Defining Functional Therapy in Research Involving Children with Cerebral Palsy: A Systematic Review

Figures & data

Table 1. Criteria of functional therapy of the Dutch guidelines (Revalidatieartsen, 2015).

1. Goal-directed

The goals have been formulated in consultation with parents and/or child. The goals are specific, measurable, achievable, relevant and time-bound (SMART) and should preferably be determined using a valid and reliable measurement instrument, such as the Goal Attainment Scale (GAS)a or the Canadian Occupational Performance Measures (COPM)b

2. Based on the activities/participation level of the ICF-CYc

The goals of the therapy should always be formulated at the ICF-CY level of activities and/or participation

3. Task-specific

The intervention is based on a task analysis and focuses on practicing the activities (or partial activities), which are formulated in the goals

4. Active involvement of the child and parents to find solutions, learn motor skills and discover new possibilities

During therapy, the child is actively trying to find solutions regarding motor activities. The approach is basically hands-off

5. Focused on functionality rather than normality

The focus of the treatment and the most important goal of the intervention is functionality and not normality. It is important that the child is successful in performing the motor tasks, and the quality of the performance is not the main focus

6. Context-specific

Therapy takes into account contextual factors that specifically concern the formulated goals, and if possible takes place in the context that is relevant to the child.

^aTurner-Stokes (2009).

^bLaw et al. (1990).

^cWHO (2007).

Figure 1. Flow diagram of the study identification and selection.

Table 2. Characteristics of the included studies.

Study	Design	Diagnosis	Age	N	Intervention	Control
Xu et al. (2015)	Single-blinded RCT	Unilateral CP	2–14 years	68	CIMT (involved intensive functional training of the involved hand) (n = 22) or CIMT plus electrical stimulation (n = 23)	Traditional occupational therapy (involved functional unimanual and bimanual training) (n = 23)
Chen et al. (2014)	RCT	Unilateral CP	6–12 years	45	Home-based constraint-induced therapy (involved intensive functional training of the more affected upper extremity) (n = 23)	Traditional rehabilitation (involved functional unimanual and bimanual training) (n = 22)
Chen et al. (2013)	Single-blinded RCT	Unilateral CP	6–12 years	47	Constraint-induced therapy (involved intensive functional training of the more affected arm) (n = 24)	Traditional rehabilitation (involved functional unilateral and bilateral arm training) (n = 23)
Storvold and Jahnsen (2010)	Multiple single-subject (ABA) design	Unilateral CP (n = 4), bilateral CP (n = 1) and quadrilateral CP (n = 1)	3–11 years	6	Intensive goal-directed functional training combining group and individual sessions
de Brito Brandao et al. (2010)	Single-blinded RCT	Unilateral CP	4–8 years 8 months	16	One week of bimanual functional training following constraint therapy (n = 8)	Usual rehabilitation (n = 8)
Rameckers et al. (2010)	Randomized design	Spastic unilateral CP	4–16 years	20	Standardized functional training program with vs. without the addition of chemodernervation of the muscles of the forearm and hand
Lowing et al. (2009)	Prospective intervention study	Uni- (n = 17) or bilateral (n = 27) CP	Mean age 4 years 1 months	44	Goal-directed functional therapy (GDT) versus activity focused therapy (AT)
Gorter et al. (2009)	Test–retest repeated measures design	CP	8–13 years	13	Functional physical training program
Rameckers et al. (2008)	RCT	Spastic unilateral CP	4–16 years	20	Standardized functional training program versus without the addition of chemodenervation of forearm and hand muscles
Ahl et al. (2005)		Spastic bi- (n = 12) or trilateral (n = 2) CP	1 years 6 months– 6 years	14	Goal-directed functional therapy
Lowing et al. (2010)	Prospective longitudinal intervention study	Uni- (n = 8) or bilateral (n = 14) CP	1–6 years	22	Goal-directed functional therapy
Akbari et al. (2009)	Pre- and post design study	Uni- (n = 7), bi- (n = 6) and quadrilateral (n = 2) CP	Mean age 21.87 months	15	Functional physical therapy program
Lammi and Law (2003)	Single subject, multiple baseline design	CP	3–3 years 6 months	3	Family-Centred Functional Therapy (FCFT)
Ketelaar et al. (2001)	Randomized block design	Uni- (n = 32), bi- (n = 11) or quadrilateral (n = 12) CP	2–7 years	55	Functional physical therapy
Scholtes et al. (2010)	Single-blinded RCT	Spastic uni- (n = 17) or bilateral (n = 32) CP	mean age 10 years 5 months	49	Functional progressive resistance exercise (n = 24)	Usual care (n = 25)
Blundell et al. (2003)	Nonrandomized ABA trial	Spastic bilateral CP (n = 7) or spastic/ ataxic quadrilateral CP (n = 1)	4–8 years	8	Functional strength training
Lee et al. (2015)	Single-blinded RCT	Spastic CP	5–10 years	26	General NDT and additional progressive functional training	General NDT
Gordon et al. (2011)	Randomized trial	Unilateral CP	3.5–10 years	42	90 h of CIMT (n = 21) versus an equivalent dosage of functional bimanual training (HABIT) (n = 21)
Liao et al. (2007)	Single-blind, randomized block design	Spastic bilateral CP	5–12 years	20	Regular physical therapy plus functional strengthening program, the loaded sit-to-stand (STS) resistance exercise (n = 10)	Regular physical therapy (n = 10)
Sung et al. (2005)	Prospective case series	Unilateral CP	Mean age intervention group 33.2 months, mean age control group 43.2 months	31	Short-arm Scotchcast On the unaffected arm for 6 weeks plus Conventional rehabilitation program that included stretching Exercises and functional occupational therapy for the upper extremity (n = 18)	Conventional rehabilitation Program (n = 13)
Chen et al. (2016)		Spastic unilateral CP	Younger group: 6–8 years (n = 11) and older group: 9–12 years (n = 12)	23	Home-based constraint-induced therapy (CIT) (involved intensive functional training of the more affected upper-limb)
Lin et al. (2015)		Spastic bilateral CP	Mean age 7.60 years	12	Botulinum toxin type A (BoNT-A) combined with functional occupational therapy (OT)
Ferre et al. (2016)	RCT	Spastic unilateral CP	2 years 6 months– 10 years 1 months	24	Home-based HABIT (n = 12) versus lower-limb functional intensive training (LIFT) (n = 12)
Kusumoto et al. (2016)	Single-blind randomized clinical trial	Spastic bilateral CP	12–18 years	16	Regular physical therapy (involved functional training) with slow loaded sit-to-stand exercise group (n = 8) or self-paced loaded sit-to-stand exercise group (n = 8)
Moura et al. (2017)	Randomized sham-controlled study	Spastic unilateral CP	6–12 years	20	Functional training of the paretic upper limb combined with anodic transcranial stimulation (n = 10)	Functional training of the paretic upper limb combined with sham transcranial stimulation (n = 10)
Peungsuwan et al. (2017)	RCT	Spastic uni- or bilateral CP	7–16 years	15	Functional exercise program and physical therapy (n = 8)	Physical therapy (n = 7)
van Vulpen et al. (2017)	Study protocol of double baseline trial	Spastic uni- or bilateral CP	4–10 years	22	Functional power training

CIMT: constraint induced movement therapy; HABIT: hand-arm bimanual intensive therapy; NDT: neurodevelopmental treatment; RCT: randomized controlled trial.

Figure 2. Criteria and definition mentioned in the method section of each study. When the definition was not in line with the proposed definition an * was placed in the box.

Table 3. Criteria of functional therapy mentioned in the included papers, and in which section of the paper.

Study	Functional therapy	Goal- directed	Based on activities/ participation level of the ICF-CY	Task- specific	Active involvement	Focused on functionality rather than normality	Context specific
Xu et al. (2015)	M	—	M	—	—	M	M
Chen et al. (2014)	M	—	M	—	M	—	M
Chen et al. (2013)	M	—	M	—	M	—	M
Storvold and Jahnsen (2010)	M	M	M	M	M	M	M
de Brito Brandao et al. (2010)	M	—	M	—	—	—	M
Rameckers et al. (2010)	A + D	M	M	M	—	—	–
Lowing et al. (2009)	M	M	M	—	M	M	I
Gorter et al. (2009)	T + A+I	—	—	—	—	—	–
Rameckers et al. (2008)	M	M	—	M	—	—	–
Ahl et al. (2005)	M	M	M	M	M	—	M
Lowing et al. (2010)	T + A+I + M+D	M	M	M	M	—	M
Akbari et al. (2009)	M	M	M	M	M	M	–
Lammi and Law (2003)	M	M	I	I	I	—	I
Ketelaar et al. (2001)	M	M	—	M	M	M	M
Scholtes et al. (2010)	M	D	M	—	—	—	D
Blundell et al. (2003)	M	I + D	—	A + D	—	—	D
Lee et al. (2015)	M	—	—	—	—	—	–
Gordon et al. (2011)	A	M	M	I + D	M	—	M
Liao et al. (2007)	M	—	—	I + D	—	—	–
Sung et al. (2005)	M	M	M	—	—	—	–
Chen et al. (2016)	M	—	—	—	—	—	M
Lin et al. (2015)	M	D	M	D	—	—	–
Ferre et al. (2016)	A + I+M	A + M+D	M	M	—	—	T + I+M
Kusumoto et al. (2016)	I + M	—	—	I	—	—	–
Moura et al. (2017)	A + I	—	—	—	—	—	–
Peungsuwan et al. (2017)	I + M	—	—	—	—	—	–
van Vulpen et al. (2017)	T + A+I + M	M	M	—	—	—	–

A: mentioned in the abstract; D: mentioned in the discussion; I: mentioned in the introduction; M: mentioned in the methods; T: mentioned in the title; —: not mentioned at all.

Table 4. Comparison of the proposed definitions with the definitions of the criteria that were mentioned in the methods section of the included papers.

Study	Goal- directed	Based on the activities/ participation level of the ICF-CY	Task- specific	Active involvement	Focused on functionality rather than normality	Context specific
Xu et al. (2015)	—	No	—	—	No	No
Chen et al. (2014)	—	No	—	Yes	—	Yes
Chen et al. (2013)	—	No	—	Yes	—	Yes
Storvold and Jahnsen (2010)	Yes	Yes	Yes	Yes	Yes	Yes
de Brito Brandão et al. (2010)	—	No	—	—	—	No
Rameckers et al. (2010)	Yes	No	Yes	—	—	—
Lowing et al. (2009)	Yes	Yes	—	Yes	Yes	–
Gorter et al. (2009)	—	—	—	—	—	—
Rameckers et al. (2008)	No	—	Yes	—	—	—
Ahl et al. (2005)	Yes	Yes	Yes	Yes	—	Yes
Lowing et al. (2010)	Yes	Yes	Yes	Yes	—	Yes
Akbari et al. (2009)	Yes	Yes	Yes	Yes	Yes	—
Lammi and Law (2003)	Yes	—	—	—	—	—
Ketelaar et al. (2001)	No	—	Yes	Yes	Yes	Yes
Scholtes et al. (2010)	—	No	—	—	—	—
Blundell et al. (2003)	—	—	—	—	—	—
Lee et al. (2015)	—	—	—	—	—	—
Gordon et al. (2011)	Yes	Yes	—	Yes	—	Yes
Liao et al. (2007)	—	—	—	—	—	—
Sung et al. (2005)	No	No	—	—	—	—
Chen et al. (2016)	—	—	—	—	—	No
Lin et al. (2015)	—	No	—	—	—	—
Ferre et al. (2016)	No	No	No	—	—	No
Kusumoto et al. (2016)	—	—	—	—	—	—
Moura et al. (2017)	—	—	—	—	—	—
Peungsuwan et al. (2017)	—	—	—	—	—	—
van Vulpen et al. (2017)	Yes	Yes	—	—	—	—

Yes: description in line with suggested definition in this paper; No: description not in line with suggested definition in this paper; —: criteria were not mentioned in the method section.

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