Lien vers les tableaux de données probantes et la liste des références
In general, there is a dearth of studies that evaluate rehabilitation interventions among the pediatric stroke population. This discussion will focus on the evidence for pediatric stroke specifically. Pediatric specific studies have been conducted in the following areas: functional electrical stimulation (FES), constraint induced movement therapy (CIMT), mirror therapy, botulinum toxin type A, and repetitive transcranial magnetic stimulation (rTMS).
Although CIMT is a widely studied therapeutic intervention in the adult stroke population, studies of its effect among pediatric stroke patients are just emerging. Taub et al. (2011) studied 20 children with congenital hemiparesis to evaluate the effect of early (immediate) versus delayed (at 6 months post stroke) CIMT. Participants were randomized initially, and then crossed over to the other treatment arm at 6 months. The authors reported that compared to the delayed group, individuals who received early CIMT had large increases on the Pediatric Motor Activity Log (p<0.0001), and that at 6-month follow-up they continued to show larger gains on the Pediatric Motor Activity Log, Pediatric Arm Function Test, as well as passive and active range of motion (ROM). These findings are supported by an earlier study by Williw et al. (2002) which also compared early (immediate) versus delayed (6 months) CIMT in a cross-over RCT. Similarly, the authors reported that participants improved in the Peabody Development Motor Scale score one month post CIMT in both groups, but only after CIMT was completed. Previous pre-post studies have also demonstrated significant improvements in amount and quality of use of the affected extremity (Karmman et al. 2003), Pediatric Motor Activity Log-Revised (Rickards et al. 2014; Sterling et al. 2013), as well as the Pediatric Arm Function Test (Rickards et al. 2014). Challenges with CIMT include fatigue and compliance with the protocol.
Functional Electrical Stimulation (FES) is a commonly used therapeutic application for adult rehabilitation patients; there is little evidence for pediatric patients. One recent pre-post study has evaluated the use of 48 hours of FES in just four pediatric stroke participants (Kapadia et al. 2014). The authors reported significant improvement on the object manipulation sub-scale of the Rehabilitation Engineering Laboratory hand Function Test; all other measures revealed no significant improvements.
The effectiveness of mirror therapy in improving upper extremity function has been assessed in a single cross-over RCT (Gygax et al. 2011). Ten children were randomized to receive bimanual training with or without a mirror for three weeks; participants then crossed over to the other arm. Gugax et al. (2011) reported that grasp strength (p=0.033) and upper limb dynamic position (p=0.044) significantly improved with training with the mirror, whereas pinch strength improved without the use of a mirror.
Botulinum toxin type A is regularly used around the world to reduce excessive tone in the spastic affected extremity of individuals post stroke. Extensive evidence exists in the adult stroke population. With the exception of studies assessing a cerebral palsy population, there has not been a studied which has examined the use of botulinum toxin specifically among pediatric stroke patients. Given the low prevalence of pediatric stroke, these patients are often combined with cerebral palsy patients in rehabilitation trials. Thus, the evidence for botulinum toxin for pediatric stroke is limited, despite extensive evidence in other populations (e.g., cerebral palsy, adult stroke).
Repetitive transcranial magnetic stimulation (rTMS) likely improves motor recovery in adult stroke and is now Health Canada approved for treating spasticity and major depression. In the pediatric stroke population, three RCTs have evaluated the effect of rTMS in improving upper extremity function. Gillick et al. (2014) reported a significant improvement among children with perinatal stroke in the rTMS group compared to the sham group on the Assisting Hand Assessment measure; however, no differences between groups were reported on the Canadian Occupational Performance Measure. Kirton et al (2015, in press) performed a factorial trial of rTMS and CIMT in 45 children with perinatal stroke and hemiparesis, demonstrating additive effects lasting 6 months when combined with 2 weeks of intensive motor therapy. Kirton et al. (2008) also examined ten children with childhood stroke receiving either active or sham rTMS with possible modest improvements noted in grip strength and the Melbourne Assessment of Upper Extremity Function measure.
Overall, there has been limited research evaluating the use of specific rehabilitation interventions in the pediatric population, although multiple studies, some with small numbers, are increasingly being added. Studies from adult stroke populations have shown various treatments to be effective in improving outcomes. As a result, many of the therapies used among children have been derived from research study and clinical use in the older population. Future studies should recruit a greater number of pediatric stroke participants and evaluate a wide range of interventions. Adherence to strict methodological protocols would be beneficial in comparing between studies.
Finally, it is worth noting that the psychological well-being of the entire family is an important component of pediatric stroke rehabilitation. Often, the cause of perinatal stroke cannot be identified and, as such, parents, particularly mothers, place blame on themselves or doctors and health care professionals. This is largely the result of receiving a gross amount of medical information (or misinformation) during pregnancy. Important research has begun to be investigated in this area. Bemister et al. (2014) reported that when compared to mothers of children without stroke, those who had a child that suffered a stroke were significantly more depressed. Further, there were significant differences in family functioning, parent health-related quality of life, and marital satisfaction. When specifically comparing mothers and fathers of children with pediatric stroke, mothers were found to have significantly higher anxiety and guilt regarding their child’s condition. In a follow-up study, Bemister et al. (2015) reported that several factors including stroke severity, anxiety, social support, stress levels, marital quality, guilt, and blame significantly predicted a caregiver’s depression. In addition to these variables, cognitive and behavioural impairments also predicted family functioning. These psychological complications among parents add to the overall morbidity incurred by the family. Simple educational interventions are likely very effective at reducing or eliminating this complication; however, there are few studies which have assessed these therapeutic strategies and therefore, would be an important avenue for future research.