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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]
luciana.weinert@ufpr.br

Artigos
Abstract
Introduction: The intensive physical therapy program using dynamic clothing
and elastic cords is an innovative approach in pediatric neurology 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,

de literatura
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.

ConScientiae Saúde, 2016;15(2):297-303. 297


Use of dynamic clothes in cerebral palsy rehabilitation: systematic review

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:
tionality, during the rehabilitation process is Therasuit, Pediasuit, Suit Therapy, Adeli Suit,
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-
muscle strength6. 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
mitted to travel with absence of gravity7. 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

298 ConScientiae Saúde, 2016;15(2):297-303.


Weinert LVC, Neves EB

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-
plated since heating14-16, massage7,13-15, stretch-

de literatura
Results

Revisões
ing7,12,14-15 and muscular strength training12-16, up
training of functional skills7,11-16, osteopathy cra-
The 14 articles included in this systematic niosacral15 and kinesiotape 15.
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 trials 7,11-15
and case study , and Table 2 of
16
fracture7, dislocation or subluxation of the
narrative reviews 3,6,17-20
and the systematic review .
5
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 group . In randomized studies, there
11,15
for analysis in this study, six were narrative re-
were two blind ones12,14 and 2 with follow-up 7,13, views 3,6,17-20, and 1 systematic review5. There was

ConScientiae Saúde, 2016;15(2):297-303. 299


Use of dynamic clothes in cerebral palsy rehabilitation: systematic review

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. , 2006
7
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 techniques 3. communicate the positive results of clinical tri-

300 ConScientiae Saúde, 2016;15(2):297-303.


Weinert LVC, Neves EB

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
Liptak , 2005
18
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 ataxia 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
PediaSuitTM to facilitate

Artigos
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.
review protocol with dynamic

de literatura
Reported that this is a comprehensive approach that

Revisões
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
Frange , 2012
5
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
effect 23. 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

ConScientiae Saúde, 2016;15(2):297-303. 301


Use of dynamic clothes in cerebral palsy rehabilitation: systematic review

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- bilitation 28,29. 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
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