Systematic review and meta-analysis of therapeutic management of upper-limb dysfunction in children with congenital hemiplegia

Pediatrics. 2009 Jun;123(6):e1111-22. doi: 10.1542/peds.2008-3335. Epub 2009 May 18.


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 > or = 5), and systematic reviews rated strongly (AMSTAR [Assessment of Multiple Systematic Reviews] score > or = 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.

Publication types

  • Comparative Study
  • Meta-Analysis
  • Research Support, Non-U.S. Gov't
  • Review
  • Systematic Review

MeSH terms

  • Adolescent
  • Botulinum Toxins, Type A / administration & dosage*
  • Cerebral Palsy / congenital*
  • Cerebral Palsy / rehabilitation*
  • Child
  • Child, Preschool
  • Combined Modality Therapy
  • Humans
  • Infant
  • Occupational Therapy*
  • Physical Therapy Modalities*
  • Psychomotor Disorders / congenital*
  • Psychomotor Disorders / rehabilitation*
  • Randomized Controlled Trials as Topic
  • Splints


  • Botulinum Toxins, Type A