders that affect the development of movement and posture, and cause activity limitation, that attributed to nonprogressive disturbances that occurred in the developing fetal or infant brain. The disorders of motor system of cerebral palsy are often

accompanied by disturbances of sensation, perception, cognition, communication, and behavior, by epilepsy, and by secondary musculoskeletal problems”. [1] The prevalence of CP in children is 2-2.5 per 1000 live births in developed countries] . 3[

Surveillance of Cerebral Palsy in Europe (SCPE) has classified CP into three groups depending on neurological signs;

1. Spastic CP: patients have increased muscle tonus, and pathological reflexes (e.g., hyperreflexia,

Babinski response) and impairment of movement and posture. This type is caused by a lesion of the upper motor neuron. This type is divided in two subtypes: spastic unilateral CP when limbs in one body side are affected; and bilateral, when CP affects symmetrical parts of the body.

2. Dyskinetic CP: is characterized by presence of uncontrolled, recurring, and occasionally rapid

movements. This type is due to damage to basal ganglia, which is responsive for movement control. SCPE [

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] divides this type to dystonic and choreo-athetotic CP subtypes. Dystonic CP is diagnosed when main signs of CP are abnormal postures and hypertonia. Choreo-athetotic CP is diagnosed when the main clinical disturbances of movement and posture are hyperkinesia and hypotonia.

3. Ataxic CP: is caused by a lesion of the cerebellum. Main symptoms of this type are: (1) loss of muscular coordination, which result in performing the movements with abnormal force, precisity, and rhythm, typical features are ataxic gait (disturbed balance) (2) Tremor (3) Low tone.

4. Mixed CP: is diagnosed when child has movement problems that fall into several types of CP (e.g. child has spasticity together with ataxia or dyskinesia). While the SCPE describe a child’s presentation, they do not define any criteria for recording the functional abilities of the child. ]4-9[

Further functional classification systems for children with CP were developed: The Gross Motor Function Classification System (GMFCS), the Manual Ability Classification System (MACS), Communication Function Classification System, and Eating and Drinking Ability Classification System for Individuals with Cerebral palsy. [10]

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self-initiated movements, in particular sitting and walking. It is an age-related five-level system in which level I represents the least limitation and level V the most. [10]

Level 1: children can walk independently without support, can climb, run with decreased speed. Level 2: children walk without restrictions, limitations walking outdoors and, in the community,

Level 3: Children walk with assistive mobility devices, limitations walking outdoors and in community. Level 4: Self mobility with limitations, children are transported or use power mobility outdoors and in the community.

Level 5: Self mobility is severely limited, even with use of assistive technology. (Figure 1)

Figure 1. Gross Motor Function Classification System. Source (Paulson et. al., 2017)[10]

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Level 1- Handles objects easily and successfully

Level 2- Handles most objects but with somewhat reduced quality and/or speed of achievement, some activities achieved with little difficulty.

Level 3- Handles objects with difficulty, needs help to prepare or modify activities.

Level 4- Handles a limited selection of easily managed objects in adapted situations; performs parts of activities with effort and with limited success.

Level 5- Does not handle objects and has severely limited ability to perform even simple actions, need total assistance.

3.2 ICF framework

Functional consequences of CP can be displayed using the International Classification of Functioning, Disability, and Health (ICF). It was developed by World Health Organization (WHO) and approved for use by the World Health Assembly in 2001. The ICF is a conceptual framework is based on a model of variety dimensions is made apparent by bidirectional arrows reflecting the ongoing influence of

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Health (ICF). (WHO, 2001) [8]

3.3 Participation, definition, construct and related concepts

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Figure2: A family of participation and participation-related constructs. (Imms, 2016) [15]

3.4 Participation of children with CP

There were studies about the participation of children with CP which aims to explore what children who have cerebral palsy do. Children with CP have greater participation restriction comparing to healthy children, and they have weaker participation outcomes comparing with other disability groups. Law et al.

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possible 16-point difference in LAQ score depending on the district the child lived. Different factors have effects on participation, such as Social supports and physical accessibility. [18-20] There was no study describing the intervention to promote participation of children with CP, and this was the reason to conduct the review of papers published after 2009. The aim of the study to determine the efficacy of interventions aimed at increasing the level of participation in children with CP.

3.5 Systemic review

Systematic review: Summarizes the results of available studies that are selected by specific criteria. Differences between narrative and systemic analysis are; in the narrative, data chosen without specific criteria for selection based on author selection, these are for descriptive study. The systemic review uses Several steps to follow-on;

1- formulate a focused question that you need to get an answer for it, and title of the research is better to keep it as shorter as possible.

2- Define inclusion and exclusion criteria, for example, age of people involved in the study, interventions, outcomes.

3- Develop search strategy and locate reviews, It is essential to come up with a comprehensive list of key terms (i.e., “MeSH” terms) while using the references to find the studies.

4- Select studies: This process of review is done by at least two reviewers to establish reliability. The authors should keep a log of all reviewed studies with reasons for inclusion or exclusion.

5- Extract data: is helpful to use and create data extraction form for organizing the information extracted from each reviewed study (e.g., authors, publication year, number of participants, age range, study design, outcomes, included/excluded).

6- Assess study quality: There are comprehensive recommended guidelines and standards available such as the Consolidated Standards of Reporting Trials (CONSORT Statement;

http://www.consort-statement.org/), as well as articles providing recommendations for improving quality in RCTs and meta-analyses for psychological interventions.

7- Analyze and interpret results: There are various statistical programs available to calculate effects sizes for meta-analyses.

8- Disseminate findings: Although reviews should publish online. PRISMA Checklist used in literature (Table1).

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Section/topic # Checklist item TITLE

Title 1 _{Identify the report as a systematic review, meta-analysis, or both.} ABSTRACT

Structured summary

2 _{Provide a structured summary including, as applicable: background;} objectives; data sources; study eligibility criteria, participants, and interventions; study appraisal and synthesis methods; results; limitations; conclusions and implications of key findings; systematic review

registration number. INTRODUCTION

Rationale 3 _{Describe the rationale for the review in the context of what is already} known.

Objectives 4 _{Provide an explicit statement of questions being addressed with reference} to participants, interventions, comparisons, outcomes, and study design (PICOS).

METHODS Protocol and registration

5 _{Indicate if a review protocol exists, if and where it can be accessed (e.g.,} Web address), and, if available, provide registration information

including registration number. Eligibility

criteria

6 _{Specify study characteristics (e.g., PICOS, length of follow-up) and} report characteristics (e.g., years considered, language, publication status) used as criteria for eligibility, giving rationale.

Information sources

7 _{Describe all information sources (e.g., databases with dates of coverage,} contact with study authors to identify additional studies) in the search and date last searched.

Search 8 _{Present full electronic search strategy for at least one database, including} any limits used, such that it could be repeated.

Study selection

9 _{State the process for selecting studies (i.e., screening, eligibility, included} in systematic review, and, if applicable, included in the meta-analysis). Data

collection process

10 Describe method of data extraction from reports (e.g., piloted forms, independently, in duplicate) and any processes for obtaining and confirming data from investigators.

Data items 11 List and define all variables for which data were sought (e.g., PICOS, funding sources) and any assumptions and simplifications made. Risk of bias

in individual studies

12 Describe methods used for assessing risk of bias of individual studies (including specification of whether this was done at the study or outcome level), and how this information is to be used in any data synthesis. Summary

measures

13 State the principal summary measures (e.g., risk ratio, difference in means).

Synthesis of results

14 Describe the methods of handling data and combining results of studies, if done, including measures of consistency (e.g., I2) for each meta-analysis.

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across studies evidence (e.g., publication bias, selective reporting within studies). Additional

analyses

16 Describe methods of additional analyses (e.g., sensitivity or subgroup analyses, meta-regression), if done, indicating which were pre-specified. RESULTS

Study selection

17 Give numbers of studies screened, assessed for eligibility, and included in the review, with reasons for exclusions at each stage, ideally with a flow diagram.

Study

characteristics

18 For each study, present characteristics for which data were extracted (e.g., study size, PICOS, follow-up period) and provide the citations. Risk of bias

within studies

19 Present data on risk of bias of each study and, if available, any outcome level assessment (see item 12).

Results of individual studies

20 For all outcomes considered (benefits or harms), present, for each study: (a) simple summary data for each intervention group (b) effect estimates and confidence intervals, ideally with a forest plot.

Synthesis of results

21 Present results of each meta-analysis done, including confidence intervals and measures of consistency.

Risk of bias across studies

22 Present results of any assessment of risk of bias across studies (see Item 15).

Additional analysis

23 Give results of additional analyses, if done (e.g., sensitivity or subgroup analyses, meta-regression [see Item 16]).

DISCUSSION Summary of evidence

24 Summarize the main findings including the strength of evidence for each main outcome; consider their relevance to key groups (e.g., healthcare providers, users, and policy makers).

Limitations _{25 Discuss limitations at study and outcome level (e.g., risk of bias), and at} review-level (e.g., incomplete retrieval of identified research, reporting bias).

Conclusions _{26 Provide a general interpretation of the results in the context of other} evidence, and implications for future research.

FUNDING

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CHAPTER 4: RESEARCH METHODOLOGY AND METHODS

Systematic literature review where searches were conducted using Medline (PubMed), all articles

published from 2012 included in the searches with no more than five years search criteria used. The search terms used were: "cerebral palsy" AND "participation, patient" one search; another search "cerebral palsy" AND "community participation"; and another one "cerebral palsy" AND "participation, social". Inclusion and exclusion criteria listed in the (Table2) below.

Table.2

Inclusion Exclusion Children study Adult studies

Human studies Animal studies Full-text articles Reviews

Cerebral palsy Other neurological diseases Participation studies Not participation studies Within five years More than five years

Intervention studies Studies without intervention Studies in English Other languages

For all selected studies, the full text retrieved and examined. Data on the interventions aimed to enhance the participation of children with CP were extracted using a standardized data extraction form. Data obtained included: (1) general information about the study (author(s), year of publication, study location); (2) specific information related to the study population, aims of the study, study design, intervention (type, intensity, duration), outcome measures, main results. The information was analyzed using two approaches: (1) table in which a descriptive summary (author, year, and country, the aim of the study, study design, participants, intervention, results) provided. (2) A narrative synthesis to summaries the data on effects of interventions aimed to improve participation within functional domains of leisure, school, and community. The ICF framework and terminology employed as a guide for this review.”

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CHAPTER 5: RESULTS

After the search in PubMed 340 articles were found, and 11 met the inclusion criteria (figure 4). Articles were from the USA (2 studies), Belgium (1 study), Taiwan (1 study), Canada (2 studies), Australia (2 studies), and Netherland (3 studies). Most studies were randomised-controlled (8 studies), while others explored single-subject exploratory (1 study) or prospective, one group repeated-measures design (2 studies).

In the studies selected for the review, five different outcome measures for participation were used: Assessment of Life Habits (Life-HABITs), [21,22,26,27,29], (PEM-CY), [28], (PODCI), [31], (APCP), [24], (CAPE) [27,29,30] and (ICF checklist) [23,25].

Three studies focused on interventions targeted to improve upper limb function:hand and arm bimanual intensive therapy (HABIT) [21], robot-assisted therapy [22], and constraint-induced movement therapy [27]. Results of these studies indicate that arm and hand training addresses through either CIMT or HABIT achieved gains in hand function and social participation. Robot-assisted upper-limb therapy improved upper limb functions, but not functional activities and social participation.

Six investigated the effect of physiotherapy interventions: physical fitness training [26,29], progressive resistance exercise (PRE) [30], running interventions, hippotherapy [23,28], and classical ballet program [25]. Findings of these studies show equivocal results. No effects on participation found in the studies that analysed outcomes of PRE and lifestyle intervention (e.g., physical fitness training, counselling sessions focused on physical behaviour and sports participation). Running interventions had an effect on school participation but didn't affect participation at home or community. Six-month physical activity stimulation program consisting of motivational interviewing, home-based physiotherapy, and 4 months of fitness training as well as hippotherapy improved social participation of children with CP. The children who participated in a classical ballet program reported high enjoyment level and desire for more classes. The parents of children reported perceived therapeutic benefit, and the therapists viewed the class as a positive adjunct to therapy as well.

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tasks. In the context-focused group, therapists were modifying physical characteristics of the environment, task, materials or tools, practice of functional mobility activities, changing a task instruction, adding adaptive equipment, and providing education/instruction to the family. Both approaches resulted in equivalent and significant improvements in self-care, mobility, and participation outcomes of the children with CP. Wright et al. [31] analysed effect of botulinum toxin (BTX) therapy on participation and had found it effective as measured by PODCI scales.

Figure 4. Flowchart of the study design

Records identified through database searching (n =345) Scr e e n in g In cl u d e d El ig ib ili ty Id e n ti fi cat ion

Additional records identified through other sources

(n =0)

Records after duplicates removed (n =55)

Records screened (n =290)

Records excluded (n =242)

Full-text articles assessed for eligibility

(n = 48)

Full-text articles excluded, with reasons (n =32) • Not children studies

n=9

• Not cerebral palsy n = 3

• Not intervention study n=9

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Articles identified with the search, of studies that investigated interventions aimed to improve participation of CP children (Table3).

Table3. studies that investigated interventions aimed to improve participation of CP children

Author/year Country , sample N (age) Study design, interventions Participatio n measures Results Bleyenheuft et al. (2015) [21] USA, N=24 (6 -13) Randomized controlled I group (n=12) - immediate HABIT-ILE; II group (n=12) - delayed HABIT-ILE; duration - 10 days = 90 hours Life-HABITs Social participation performance, as well as satisfaction of the parents, improved Gilliaux et al. (2015) [22] Belgiu m, N=16 (7-18) Randomized controlled I group (n=8) - conventional

therapy 5 sessions per week over 8 weeks II group (n=8) - 3

sessions of conventional and 2 sessions of robot-assisted therapy per week over 8 weeks

Life-HABITs

Robot-assisted therapy improved upper limb functions, but not functional activities and social participation Hsieh et al. (2017) [23] Taiwan, N=14 (3–8)

Single case (ABA) Hippotherapy 30 min, once weekly for 12 weeks Withdrawal phase – 12 weeks ICF-CY checklist Participation of children at GMFCS levels I– III showed significant improvement, but those at GMFCS levels IV and V remained unchanged Law et al. (2011) [24] Canada, N=128 (1-5) Randomized controlled I group (n=71) - child-focused and II group

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(n=57) - context-focused intervention over 6 months

found for play intensity (p<0.04), physical activity intensity and diversity (p<0.001), and total score intensity (p<0.01). Lopez-Ortiz et al. (2012) [25] USA, N=16 Pilot exploratory Classical ballet training once weekly over 5-8 weeks

ICF-CY checklist

The children expressed the desire for more classes (p=0.0001), a high enjoyment level (p=0.0001), new interest in participation in a school group (p=0. .04), new interest in watching a dance show (p=0.0001) and new interest in attending an art show ( p=0.004). Slaman et al. (2015) [26] Netherl ands N=456 (16-24) Randomized controlled 6-month lifestyle intervention: physical fitness training, counseling sessions focused on physical behavior and sports participation

Life-HABITs

No intervention effects were noted for social participation Sakzewski et al. (2011) [27] Australi a, N=64 (5-14) Randomized controlled CIMT delivered in day camps (total 60 h over 10 d) using a circus theme with goal directed training Life-HABITs, CAPE Changes in participation in specific life habits achieved, which corresponded with goals identified by children and their caregivers. Gibson et al. (2017) [28] Australi a, N=42 (9–18) Randomized controlled 12-week running intervention

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24 the school environment (mean difference 1.18: 95%, CI 1.00– 1.39, p=0.045). Wely et al. (2014) [29] Netherl and, N=49 (7–13) Randomized controlled 6-month physical activity stimulation program: motivational interviewing, home-based physiotherapy and 4 months of fitness training. Life-HABITs, CAPE Intervention resulted in a positive effect on social participation in domestic life (mean between-group difference = 0.9, 95% confidence interval (CI) = 0.1 to 1.7 [1–10 scale], P = 0.03), but not in recreation and leisure. Scholtes et. al. (2012) [30] Netherl and, N=51 (6-13) Randomized controlled I group (n=26) – 12 weeks functional PRE-circuit training, for 3 times a week

II group (n=25) – conventional therapy

CAPE The intervention had no significant effect on CAPE. Wright et al. (2015) [31] Canada, N=85 (3-12)

Prospective, one group repeated-measures BTX for leg muscles

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CHAPTER 6: DISCUSSION OF RESULTS

Participation reported as a key outcome of health and main human right for all children. Participation of children with CP investigated. The more recent review of Imms (2008) provided analysis of 40 studies describing the participation of children with CP. The results of these 40 studies indicate that children with CP have a reduced level of participation, and those with greater functional impairment are the most

restricted. Children with CP were reported to be less involved in activities as well. However, interventions aimed to promote and support the participation of children with CP are less investigated. Our search has identified only eleven studies of interventions focused mainly on body structures and functions but less on contextual factors.

Adair et al. (2015) has published a systematic review of 29 studies aimed to promote participation of children with all kind of disabilities. Authors of the review didn’t find that interventions targeted to improve body structures or functions could be effective. In contrast, individually tailored education and mentoring were reported to be highly effective. Differently, from these authors, we have found that some interventions aimed to improve body structures and functions might be effective and to promote

participation of children with CP. It seems that main key to success is a goal-oriented approach to intervention planning. For example, goal oriented upper limb interventions resulted in the better social participation of children with hemiplegic CP in all studies. In contrast, robotic-assisted upper-limb training following standard (not individual) protocols improved upper limb kinematics but not functional activities or participation of children with hemiplegic CP.

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Results of Law et al. (2011) who investigated 128 children with CP confirm that child- or context-focused therapy approaches can be equally effective. The goal setting may be a critical component of the

successful intervention.

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CHAPTER 7: CONCLUSIONS

1. Interventions aimed to promote and support the participation of children with CP are insufficiently investigates.

2. Research that shows that both child-focused and context-focused interventions could be effective. The goal setting is a critical component of the successful intervention.

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CHAPTER 8: PRACTICAL RECOMMENDATIONS

Recommendations for the research: most of studies focused on body function of children with CP, future studies should focus on other factors like environmental, and personal factors that also have effect on children with CP.

Recommendations for the clinicians: practitioners should combine child- and context- focused interventions to achieve best outcomes. For example, it would be helpful to combine conventional physiotherapy with parent training.

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CHAPTER 9: REFERENCES

1- Rosenbaum, P, Paneth, N, Leviton, A, Goldstein, M, Bax, M, Damiano, D, Dan, B, Jacobsson, B. "A report: The definition and classification of cerebral palsy. April 2006". Developmental Medicine & Child Neurology Supplement. 109: 8–14

2- Adair B, Ullenhag A, Keen D, Granlund M, Imms C. The effect of interventions aimed at improving participation outcomes for children with disabilities: a systematic review. 2015. Developmental medicine Child Neurol. 57(12):1093-104.

3- Blair E, Love S. Definition and classification of cerebral palsy. 2005. Dev Med Child Neuro. l47:510. 4- Cans C, McManus V, Crowley M, Guillem P, Platt M J, Johnson A, Arnaud C. Cerebral palsy of

post-neonatal origin: characteristics and risk factors. 2004. Pediatric Perinat Epidemiol. 18:214-220 5- Colver A, Sethumadhavan T. The term diplegia should be abandoned. 2003. Arch Dis Child. 88:

286-290

6- Sanger TD, Delgado MR, Gaebler-Spira D, Hallett M, Mink JW. Classification and definition of disorders causing. 2003

7- Surveillance of Cerebral Palsy in Europe (SCPE). Prevalence and characteristics of children with cerebral palsy in Europe. 2002. Developmental medicine Child Neuro. l44 633-640.

8- World Health Organization. International Classification of Functioning, Disability, and Health: Children and Youth Version (ICF-CY). 2007. Geneva: World Health Organization.

9- Granlund M. Participation – challenges in conceptualization, measurement, and intervention. 2013. Child Care Health Developmental. 39: 470–3.

10- Andrea Paulson, Jilda Vargus Adams. Overview of Four Functional Classification Systems Commonly Used in Cerebral Palsy. 2017. USA

11- King G. Perspectives on measuring participation: going forward. 2013. Child Care Health Developmental. 39: 466–9.

12- Maxwell G, Alves I, Granlund M. Participation and environmental aspects in education and the ICF and the ICF-CY: findings from a systematic literature review. 2012. Developmental Neurorepair. 15: 63–78

13- Law M, Finkelman S, Hurley P, Rosenbaum P, King S, King G, Hanna S. Participation of children with physical disabilities: Relationships with diagnosis, physical function and demographic variables. 2004. Scand J Occupy Therapy. 11:156 – 162.

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15- Christine Imms, Brooke Adair, Deb Keen, Anna Ullenhag, Peter Rosenbarum, Mats Granlund. Participation’: a systematic review of language, definitions, and constructs used in intervention research with children with disabilities. 2016. Australia

16- Law M, Finkelman S, Hurley P, Rosenbaum P, King S, King G, Hanna S. Participation of children with physical disabilities: Relationships with diagnosis, physical function and demographic variables. 2004. Scand J Occupy Therapy. 11:156 – 162

17- Morris C, Kurinczuk JJ, Fitzpatrick R, Rosenbaum P. Do the abilities of children with cerebral palsy explain their activities and participation. 2006. Developmental medicine Child Neural. 48:954 – 961. 18- Forsyth R, Colver A, Alvanides S, Woolley M, Lowe M. Participation of young severely disabled

children is influenced by their intrinsic impairments and environment. 2007. Developmental medicine Child Neurol. 49:345 – 349.

19- Heah T, Case T, McGuire B, Law M. Successful participation: The lived experience among children with disabilities. 2007. Can J Occupy Therapy. 74:38 – 47.

20- Lawlor K, Mihaylov SI, Welsh B, Jarvis S, Colver A. A qualitative study of the physical, social and attitudinal environments influencing the participation of children with cerebral palsy in northeast England. 2006. Pediatric rehabilitation. 9:219 – 228.

21- Bleyenheuft, Yannick, Arnould, Carlyne, Brandao, Marina B, Bleyenheuft, Corrine, Gordon, Andrew M. Hand and Arm Bimanual Intensive Therapy Including Lower Extremity (HABIT-ILE) in Children with Unilateral Spastic Cerebral Palsy: A Randomized Trial. 2014. Neurorehabilitation and Neural Repair, 645-657. doi:10.1177/1545968314562109

22- Gilliaux, Maxime, Renders, Anne, Dispa, Delphine, Holvoet, Dominique, Sapin, Julien, Dehez, Bruno, Detrembleur, Christine, Lejeune, Thierry M, Stoquart, GaĆ«tan. Upper Limb Robot-Assisted Therapy in Cerebral Palsy: A Single-Blind Randomized Controlled Trial. 2014. Neurorehabilitation and Neural Repair. 183-192. doi:10.1177/1545968314541172

23- Yueh-Ling Hsieh, Chen-Chia Yang, Shih-Heng Sun, Shu-Ya Chan, Tze-Hsuan Wang & Hong-Ji Luo. Effects of hippotherapy on body functions, activities and participation in children with cerebral palsy based on ICF-CY assessments. 2016. Disability and Rehabilitation.

39:17,1703-1713, DOI: 10.1080/09638288.2016.1207108

24- Law MC, Darrah J, Pollock N, et al. Focus on function: a cluster, randomized controlled trial comparing child- versus context-focused intervention for young children with cerebral

(31)

31

25- López-Ortiz C, Gladden K, Deon L, Schmidt J, Girolami G, Gaebler-Spira D. Dance program for physical rehabilitation and participation in children with cerebral palsy. 2012. Arts & Health. 4(1):39-54. doi:10.1080/17533015.2011.564193.

26- Slaman, J, van den Berg-Emons, HJG, van Meeteren, J, Twisk, J, van Markus, F, Stam, HJ, van der Slot, WM, Roebroeck, ME. A lifestyle intervention improves fatigue, mental health and social support among adolescents and young adults with cerebral palsy: focus on mediating effects. 2015. Clinical Rehabilitation. 717-727. doi:10.1177/0269215514555136

27- Leanne Sakzewski PhD, B.OccThy, Jenny Ziviani PhD, MEd, BAppSc, O, David F. Abbott PhD, Richard A. MacdonellMD, FRACP, FAFRM, Graeme D. Jackson MD, FRACP, Roslyn N. Boyd PhD. Participation Outcomes in a Randomized Trial of 2 Models of Upper-Limb Rehabilitation for Children with Congenital Hemiplegia. 2011. Australia. Physiotherapy. 531-539.

28- Noula Gibson, Annie Chappell, Amanda Marie Blackmore, Susan Morris, Gavin Williams, Natasha Bear & Garry Allison. The effect of a running intervention on running ability and participation in children with cerebral palsy: a randomized controlled trial. 2017. Disability and Rehabilitation. DOI: 10.1080/09638288.2017.1367426

29- Van Wely, Leontien, Balemans, Astrid CJ, Becher, Jules G, Dallmeijer, Annet J. The effectiveness of a physical activity stimulation programme for children with cerebral palsy on social participation, self-perception and quality of life: a randomized controlled trial. 2013. Clinical Rehabilitation. 972-982. doi: 10.1177/0269215513500971

30- Vanessa A.Scholtes, Jules G.Becher, Yvonne J.Janssen-Potten, HurnetDekkers, LindaSmallenbroek, Annet J.Dallmeijer. Effectiveness of functional progressive resistance exercise training on walking ability in children with cerebral palsy: A randomized controlled trial. 2011. Rehabilitation Centre Heliomare. Doi.org/10.1016/j.ridd.2011.08.026-31.

(32)

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