ConScientiae Saúde ISSN: 1677-1028 [email protected] Universidade Nove de Julho Brasil

Vieira Castilho Weinert, Luciana; Borba Neves, Eduardo Use of dynamic clothes in rehabilitation: systematic review ConScientiae Saúde, vol. 15, núm. 2, 2016, pp. 297-303 Universidade Nove de Julho São Paulo, Brasil

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How to cite Complete issue Scientific Information System More information about this article Network of Scientific Journals from Latin America, the Caribbean, Spain and Portugal Journal's homepage in redalyc.org Non-profit academic project, developed under the open access initiative DOI:10.5585/ConsSaude.v15n2.6224 Recebido em 17 dez. 2015 / aprovado em 21 maio 2016

Use of dynamic clothes in cerebral palsy rehabilitation: systematic review

Utilização de vestes dinâmicas na reabilitação da paralisia cerebral: revisão sistemática

Luciana Vieira Castilho Weinert1, Eduardo Borba Neves2 1 Fisioterapeuta, Doutora em Ciências – Engenharia Biomédica – Universidade Tecnológica Federal do Paraná - UTFPR, Docente e Orientadora do Programa de Mestrado em Desenvolvimento Territorial Sustentável e do Curso de Licenciatura em Educação Física – Universidade Federal do Paraná – UFPR. Matinhos, PR – Brasil. 2 Fisioterapeuta, Doutor em Saúde Pública e Meio Ambiente – Fundação Oswaldo Cruz - FIOCRUZ, Pesquisador do Instituto de Pesquisa da Capacitação Física do Exército, Docente e Orientador do Programa de Mestrado em Engenharia Biomédica – Universidade Tecnológica Federal do Paraná – UTFPR. Curitiba, PR – Brasil.

Endereço de Correspondência: Luciana Vieira Castilho Weinert Rua Jaguariaiva, 512, Caiobá 83260-000 – Matinhos - PR [Brasil] [email protected] Artigos

Abstract Introduction: The intensive program using dynamic clothing and elastic cords is an innovative approach in pediatric physiotherapy area. Objective: To analyze the benefits of using dynamic clothes in intensive physical therapy protocols in patients with cerebral palsy. Methods: Electronic databases were used retrospectively without date restriction, in English, literatura de Portuguese and Spanish. The search focused on studies to document the use of Revisões intensive physical therapy protocols with the clothes on PC. Results: 14 stud- ies were reviewed 6 narrative reviews, 1 systematic review, 6 clinical trials and one case study. It was not possible to group the results due to the diversity of

protocols, the characteristics of the participants and the instruments used. Conclusion: All analysed studies reported improvement in gross motor control of patients, however, it is suggested the realization of double blind randomized and controlled clinical trials to prove the benefits of intensive physiotherapy programs with dynamic clothes. Keywords: Exercise Therapy; Neurological Rehabilitation; Psychomotor Performance.

Resumo Introdução: O programa de fisioterapia intensiva com a utilização de vestimentas dinâmicas e cordas elásticas é uma abordagem inovadora na área de fisioterapia neuropediátrica. Objetivo: analisar os benefícios da utilização dos trajes dinâmi- cos em protocolos de fisioterapia intensiva em pacientes com paralisia cerebral. Método: Foram consultadas bases de dados eletrônicas retrospectivamente, sem restrição de data, nos idiomas inglês, português e espanhol. A busca se concen- trou em trabalhos que documentassem o uso de protocolos intensivos de fisiote- rapia com a vestimenta na PC. Resultados: Foram revisados 14 estudos, sendo 6 revisões narrativas, 1 revisão sistemática, 6 ensaios clínicos e 1 estudo de caso. Não foi possível realizar o agrupamento dos resultados devido à diversidade dos protocolos, das características dos participantes e dos instrumentos utilizados. Considerações finais: Todos os estudos analisados relataram melhora na motri- cidade grossa dos pacientes, entretanto, sugere-se a realização de ensaios clínicos duplo cegos randomizados e controlados para comprovação dos benefícios de programas de fisioterapia intensiva com trajes dinâmicos. Descritores: Terapia por Exercício; Reabilitação Neurológica; Desempenho Psicomotor.

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Introduction In a search of the scientific literature found few studies that addressed intensive physiother- Among the diseases that cause neuromotor apy protocols in neuromotor rehabilitation child, deficits in childhood, non-progressive chronic because the use of dynamic clothing in PC reha- encephalopathy, also known as cerebral palsy bilitation is a new and innovative feature. Thus, (CP) is one of the most frequent. The PC runs this systematic literature review is to analyze the with sensory disorders, cognitive disorders, ab- benefits of using dynamic clothes in intensive normal patterns of posture and movement, and physiotherapy protocols used in CP patients. changes in postural tone1. The child with neuromotor deficits uses compensatory mechanisms to overcome the Methods force of gravity and get moving. Thus, the rep- etition in conducting such compensation creates In this systematic review, we consulted the muscle imbalances, deformity, stiffness, and electronic databases: MEDLINE, PEDro, Lilacs, loss of functionality2. Having physical therapy SciELO, Scopus, Web of Science retrospectively in order to seek to promote and restore func- without date restriction, using the keywords: Therasuit, Pediasuit, Suit Therapy, Adeli Suit, tionality, during the rehabilitation process is Penguin Suit, Penguin Suit, PediaSuit, Neuro¬Suit, very important that the therapist keep the child PolishSuit and Dynamic Suit. The search took in a proper postural biomechanical alignment3. place in English, Portuguese and Spanish. The This alignment facilitates the occurrence of vol- last consult was conducted in January 2015. untary movement in the closest possible to the Articles identified by the initial search standards as a typical, it promotes an adaptation strategy were evaluated independently by two in tonic activity4. authors, according to the following inclusion The literature reports some innovative criteria: (1) population (individuals with CP), (2) protocols that seem to extend the functional re- intervention (rehabilitation with use of dynamic habilitation possibilities of the patients with ce- clothes). Articles in another language or who rebral dysfunction and improve their quality of had repeated information available or other life5. As the intensive physical therapy program items were excluded. Such inclusion and exclu- that uses clothing stabilized by a dynamic sys- sion criteria were applied when there was dis- tem of elastic cords, this dynamic costume per- agreement between the opinion of evaluators. forms corrections in biomechanical alignment It previously selected 25 works by title con- that allow the learning of motor skills and gain tent. After reading the abstracts, 11 were exclud- 6 muscle strength . ed for not meeting the inclusion criteria: 8 for The dynamic costume appeared in Russian being in Russian, 1 as it is medical equipment research to develop a uniform that would pre- (not physical therapy), 1 because only possessed vent bone loss and muscle cosmonauts sub- the summary available for analysis and one for 7 mitted to travel with absence of gravity . From being comment. So, 14 trials were included to this, some have developed protocols intensive step review (Figure 1). therapy using these dynamic garments such as The methodological quality assessment Pediasuit the TheraSuit the PenguinSuit, and of the selected studies were conducted through the AdeliSuit5,8. These special garments are usu- PEDro scale, which rates trials with a score that ally composed of: vest, shorts, knee pads and ranges from 0 to 10 according to specific criteria9. shoes, equipped with hooks and elastic cords This score was stablished after the analysis of two that assist in positioning and alignment of body independent reviewers and the disagreements segments6. were solved by consensus after discussions. As the

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one after 4 months13 and another, nine months after the end of the study7. The common use of some as- sessment tools such as the Gross Motor Function Measure (GMFM) applied in six studies7,12-16 and the Gross Motor Function Classification System (GMFCS) in five studies, was observed7,13-16. The Pediatric Evaluation Disability Inventory (PEDI) was mentioned in two stud- ies14,15. The electroencephalogram11, the heart rate monitoring7, the three-dimensional gait analysis16, the wi-fi electrogoniometry15, and Figure 1: Flowchart of articles selection process the analysis of parental satisfac- tion14 were cited in only one study. Artigos quality of reports of randomized controlled trials The protocols are diverse and occur in a to- varies between subdisciplines of physiotherapy, in tal of fifteen12,14,16, twenty7,13 or twenty five15 ses- paediatric area the mean total PEDro score is 4.69 sions. The duration of each session varied from 10. Thus, this study considered that the papers with forty minutes11 to four hours of intervention14,16 score upper than 5 had a high quality. (some studies have used two7,12,13 or three16 hours of terapy). Intervention techniques contem- de literatura de 14-16 7,13-15 plated since heating , massage , stretch- Revisões Results ing7,12,14-15 and muscular strength training12-16, up training of functional skills7,11-16, osteopathy cra- 15 15 The 14 articles included in this systematic niosacral and kinesiotape . review are presented in Tables 1 and 2. In these In five studies there was explanation of tables there are the main characteristics of each some contraindications to the use of intensive study. Tables 1 shows the result of the analysis of physiotherapy with dynamic clothes, as spine clinical trials7,11-15 and case study16, and Table 2 of fracture7, dislocation or subluxation of the narrative reviews 3,6,17-20 and the systematic review5. hip7,13-15, severe scoliosis7,13,14,16, severe spasticity with contractures or other congenital deformi- ties7,11,12, epilepsy and neuromuscular dystro- Characterization, Assessment phies7,13, systemic and cardiac disorders13. Some and Intervention of Experimental researches14,16 specify that the contraindication Studies in subluxation occurs when the migration rate The sample size of the selected experi- is above 35% and in case of scoliosis when the mental studies ranged from two to 94 children. Cobb angle is greater than 25º. In experimental studies there was only one case study16, and six clinical trials7,11-15. Of those six clinical trials, four were randomized con- Characteristics of Studies Review trolled7,12,13,14, and, 2 without randomization and Of the seven studies revision included control group11,15. In randomized studies, there for analysis in this study, six were narrative re- were two blind ones12,14 and 2 with follow-up7,13, views3,6,17-20, and 1 systematic review5. There was

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Table 1: Description of the studies (clinical trials and case study) selected Author/ Year Type Participants Aims Tools Intervention Results PEDro Acquisition of voluntary 94 children Semyonova11, Motor control, walking Observation 30 to 40 motor skills, walking Clinical Trial with spastic 2/10 1996 and speech and EEG minutes improvement and dysarthria diplegia reduction Lower energy expenditure 24 children Randomized and improvement in with spastic controlled GMFCS, 20 sessions: functional status in Adeli diplegia, Functional status and Bar-Haim et clinical GMFM-66 and 5 days/week Suit and Bobath Therapy triplegia and metabolic expenditure 6/10 al.7, 2006 trial with monitoring 4 weeks Group. Children with quadriplegia, (climb stairs) follow-up in heart rate 2 hours/ day higher GMFM had a better and ataxic 9 months improvement in their energy quadriplegia expenditure Experimental group had Randomized 15 sessions: 30 children superior improvement in Jagatheesan12 controlled 5 days/week with spastic Functional status GMFM-88 GMFM than the control 4/10 et al., 2010 clinical blind 3 weeks diplegia group with conventional trial 2 hours/day physiotherapy Randomized Modified Adeli Suit 36 children controlled 20 sessions: Therapy Group obtained with spastic Mahani et clinical trial GMFCS, 5 days/week higher GMFM than diplegia and Functional status 6/10 al.13, 2011 with GMFM-66 4 weeks Adeli Suit Therapy and quadriplegia, follow-up in 2 hours/day Neurodevelopmental and dystonia 4 months Treatment Groups Experimental group Functional skills, improved their functional GMFCS, PEDI, Clinical trial caregiver assistance, 15 sessions: abilities and reduced the GMFM-66 Bailes et al.14, randomized 20 children functional status, 5 days/week need for caregiver assist- and parental 7/10 2011 blind with CP perception of parents 3 weeks ance. All parents reported satisfaction controlled about comfort and 4 hours/day some degree of discomfort assessment improvement and some were in doubt about the improvement GMFCS, 25 sessions: Improvement in functional Neves et al.15, 22 children Functional status and GMFM-88, Wifi 5 days/week Clinical Trial status and reduction in the 4/10 2013 with PC trunk control electrogoniom- 5 weeks trunk swing etry 3 hours/day Functional skills, GMFCS, Minimal changes and small caregiver assistance, PEDI, GMFM 15 sessions: reductions in functional Bailes et al.16, 2 children functional status, (dimensions D 5 days/week abilities and in caregiver Case Study 3/10 2010 with diplegia motor skills standing, and E), three- 3 weeks assistance. Minimal walking, running and dimensional 4 hours/day changes in motor skills to jumping gait analysis stand, walk, run and jump GMFCS= Gross Motor Function Classification System; GMFM= Gross Motor Funcion Measure; PEDI= Pediatric Evaluation of Disability Inventory.

no systematic review with meta-analysis of reg- Discussion istration in searches carried out in databases. In narrative reviews it was found that four of them The studies used in this review are, except ranged various techniques and rehabilitation the narrative and systematic reviews, different treatment described as alternative and comple- in matter of the participant’s profile, type of in- mentary17-20 and the intensive therapy protocol tervention and defining the outcome. However, with dynamic garment has been classified and many authors of systematic reviews tend to only described as one of these techniques3. communicate the positive results of clinical tri-

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Table 2: Description of the selected revisions Author/ Year Study Type Aim Results Discuss difficulties to hit Briefly discusses various techniques, among them the Rosembaum17, Narrative a treatment for CP and Adeli Suit, which mentions only that the technique itself 2003 review consider rules to analyze are controlled exercises against resistance (strengthening). a new treatment Review 9 modalities The benefits of the technique are: muscle strengthening, Narrative of complementary and Liptak18, 2005 posture and coordination improvement, increased sensory review alternative therapies for and proprioceptive information. children with CP. Discuss 11 comple- Includes some risks and benefits. Among them the Adeli Oppenheim19, Narrative mentary and alternative suit therapy that has specific accessories and coupling 2009 review methods of treatment the elastic cords able to offer strength and support to the of PC. movement. Describes Adeli Suit therapy benefits to strength and Analyze the rehabilita- sensory feedback. Points out that the technique prevents tion of orthoses, drug Papavasilion20, Narrative osteoporosis, reduces and dysarthria, stimulates therapy, and comple- 2009 review the vestibular system, improves mechanical efficiency, mentary and alternative promotes gross motor skills gains, and that presence of a treatments for PC. family member in intensive therapy bring engagement. States that the protocol combines intensive physiotherapy Describe the protocol with dynamic clothes up to 4 hours per day, five days a Artigos PediaSuitTM to facilitate week for 3 or 4 weeks in 4 steps: heating and stretching, Scheeren6, Narrative the occurrence of dynamic costume, “monkey cage” and “spider cage”. 2012 review functional ability in Describes the interventions at each step and the com- patients with neurological ponents of the dynamic costume: vest, short, keepads, disorders. shoes, hooks and elastic cords. Indicates resources for monitoring the results: AIMS, Discuss the benefits of GMFM, GMFCS; force platform, wifi electrogoniometry, Narrative intensive physical therapy Neves3, 2013 electromyography, mechanomyography and DEXA. literatura de review protocol with dynamic Revisões Reported that this is a comprehensive approach that clothes. combines the best elements of several techniques. Determine intensive phys- There is insufficient evidence to support the clinic and that

Systematic iotherapy using clothes Frange5, 2012 there is need for further studies involving dynamic clothes Review with elastic benefits to and intensive physiotherapy practice. neurological deficits. AIMS= Albert Infant Motor Scale; PEDI= Pediatric Evaluation of Disability Inventory; GMFM= Gross Motor Funcion Measure; GMFCS= Gross Motor Function Classification System; DEXA= Dual-energy X-ray Absorptiometry. Note: literature reviews found in this study are narrative reviews, addressing the subject broadly and without pre-established selection methodology, like book chapters21,22. als, that is, the results of interventions that took provide functional improvement, maintenance effect23. It is also important to present the nega- and reduction of motor deficits. This occurs tive results of the studies and their limitations, through the stimulation of motor development, since professionals, who are in the clinic, need strengthening and muscle stretching5. These this information to improve your practice24. The protocols are based on three principles: 1) the ef- heterogeneity in the samples of experimental fect of clothing, generating load / resistive volt- studies reviewed did not allow a thorough com- age applied to the muscles (muscle-building), parative analysis. increasing proprioception and biomechanical It can be noticed that the intensive physi- alignment (antigravity postures that organize cal therapy protocols with dynamic garments tone); 2) intensive physical therapy training of are used in neurological patients, in order to motor skills (exercises with prolonged duration

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and daily sessions over a period of a few weeks) the studies, the results shows few effectiveness and 3) the active participation of the patient mo- when compared to conventional techniques, as tor (proposing activities of functional context)25. found in other systematic reviews about reha- The theory involving the benefits of using dy- bilitation28,29. This fact suggests de necessity of namic clothes is the occurrence of different more studies in this area. proprioceptive sensory stimuli11,26. Within this paradigm, the tonic-postural reorganization promotes learning and motor control suitable27. Conclusion The review that there is no single form of technical application, as there are different proto- The intensive physiotherapy protocol as- cols. There are variations in the number of hours sociated with the use of dynamic clothes in PC per day, the total number of days and also used is a promising feature that still needs inves- in the treatment management, making it impos- tigation. Due to lack of standardization in the sible the comparison between the found inter- methodology of the studies conducted so far, vention programs. It is noted that despite the it is difficult to say precisely what are the ben- absence of standards, all studies used pipes with efits of the technique and if these are superior a focus on functional training skills and 70% (5 to other techniques. There was the emergence of studies) dedicated part of the intervention time a name with a focus on technical methodology, massage7,11-13,16 and stretching exercises 7,12,14-16 and Intensive Therapy Neuromotor (TNMI) encom- strengthening12-16. In addition, one study showed passing the intensive physical therapy protocols a more complete protocol covering all lines of using dynamic clothes and conventional reha- other studies and included the application of cra- bilitation techniques. niosacral osteopathy and Kinesiotape15. It was verified the influence potential of Some of the reviewed studies refers to the technique on the evolution of the motor ca- the intensive therapy protocol with dynamic pacity in neuropediatric patients, which indi- clothes as a complementary and alternative cates the need for the realization of double blind technique17-20. Others also shows that different randomized and controlled clinical trials, and classifications are used to refer to the protocols studies with similar goals and methodologies as Therasuit, Pediasuit, Suit Therapy, Adeli Suit for allow researchers to conducting meta-anal- and Intensive Therapy Neuromotor (TNMI)15. ysis in order to conclude if dynamic clothes rise The analysed experimental studies em- the gains in therapy or not. ployed with great frequency instruments such as the GMFM (85%) and the GMFCS (70%) to measure the evolution of patients, but the rating References scales are subjective and its reliability could be increased in the existence of a double blind re- 1. Rosenbaum P, Paneth N, Leviton A, Goldstein M, view . Another instrument used in 30% of stud- Bax M, Damiano D et al. A report: the definition and classification of cerebral palsy April 2006. Dev Med ies was the PEDI scale in which parents or care- Child Neurol Suppl. 2007; 49(s109):8–14. givers are the informants and are responsible for the participant, a fact that also increases the 2. Forti-Bellani CD, Castilho-Weinert LV. Desenvolvimento motor típico, desenvolvimento subjectivity of the results. motor atípico e correlações na paralisia cerebral. It would therefore be of great value the use In: Castilho-Weinert LV, Forti-Bellani CD, editors. of objective tools and the measurement of the Fisioterapia em Neuropediatria. Curitiba: Omnipax; elastic tension and standardization in its posi- 2011. p.1-22. tioning for attesting the intensive protocol effi- 3. Neves EB. Trends in neuropediatric physical ciency and clothes. Despite the good quality of therapy. Front Public Health. 2013;1:1-2.

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