Management of upper limb dysfunction in children with cerebral palsy: a systematic review

A bibliometric analysis of cerebral palsy from 2003 to 2022

Purpose

This bibliometric study explores cerebral palsy (CP) research from 2003 to 2022 to reveal the topic hotspots and collaborations.

Methods

We retrieved studies on CP from the Web of Science Core Collection from 2003 to 2022 and then used CiteSpace and Bibliometrix to perform a bibliometric analysis and attain knowledge mapping, including publication outputs, funding, journals, authors, institutions, countries/territories, keywords, collaborative relationships, and topic hotspots.

Results

In total, 8,223 articles were published from 2003 to 2022. During this period, the number of publications increased continuously. Developmental Medicine and Child Neurology was the most productive and frequently co-cited journal. Boyd was the most productive and influential author, with 143 publications and 4,011 citations. The United States and Vrije Universiteit Amsterdam were the most productive countries and institutions, respectively. Researchers and institutions from the USA, Australia, and Canada constituted the core research forces, with extensive collaborations worldwide. The most common keywords were gait (553), rehabilitation (440), spasticity (325), botulinum toxin (174), therapy (148), upper extremity (141), quality of life (140), disability (115), pain (98), electromyography (97), kinematics (90), balance (88), participation (85), and walking (79).

Conclusion

This study provides a systematic and comprehensive analysis of the CP-related literature. It reveals that Developmental Medicine and Child Neurology is the most active journal in this field. The USA, Vrije Universiteit Amsterdam, and Boyd are the top countries, institutions, and authors, respectively. Emerging treatment methods, complication management, and functional recovery comprise the future research directions and potential topic hotspots for CP.

Effectiveness of virtual reality interventions of the upper limb in children and young adults with cerebral palsy: A systematic review with meta-analysis

OBJECTIVE

To examine the characteristics and the effectiveness of virtual reality systems on upper limb impairments in children and young adults with cerebral palsy.

DATA SOURCES

An electronic search was conducted on PubMed, PEDro, Web of Science, Central, and EMBASE.

METHODS

The protocol of this review was prospectively registered in the PROSPERO database (CRD42022302271). Randomized controlled trials that tested the effects of virtual reality-based interventions on the upper limb of participants with cerebral palsy were included. The methodological quality of the studies was measured by the PEDro scale. The certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation. The data of the studies were analyzed in meta-analysis and presented in forest plots and narrative synthesis.

RESULTS

Twenty-two studies involving 746 participants were included. Ten different virtual reality systems were used in the interventions, of which six were designed specifically for rehabilitation and four commercial video games. We found an effect in favor of virtual reality when it was used in combination with conventional therapy for upper limb activity (SMD = 0.65; 95% CI (0.19 to 1.11)). However, the certainty of the evidence of the comparisons ranged from very low to low.

CONCLUSION

Virtual reality seems to be an effective tool for upper limb activity in children and young adults with cerebral palsy. Nevertheless, future studies should present a better methodological quality, a larger sample size, and well-defined rehabilitation programs to reduce the inconsistency of the evidence in this domain.

Exploring relevant parameters and investigating their reproducibility of task-oriented unimanual strength measurement in children with unilateral cerebral palsy

PURPOSE

To explore relevant parameters and investigate their test-retest reliability within the scope of the push button task of the Task-oriented Arm-hAnd Capacity (TAAC) measured in children with unilateral Cerebral Palsy (CP).

METHODS

118 children diagnosed with unilateral CP, aged between 6 and 18 years, participated in this study. Thetest-retest reliability of the force generated during the push button task of the TAAC was investigated using an intraclass correlation (ICC) two-way random model with absolute agreement. The ICCs were calculated across the whole age group and for two separate age subgroups (6-12 and 13-18 years).

RESULTS

Test-retest reliability of the parameters "mean peak force of all attempts", "overshoot of force", "number of successful attempts" and "time to complete four successful attempts" were moderate to good (ICC range 0.667-0.865; 0.721-0.908; 0.733-0.817, respectively).

CONCLUSIONS

The results showed moderate to good test-retest reliability for all parameters. The parameters "mean peak force" and "number of successful attempts" are the most relevant parameters, as these parameters are task-specific and the most functional for clinical practice.Implications for RehabilitationClinical relevant information about the use of task-oriented strength during the performance of daily activity has been added to strength measurements in children with Cerebral Palsy.The Task-oriented Arm-hAnd Capacity instrument is a reliable, objective and simple instrument to measure task-oriented strength during daily activity and is ready for use in a clinical setting.The Task-oriented Arm-hAnd Capacity instrument is both a capacity and performance-based test.The measurement with the push button task showed moderate to good test-retest reliability.

Design and custom fabrication of specialized orthoses for the upper-limb stabilization in childhood dyskinesia

BACKGROUND

Childhood dyskinesia (CD) is a complex movement disorder with components of dystonic and hyperkinetic nature, characterized by involuntary, sometimes stereotypical postures and gestures that are often impossible to control and hinder the execution of willful motion. The standard orthoses for the treatment of neurological diseases, including CD, are generally poorly differentiated for functional characteristics. The application of similar devices for movement disorders is far less generalized because of the very different symptoms, including the incapacity to control rather than initiate movement.

OBJECTIVES

This article aims to describe an innovative method to fabricate personalized orthoses for the elbow-wrist joints in CD, taking into account anatomical and functional diversities. It also proposes functional elements to implement the required dynamic postural control.

METHODS

Wearable custom-made upper-limb orthoses have been fabricated and preliminarily tested on five patients with CD. Optoelectronic stereophotogrammetry was used as an innovative tool for all-in-one-frame acquisition of limb geometry. A new process for the functional personalization of the orthoses has been developed using shape memory alloys.

CONCLUSIONS

The innovative method presented, encompassing data acquisition, virtual design, fabrication, and assembling, overcomes the problems due to the involuntary movements of the patients, which cannot be avoided during the fitting operations, providing comfortable and useful orthoses with minimal nuisance for the patients. Initial tests show that the orthoses were well tolerated by all the subjects; the promising comments of caregivers, together with improvements, were observed by the clinicians using specific clinical scales.

Modified constraint induced movement therapy in children with obstetric brachial plexus palsy: a systematic review

INTRODUCTION

Obstetric brachial plexus palsy (OBPP) is a flaccid paralysis occurring in the upper limb during birth. The OBPP includes mild lesions with complete spontaneous recovery and severe injuries with no regain of arm function. Among the most promising rehabilitation treatments aimed at improving upper extremity motor activities in individuals with neurological dysfunctions, there is the modified constraint-induced movement therapy (mCIMT). The aim of this systematic review is to assess and synthesize the critical aspects of the use of mCIMT in children with OBPP.

EVIDENCE ACQUISITION

This systematic review has been carried out according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analysis). A comprehensive search of the literature was conducted using PubMed, MEDLINE and Evidence Based Medicine Reviews, databases. We enclosed experimental and original articles, case reports and book chapters. Four articles were finally included.

EVIDENCE SYNTHESIS

One case report tested the feasibility of mCIMT to encourage use of the affected arm in a child with Erb-Duchenne palsy and documented the clinical changes observed. A case series had the purpose to determine if mCIMT in combination with botulinum toxin (BTX-A) improved arm function in 2 children with OBPP. A cohort study compared the use of mCIMT in 19 OBPP and 18 unilateral Cerebral Palsy. A prospective single-blind RCT described mCIMT versus conventional therapy in a group of 39 children with OBPP.

CONCLUSIONS

This systematic review on the use of mCIMT in children with OBPP shows that there is unanimous agreement that a program should last 2 weeks at least. However, there is no scientific evidence supporting a single common mCIMT protocol in the management of OBPP because of a considerable heterogeneity. Further high methodological studies regarding the application of mCIMT for OBPP and based on larger patients' sample should have the potential to optimize the appropriateness of care provided to infants with OBPP and, therefore, their quality of life.

Rhythm and Music-Based Interventions in Motor Rehabilitation: Current Evidence and Future Perspectives

Research in basic and clinical neuroscience of music conducted over the past decades has begun to uncover music’s high potential as a tool for rehabilitation. Advances in our understanding of how music engages parallel brain networks underpinning sensory and motor processes, arousal, reward, and affective regulation, have laid a sound neuroscientific foundation for the development of theory-driven music interventions that have been systematically tested in clinical settings. Of particular significance in the context of motor rehabilitation is the notion that musical rhythms can entrain movement patterns in patients with movement-related disorders, serving as a continuous time reference that can help regulate movement timing and pace. To date, a significant number of clinical and experimental studies have tested the application of rhythm- and music-based interventions to improve motor functions following central nervous injury and/or degeneration. The goal of this review is to appraise the current state of knowledge on the effectiveness of music and rhythm to modulate movement spatiotemporal patterns and restore motor function. By organizing and providing a critical appraisal of a large body of research, we hope to provide a revised framework for future research on the effectiveness of rhythm- and music-based interventions to restore and (re)train motor function.

Muscle Selection and Dosing in a Phase 3, Pivotal Study of AbobotulinumtoxinA Injection in Upper Limb Muscles in Children With Cerebral Palsy

Background: Guidelines recommend botulinum toxin-A in pediatric upper limb spasticity as part of routine practice. Appropriate dosing is a prerequisite for treatment success and it is important that injectors have an understanding on how to tailor dosing within a safe and effective range. We report upper limb dosing data from a phase 3 study of abobotulinumtoxinA injections in children with cerebral palsy.

Methods: This was a double-blind, repeat-treatment study (NCT02106351). In Cycle 1, children were randomized to abobotulinumtoxinA at 2 U/kg control dose or clinically relevant 8 U/kg or 16 U/kg doses. Doses were divided between the primary target muscle group (PTMG, wrist or elbow flexors) and additional muscles tailored to clinical presentation. During Cycles 2–4, children received doses of 8 U/kg or 16 U/kg and investigators could change the PTMG and other muscles to be injected. Injection of muscles in the other upper limb and lower limbs was also permitted in cycles 2–4, with the total body dose not to exceed 30 U/kg or 1,000 U (whichever was lower) in the case of upper and lower limb treatment.

Results: 212 children were randomized, of which 210 received ≥1 abobotulinumtoxinA injection. Per protocol, the elbow and wrist flexors were the most commonly injected upper limb muscles. Across all 4 cycles, the brachialis was injected in 89.5% of children (dose range 0.8–6 U/kg), the brachioradialis in 83.8% (0.4–3 U/kg), the flexor carpi ulnaris in 82.4% (0.5–3 U/kg) and the flexor carpi radialis in 79.5% (0.5–4 U/kg). Other frequently injected upper limb muscles were the pronator teres(70.0%, 0.3–3 U/kg). adductor pollicis (54.3%, 0.3-1 U/kg), pronator quadratus (44.8%, 0.1–2 U/kg), flexor digitorum superficialis (39.0%, 0.5-4 U/kg), flexor digitorum profundus (28.6%, 0.5–2 U), flexor pollicis brevis/opponens pollicis (27.6%, 0.3-1 U/kg) and biceps (27.1%, 0.5–6 U/kg). AbobotulinumtoxinA was well-tolerated at these doses; muscular weakness was reported in 4.3% of children in the 8 U/kg group and 5.7% in the 16 U/kg group.

Conclusions: These data provide information on the pattern of injected muscles and dose ranges used in this study, which were well-tolerated. Per protocol, most children received injections into the elbow and wrist flexors. However, there was a wide variety of other upper limb muscles injected as physicians tailored injection patterns to clinical need.

Modified constraint-induced movement therapy during hospitalization in children with perinatal brachial plexus palsy: A randomized controlled trial

STUDY DESIGN

Prospective single-blind, randomized controlled study.

INTRODUCTION

Children with perinatal brachial plexus palsy (PBPP) have motion limitations in the affected upper extremity. Modified constraint-induced movement therapy (mCIMT) is one of the treatment options used for the improvement of the function of the affected limb.

PURPOSE OF THE STUDY

The purpose of this study was to compare the effect of mCIMT and conventional therapy in improving active range of motion (ROM) and functional use of the affected upper extremity in children with PBPP with injuries to upper and middle trunks in the hospital environment.

MATERIALS

26 patients received conventional rehabilitation program (control group) and 13 patients participated in a mCIMT program (study group). Children had a mean age 56.3 months (range 4-10 years). The mCIMT included 1 hour therapy sessions emphasizing the affected arm use for 14 consecutive days during hospitalization. Their normal arm was also constrained for 6 hour per day. All the patients were assessed at the baseline, one day, one month, and three months after completion of therapy using active ROM, active movement scale, hand dynamometer, box and blocks test.

RESULTS

The mCIMT group improved more than the control group in shoulder internal rotation, forearm supination, elbow flexion active ROMs, hand grip strength, and in upper extremity function.

CONCLUSION

mCIMT has a potential to promote functional gains for children with PBPP; this approach should be widely applied within routine clinical practice.

Efficacy and safety of onabotulinumtoxinA with standardized occupational therapy for treatment of pediatric upper limb spasticity: Phase III placebo-controlled randomized trial

BACKGROUND:

This is the first large study of onabotulinumtoxinA as treatment for pediatric upper limb spasticity.

OBJECTIVE:

Evaluate efficacy and safety of a single treatment with onabotulinumtoxinA plus occupational therapy (OT).

METHODS:

In this registrational phase III, multinational study (NCT01603602), participants were randomized 1:1:1 to onabotulinumtoxinA 3 U/kg/OT, 6 U/kg/OT, or placebo/OT. Primary endpoint was average change from baseline at weeks 4 and 6 in Modified Ashworth Scale-Bohannon (MAS) score. Secondary endpoints included Modified Tardieu Scale (MTS), Clinical Global Impression of Change (CGI) and functional Goal Attainment Scale (GAS).

RESULTS:

235 participants were randomized. At weeks 4 and 6, onabotulinumtoxinA groups had greater mean reductions in MAS (both –1.9; p < 0.001) versus placebo (–1.2). OnabotulinumtoxinA doses improved dynamic tone per MTS. Mean CGI at weeks 4 and 6 was unchanged in the overall population, but improved in a post hoc analysis of patients with a single affected upper limb (UL) muscle group (elbow or wrist). GAS score for passive goals was significantly higher for 6 U/kg versus placebo at week 12. Most AEs were mild/moderate in severity; overall incidence was similar between groups.

CONCLUSIONS:

OnabotulinumtoxinA (3 and 6 U/kg) was safe and effective in reducing upper limb spasticity in pediatric participants.

Decision-making aids for upper limb interventions in neurological rehabilitation: a scoping review

PURPOSE

To summarise the range and nature of decision-making aids that guide upper limb (UL) neurorehabilitation.

METHODS

Our scoping review followed Arksey and O'Malley's 6-step framework. Electronic databases were systematically searched; grey literature was hand-searched. Included papers were: (1) published in English; (2) related to UL rehabilitation for people with upper motor neuron conditions; and (3) provided a description of, or research on, a decision-making aid that guides therapists when choosing between two or more intervention approaches, techniques, or applications of a technique. Levels of evidence were rated. An expert panel of occupational therapists working in UL neurorehabilitation was consulted.

RESULTS

The 24 included articles described 15 decision-making aids with varying breadth and depth of the assessment process and suggested interventions. Six aids had published research, but lacked high quality evidence. The expert panel identified four key decision-making aids as being clinically useful. Preferred aids either included client-centred goal-setting within a holistic assessment or matched specific intervention options to distinct UL assessment results. Prompts to re-evaluate client performance are desirable.

CONCLUSION

Few decision-making aids guide therapists to holistically assess and make specific intervention decisions across all domains of UL neurorehabilitation. Their usefulness depends on the purpose, setting, and therapist experience.Implications for rehabilitationConsidering the complexity and heterogeneity of upper limb (UL) neurorehabilitation, a selection of evidence-based and purpose-designed decision-making aids may assist therapists across different experience levels and practice settings to choose individualised interventions.Decision-making aids for UL interventions in neurorehabilitation may be more clinically useful if they include a holistic and client-centred information gathering process that focuses on daily life goals.Decision-making aids should illustrate a clear clinical picture based on UL assessment results, with corresponding UL intervention recommendations provided.Inclusion of a cyclic process to re-evaluate client performance and function could also enhance the usefulness of a decision-making aid.

Efficacy and safety of abobotulinumtoxinA for upper limb spasticity in children with cerebral palsy: a randomized repeat-treatment study

AIM

To assess the efficacy and safety of repeat abobotulinumtoxinA injections in reducing upper limb spasticity in children with cerebral palsy (CP).

METHOD

This was a double-blind, repeat-cycle study (NCT02106351) in children with CP (2-17y). Children were randomized to receive 2U/kg (control), 8U/kg, or 16U/kg abobotulinumtoxinA injections into the target muscle group (wrist or elbow flexors) and additional muscles alongside occupational therapy via a home-exercise therapy program (HETP; minimum five 15min sessions/wk). Children received 8U/kg or 16U/kg plus HETP in cycles 2 to 4.

RESULTS

During cycle 1, 210 children (126 males, 84 females; mean age [SD] 9y [4y 5mo], range 2-17y; n=70/group) had at least one upper limb abobotulinumtoxinA injection and 209 complied with the HETP. At week 6 of cycle 1, children in the 8U/kg or 16U/kg groups had significantly lower Modified Ashworth scale scores versus the 2U/kg group (primary outcome: treatment differences of -0.4 [p=0.012] and -0.7 [p<0.001] respectively). All groups improved on Physician Global Assessment and children in all groups achieved their treatment goals at least as expected. Therapeutic benefits were sustained during cycles 2 to 4; muscular weakness was the only treatment-related adverse event reported in at least one child/group (4.3% and 5.7% vs 1.4% respectively).

INTERPRETATION

Treatment with 8U/kg or 16U/kg abobotulinumtoxinA significantly reduced upper limb spasticity versus the 2U/kg control dose. Therapeutic benefits of abobotulinumtoxinA plus HETP were sustained with repeat treatment cycles.

WHAT THIS PAPER ADDS

AbobotulinumtoxinA injections significantly reduced upper limb spasticity in children with cerebral palsy. Children treated with abobotulinumtoxinA and targeted home exercises showed global improvement and goal attainment. Benefits were sustained over 1 year with repeat cycles of abobotulinumtoxinA and home exercises. AbobotulinumtoxinA injections into the upper limb were well tolerated over 1 year.

Validity and reliability of the Turkish versions of Assessment of Children's Hand Skills and Children's Hand-Skills Ability Questionnaire in children with hemiplegic cerebral palsy

BACKGROUND

Assessment of Children's Hand Skills (ACHS) and Children's Hand-Skills Ability Questionnaire (CHSQ) are interconnected hand skills assessment tools that together contain parent questionnaire and observational assessment. With this quality, ACHS and CHSQ enable the therapist to obtain information about the child's real-life performances as well as to conduct a clinical observational assessment. The purpose of this study was to investigate the validity and reliability of the Turkish versions of ACHS and CHSQ in children with hemiplegic cerebral palsy (HCP).

METHODS

A total of 112 children with HCP between 2 and 12 years of age were included. All participants were subjected to ACHS, CHSQ, Shriners Hospital Upper Extremity Evaluation (SHUEE) and ABILHAND-Kids. Convergent construct validity was investigated through analysing the relationship between ACHS and SHUEE and between CHSQ and ABILHAND-Kids. Discriminative construct validity was investigated through analysing the differences between genders for CHSQ and ACHS. For reliability, test-retest interclass correlation coefficient (ICC) and internal consistency Cronbach's alpha were calculated and analysed.

RESULTS

ACHS showed very strong relationships with SHUEE's spontaneous functional analysis (r = 0.86) and grip-release function (r = 0.86) parameters with a strong relationship with positional dynamic analysis (r = 0.78). CHSQ's leisure (r = 0.80), school/education (r = 0.75) and activities of daily living (r = 0.76) domains showed strong relationships with the ABILHAND-Kids. There was no difference between genders for ACHS and all domains of CHSQ (p > 0.05). All domains and total score of ACHS and CHSQ had perfect test-retest reliability (ICC > 0.90). ACHS had perfect internal consistency (Cronbach's α = 0.98); CHSQ had very high internal consistency (Cronbach's α = 0.84).

CONCLUSIONS

The Turkish versions of ACHS (ACHS-TR) and CHSQ (CHSQ-TR) are valid and reliable hand skills assessment tools in children with HCP.

Effects of transcranial direct current stimulation combined with cognitive orientation to daily occupational performance in children with cerebral palsy: a protocol for a randomised controlled trial

Background/Aims

Children with hemiplegic cerebral palsy have limitations in activities requiring reach and manipulation of objects with their affected upper extremity. Transcranial direct current stimulation and the cognitive orientation to occupational performance approach are relatively new interventions that may lead to promising results for these children. This article describes the method of a randomised clinical trial that will compare the effects of the combination of transcranial direct current stimulation and cognitive orientation to daily occupational performance with transcranial direct current stimulation and neurodevelopmental treatment.

Methods

A four-armed clinical trial with a sample size of 36 participants will be performed in Tehran. Participants will be randomly divided into four groups. Group A will receive neuro-developmental treatment with sham transcranial direct current stimulation, group B will receive neurodevelopmental treatment with transcranial direct current stimulation, group C will receive cognitive orientation to daily occupational performance with sham transcranial direct current stimulation, and group D will receive cognitive orientation to daily occupational performance with transcranial direct current stimulation. The examiner will be blind to the study and assessments will be done at baseline, after the end of the intervention and 1 month after the completion of the intervention (as follow up). Data analysis will be as repeated measure analysis of variance and intention to treat.

Conclusions

This article describes the protocol of a clinical trial that compares the effects of the combination of transcranial direct current stimulation and cognitive orientation to daily occupational performance with the combination of transcranial direct current stimulation and neurodevelopmental treatment on upper extremity goals and functions of children with hemiplegic cerebral palsy.

Construct Validity of a Task-Oriented Bimanual and Unimanual Strength Measurement in Children With Unilateral Cerebral Palsy

OBJECTIVE

The purposes of this study were to (1) investigate aspects of construct validity of peak force measurements of crate-and-pitcher tasks using the Task-oriented Arm-hAnd Capacity (TAAC), an instrument designed to measure task-oriented arm and hand strength for cross-sectional and evaluation purposes, and (2) compare TAAC measurements with those of comparative measures using COSMIN guidelines.

METHODS

In this cross-sectional validity study, participants were 105 children (mean age = 12 years 10 months; number of boys = 66) diagnosed with unilateral cerebral palsy (UCP). Ten a priori hypotheses were formulated with peak force of the TAAC as index measure and compared with measures on body functions and structure and activity level of the International Classification of Functioning, Disability and Health for Children and Youth. Strength and direction of the relationship between the TAAC and comparative measures were investigated by calculating Pearson correlation coefficients (r).

RESULTS

On body functions and structures level, low-to-moderate positive correlations (0.493-0.687) were found. On activity level, low negative and positive correlations (-0.271 to 0.387) were found.

CONCLUSION

The construct of peak force measurement of the TAAC is in line with the a priori hypotheses with comparators on body function and structures and activity level, indicating a partial overlap of the construct of the TAAC with both International Classification of Functioning levels. The TAAC appears to be valuable, as it measures functional strength that differs from the constructs of the comparators. More research with a larger population and more comparators is needed.

IMPACT

Clinically relevant information is lacking about the use of strength and strength measurement during daily activities in children with UCP. This study shows that the TAAC provides unique information about functional strength in children with UCP.

Effectiveness of virtual reality in the treatment of hand function in children with cerebral palsy: A systematic review

STUDY DESIGN

Systematic review.

INTRODUCTION

Children with cerebral palsy (CP) may have limited use of their hands for functional activities and for fine motor skills. Virtual reality (VR) is a relatively new and innovative approach to facilitate hand function in children with CP.

PURPOSE OF THE STUDY

The primary purpose of this study was to determine the effectiveness of VR as an intervention to improve hand function in children with CP compared to either conventional physiotherapy or other therapeutic interventions. The secondary purpose was to classify the outcomes evaluated according to the International Classification of Functioning, Disability and Health (ICF) dimensions.

METHODS

A International prospective register of systematic reviews (PROSPERO)-registered literature search was carried out in August 2015 in MEDLINE, CINAHL, ERIC, HealthSTAR, AMED, BNI, Embase, PsycINFO, PEDro, Cochrane Central Register, DARE, OTSeeker, REHABDATA, HaPI, CIRRIE, and Scopus. PRISMA guidelines were followed. Only randomized controlled trials (RCTs) were included, and their methodological qualities were examined using the Cochrane collaboration's risk of bias (RoB) tool. A narrative synthesis was performed.

RESULTS

The 6 RCTs published on this topic provide conflicting results. Four studies reported improved hand function (2 low RoB, 1 high RoB, and 1 unclear RoB), whereas 2 studies reported no improvement. All of the RCTs reported the activity element of ICF, but no study explicitly described the effect of VR intervention based on the ICF model.

CONCLUSION

The role of VR ti imrpove hand fucntion in children with CP is unclear due to limited evidence; use as an adjunct has some support.

Effects of upper extremity surgery on activities and participation of children with cerebral palsy: a systematic review

AIM

To evaluate and synthesize the evidence for effects of upper extremity surgery (UES) on activities and participation of children and adolescents with cerebral palsy (CP).

METHOD

The databases MEDLINE, Embase, and PsycINFO were searched for publications up to September 2018. Studies included were comparative studies with or without concurrent comparison groups or case series with pretest/posttest outcomes with a minimal sample size of 10 participants; those that reported the effects of UES with a follow-up time of at least 5 months; those including patients diagnosed with CP aged up to 20 years; and those that used a validated activity-based instrument. Risk of bias was assessed using the ROBINS-I (Risk Of Bias In Non-randomised Studies - of Interventions) tool and quality assessment was performed using the Grading of Recommendations Assessment, Development and Evaluation.

RESULTS

Twelve studies, involving 310 children and adolescents, were included. The ability and perception of the patient to use the hand(s) and perform activities (measured with the Shriners Hospital Upper Extremity Evaluation, Assisting Hand Assessment, and House Functional Classification) improved significantly after UES. The quality of evidence was very low for each of the activity outcomes of interest.

INTERPRETATION

The very low evidence prohibits recommendations on the use of UES to guide clinical practice. More high-quality comparative studies are needed to obtain better insight into the effects of UES on activities and participation.

WHAT THIS PAPER ADDS

Low quality of evidence for effects of upper extremity surgery (UES) on activities and participation. Limited evidence for improvement in activities and participation after UES.

Upper limb impairments, process skills, and outcome in children with unilateral cerebral palsy

AIM

To examine the relationships between upper limb impairments and independence in self-care (ISC) in children with unilateral cerebral palsy (CP).

METHOD

One hundred and eight children with unilateral CP (46 females, 62 males; mean age 8y 7mo, SD 3y 9mo) recruited from a population register were assessed for upper limb muscle power, spasticity, sensation, motor control, and process skills, and for ISC as the functional outcome using structural equation modelling.

RESULTS

The model showed good fit indices and explained 90% of the variance in ISC. Direct effects were significant between manual ability and ISC (β=0.47), and process skills and ISC (β=0.63). Sensation had a significant positive indirect effect on ISC through manual ability (β=0.24) and a positive but marginally non-significant indirect effect through process skills (β=0.21, bootstrapped 95% confidence interval -0.05 to 0.55). Spasticity had a significant negative indirect effect on ISC through its effect on manual ability (β=-0.21). Age had a significant positive indirect effect on ISC, as did intellect, through their effect on process skills (β=0.34 and 0.21 respectively).

INTERPRETATION

ISC is affected by upper limb impairments and process skill. Sensation influences ISC through its effects on manual and process skill abilities. Both sensation and process skills require further evaluation to assist ISC in children with unilateral CP.

WHAT THIS PAPER ADDS

Process skills and manual ability most strongly positively influence independence in self-care (ISC) in children with unilateral cerebral palsy. Sensation influences ISC through manual ability and process skill.

Estimating Forearm Axial Rotation Using Vive Trackers for Interaction With Serious Games

One of the most common upper limb dysfunction seen among cerebral palsy children is the limited supination or pronation of the forearm, thus training forearm axial rotation is a common demand for interventions. We propose a method to estimate forearm axial rotation using commercially available tracking device HTC Vive tracker to support interaction with serious games with forearm axial rotation movement for rehabilitation in clinic or home environment. The proposed method provides an easy-to-access and affordable way for forearm axial angle estimation when arm is at different positions relative to torso and when tracking devices are worn in different orientations. Effectiveness of the proposed method is examined, and a serious game system that uses the method for interaction is designed which was installed in The First Hospital of Jilin University as an option of forearm movement practices for children with cerebral palsy.

Botulinum Toxin in the Management of Children with Cerebral Palsy

During the past 25 years, botulinum toxin type A (BoNT-A) has become the most widely used medical intervention in children with cerebral palsy. In this review we consider the gaps in our knowledge in the use of BoNT-A and reasons why muscle morphology and function in children with cerebral palsy are impaired. We review limitations in our knowledge regarding the mechanisms underlying the development of contractures and the difficulty in preventing them. It is clear from this review that injection of BoNT-A in the large muscles of both the upper and lower limbs of children with cerebral palsy will result in a predictable decrease in muscle activity, which is usually reported as a reduction in spasticity, for between 3 and 6 months. These changes are noted by the use of clinical tools such as the Modified Ashworth Scale and the Modified Tardieu Scale. Decreased muscle over-activity usually results in improved range of motion in distal joints. Injection of the gastrocnemius muscle for toe-walking in a child with hemiplegia or diplegia usually has the effect of increasing the passive range of dorsiflexion at the ankle. In our review, we found that this may result in a measurable improvement in gait by the use of observational gait scales or gait analysis, in some children. However, improvements in gait function are not always achieved and are small in magnitude and short lived. We found that some of the differences in outcomes in clinical trials may relate to the use of adjunctive interventions such as serial casting, orthoses, night splints and intensive therapy. We note that the majority of clinical trials of the use of BoNT-A in children with cerebral palsy have focussed on a single injection cycle and this is insufficient to understand the balance between benefit and harm. Most outcomes were reported in terms of changes in muscle tone and there were fewer studies with robust methodology that reported improvements in function. Changes in the domains of activities and participation have rarely been reported in studies to date. There were no clinical reviews to date that consider the findings of studies in human volunteers and in experimental animals and their relevance to clinical protocols. In this review we found that studies in human volunteers and in experimental animals show muscle atrophy after an injection of BoNT-A for at least 12 months. Muscle atrophy was accompanied by loss of contractile elements in muscle and replacement with fat and connective tissue. It is not currently known if these changes, mediated at a molecular level, are reversible. We conclude that there is a need to revise clinical protocols by using BoNT-A more thoughtfully, less frequently and with greatly enhanced monitoring of the effects on injected muscle for both short-term and long-term benefits and harms.

Assessment of bimanual performance in 3-D movement analysis: Validation of a new clinical protocol in children with unilateral cerebral palsy

BACKGROUND

The "Be an Airplane Pilot" (BE-API) protocol is a novel 3-D movement analysis (3DMA) protocol assessing the bimanual performance of children during a game.

OBJECTIVE

This study aimed to investigate the reliability and validity of this protocol in children with unilateral cerebral palsy (uCP).

METHODS

Angular waveforms (WAVE), maximum angles (MAX) and range of motion (ROM) of the trunk, shoulder, elbow and wrist joints were collected in children with uCP and in typically developing children (TDC) during 4 tasks of the BE-API protocol designed to explore specific degrees of freedom (DoF). The inter-trial reliability for children with uCP was assessed with the coefficient of multiple correlation (CMC) for WAVE and the intraclass correlation coefficient (ICC) and standard error of measurement (SEM) for MAX and ROM. Clinical performance-based measures, including the Assisting Hand Assessment (AHA) and ABILHAND-Kids scores, were used to explore correlations between clinical measures and kinematic parameters in children with uCP.

RESULTS

20 children with uCP (13 boys; mean age 12.0 [SD 3.2] years) and 20 TDC (11 boys; mean age 11.9 [SD 3.4] years) were included. In children with uCP, most kinematic parameters showed high reliability (WAVE: CMC≥0.82; MAX and ROM: ICC≥0.85, SEM≤4.7°). Elbow extension, forearm supination, and wrist adduction were reduced and wrist flexion was increased for children with uCP versus TDC (P<0.01). In children with uCP, MAX and ROM values were moderately correlated with clinical assessments (AHA score: r=0.48-0.65; ABILHAND-Kids score: r=0.48-0.49).

CONCLUSIONS

The BE-API protocol is a 3DMA-bimanual performance-based assessment that is highly reliable in children with uCP. Children with uCP and TDC significantly differed in some clinically relevant kinematic parameters. The BE-API is a promising playful tool, helpful for better understanding upper-limb motor movement abnormalities in bimanual conditions and for tailoring treatments to individual deficits.

Constraint-induced movement therapy in children with unilateral cerebral palsy

BACKGROUND

Unilateral cerebral palsy (CP) is a condition that affects muscle control and function on one side of the body. Children with unilateral CP experience difficulties using their hands together secondary to disturbances that occur in the developing fetal or infant brain. Often, the more affected limb is disregarded. Constraint-induced movement therapy (CIMT) aims to increase use of the more affected upper limb and improve bimanual performance. CIMT is based on two principles: restraining the use of the less affected limb (for example, using a splint, mitt or sling) and intensive therapeutic practice of the more affected limb.

OBJECTIVES

To evaluate the effect of constraint-induced movement therapy (CIMT) in the treatment of the more affected upper limb in children with unilateral CP.

SEARCH METHODS

In March 2018 we searched CENTRAL, MEDLINE, Embase, CINAHL, PEDro, OTseeker, five other databases and three trials registers. We also ran citation searches, checked reference lists, contacted experts, handsearched key journals and searched using Google Scholar.

SELECTION CRITERIA

Randomised controlled trials (RCTs), cluster-RCTs or clinically controlled trials implemented with children with unilateral CP, aged between 0 and 19 years, where CIMT was compared with a different form of CIMT, or a low dose, high-dose or dose-matched alternative form of upper-limb intervention such as bimanual intervention. Primarily, outcomes were bimanual performance, unimanual capacity and manual ability. Secondary outcomes included measures of self-care, body function, participation and quality of life.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts to eliminate ineligible studies. Five review authors were paired to extract data and assess risk of bias in each included study. GRADE assessments were undertaken by two review authors.

MAIN RESULTS

We included 36 trials (1264 participants), published between 2004 and 2018. Sample sizes ranged from 11 to 105 (mean 35). Mean age was 5.96 years (standard deviation (SD) 1.82), range three months to 19.8 years; 53% male and 47% participants had left hemiplegia. Fifty-seven outcome measures were used across studies. Average length of CIMT programs was four weeks (range one to 10 weeks). Frequency of sessions ranged from twice weekly to seven days per week. Duration of intervention sessions ranged from 0.5 to eight hours per day. The mean total number of hours of CIMT provided was 137 hours (range 20 to 504 hours). The most common constraint devices were a mitt/glove or a sling (11 studies each).We judged the risk of bias as moderate to high across the studies.

KEY RESULTS

Primary outcomes at primary endpoint (immediately after intervention)CIMT versus low-dose comparison (e.g. occupational therapy)We found low-quality evidence that CIMT was more effective than a low-dose comparison for improving bimanual performance (mean difference (MD) 5.44 Assisting Hand Assessment (AHA) units, 95% confidence interval (CI) 2.37 to 8.51).CIMT was more effective than a low-dose comparison for improving unimanual capacity (Quality of upper extremity skills test (QUEST) - Dissociated movement MD 5.95, 95% CI 2.02 to 9.87; Grasps; MD 7.57, 95% CI 2.10 to 13.05; Weight bearing MD 5.92, 95% CI 2.21 to 9.6; Protective extension MD 12.54, 95% CI 8.60 to 16.47). Three studies reported adverse events, including frustration, constraint refusal and reversible skin irritations from casting.CIMT versus high-dose comparison (e.g. individualised occupational therapy, bimanual therapy)When compared with a high-dose comparison, CIMT was not more effective for improving bimanual performance (MD -0.39 AHA Units, 95% CI -3.14 to 2.36). There was no evidence that CIMT was more effective than a high-dose comparison for improving unimanual capacity in a single study using QUEST (Dissociated movement MD 0.49, 95% CI -10.71 to 11.69; Grasp MD -0.20, 95% CI -11.84 to 11.44). Two studies reported that some children experienced frustration participating in CIMT.CIMT versus dose-matched comparison (e.g. Hand Arm Bimanual Intensive Therapy, bimanual therapy, occupational therapy)There was no evidence of differences in bimanual performance between groups receiving CIMT or a dose-matched comparison (MD 0.80 AHA units, 95% CI -0.78 to 2.38).There was no evidence that CIMT was more effective than a dose-matched comparison for improving unimanual capacity (Box and Blocks Test MD 1.11, 95% CI -0.06 to 2.28; Melbourne Assessment MD 1.48, 95% CI -0.49 to 3.44; QUEST Dissociated movement MD 6.51, 95% CI -0.74 to 13.76; Grasp, MD 6.63, 95% CI -2.38 to 15.65; Weightbearing MD -2.31, 95% CI -8.02 to 3.40) except for the Protective extension domain (MD 6.86, 95% CI 0.14 to 13.58).There was no evidence of differences in manual ability between groups receiving CIMT or a dose-matched comparison (ABILHAND-Kids MD 0.74, 95% CI 0.31 to 1.18). From 15 studies, two children did not tolerate CIMT and three experienced difficulty.

AUTHORS' CONCLUSIONS

The quality of evidence for all conclusions was low to very low. For children with unilateral CP, there was some evidence that CIMT resulted in improved bimanual performance and unimanual capacity when compared to a low-dose comparison, but not when compared to a high-dose or dose-matched comparison. Based on the evidence available, CIMT appears to be safe for children with CP.

Effects of virtual reality in body oscillation and motor performance of children with cerebral palsy: A preliminary randomized controlled clinical trial

BACKGROUND AND PURPOSE

Virtual reality is an adjuvant technique to rehabilitation of children with cerebral palsy (CP). It has been gaining prominence in this field because of its accessibility and great levels of motivation it promotes in treatment. However, there is a lack of studies addressing the effects of virtual reality-based therapy on activity levels regarding postural stability, especially considering the level of evidence presented by studies addressing this issue. Therefore, we aim to evaluate the effects of intervention in body sway and gross motor function of children with CP using an active video game.

MATERIALS AND METHODS

In this blind randomized controlled trial, fifteen children with CP, Gross Motor Function Classification System (GMFCS) I-II, regularly attending conventional physical therapy programs, were randomly assigned to an intervention (IG:n = 7) or to a control group (CG:n = 8). In both groups, children remained attending conventional therapy. In addition, IG underwent intervention using an active video game twice a week for 45 min and eight weeks. Standing body sway was assessed using a force plate, and Gross Motor Function Measure (GMFM) dimensions D (Standing) and E (Walking, Running and Jumping) were tested.

RESULTS

Following the virtual reality-based intervention, the IG only showed significant improvements in the GMFM dimensions D (p = 0.021) and E (p = 0.008). Improvements were clinically significant (D = 10.8%; E = 14.0%). For the CG, no variable analyzed showed differences after eight weeks.

CONCLUSIONS

Intervention using an active video game is a promising tool that can improve the gross motor function of children with CP, GMFCS I-II.

Reproducibility of Task-Oriented Bimanual and Unimanual Strength Measurement in Children with Unilateral Cerebral Palsy

Aim: To examine reproducibility of the arm-hand strength measured while performing the bimanual crate task and the unimanual pitcher task. Methods: 105 children diagnosed with unilateral Cerebral Palsy, aged between 6 and 18 years, participated in this study. The test-retest reliability of the force generated during bimanual crate task and unimanual pitcher task of the Task-oriented Arm-hAnd Capacity instrument was investigated using intraclass correlation two-way random model with absolute agreement. The intraclass correlations were calculated for two age groups (6-12 and 13-18 years old). Results: The results showed good test-retest reliability for the crate and pitcher task with the non-affected hand for both age groups. The results of the pitcher task for the affected hand showed moderate test-retest reliability for both age groups. Conclusion: The Task-oriented Arm-hAnd Capacity instrument has moderate to good test-retest reliability. It is a simple and objective instrument to assess task-oriented strength in children with unilateral cerebral palsy.

The Immediate Effects of a Dynamic Orthosis on Gait Patterns in Children With Unilateral Spastic Cerebral Palsy: A Kinematic Analysis

This study analyzes the immediate effects of wearing a Therasuit on sagittal plane lower limb angular displacements during gait in children with unilateral spastic cerebral palsy (US-CP). Seven participants (median age = 7.00 years; ranging from 5.83 to 9.00 years) with US-CP, levels I and II of the Gross Motor Function Classification System, were assessed with kinematic gait analysis in three different conditions: (A) Baseline; (B) Therasuit without elastics and (C) Therasuit with elastics. Significant improvements were observed at the hip joint of both lower limbs during most of the gait cycle in participants wearing a Therasuit, including a decrease in the flexion pattern at the initial contact and swing phase in both lower limbs, and an increase in the extension pattern in the paretic lower limb during the stance phase. At the knee joint in the paretic lower limb, significant differences were found between the baseline and Therasuit with elastics conditions on the knee angle at initial contact, and between baseline and both Therasuit conditions on the flexion angle at swing phase. However, the inter-individual variability in kinematic patterns at the knee joint was high. At the ankle joint, decreased plantar flexion at initial contact and increased dorsiflexion during stance and swing phases were observed at the Therasuit with elastics condition, helping to correct the equinus-foot in the paretic lower limb during the whole gait cycle. The Z-values showed large effect sizes particularly for most of the angular hip variables in both lower limbs and for the angular ankle variables in the paretic lower limb. The Therasuit seems to have some positive immediate effects on gait kinematics in children with spastic unilateral cerebral palsy by providing a more functional and safer gait pattern. Future investigations with larger samples are recommended to further support these findings.

Effect of feedback from a socially interactive humanoid robot on reaching kinematics in children with and without cerebral palsy: A pilot study

PURPOSE

To examine whether children with or without cerebral palsy (CP) would follow a humanoid robot's (i.e., Darwin) feedback to move their arm faster when playing virtual reality (VR) games.

METHODS

Seven children with mild CP and 10 able-bodied children participated. Real-time reaching was evaluated by playing the Super Pop VR^TM system, including 2-game baseline, 3-game acquisition, and another 2-game extinction. During acquisition, Darwin provided verbal feedback to direct the child to reach a kinematically defined target goal (i.e., 80% of average movement time in baseline). Outcome variables included the percentage of successful reaches ("% successful reaches"), movement time (MT), average speed, path, and number of movement units.

RESULTS

All games during acquisition and extinction had larger "%successful reaches," faster speeds, and faster MTs than the 2 games during baseline (p < .05).

CONCLUSION

Children with and without CP could follow the robot's feedback for changing their reaching kinematics when playing VR games.

Efeito da intervenção com videogame ativo sobre o autoconceito, equilíbrio, desempenho motor e sucesso adaptativo de crianças com paralisia cerebral: estudo preliminar

RESUMO Crianças com paralisia cerebral (PC) comumente são identificadas como diferentes de seus pares típicos devido à sua condição neuromotora, o que afeta a motivação e consequentemente o desempenho em atividades. A realidade virtual (RV) pode ser uma ferramenta potencial para melhora de aspectos motivacionais e desempenho motor durante a reabilitação. O objetivo deste estudo foi verificar o efeito de um programa de intervenção fundamentado em RV utilizando um videogame ativo no autoconceito, equilíbrio, desempenho motor e sucesso adaptativo de crianças PC. Participaram do estudo oito crianças entre 5 e 14 anos (10,37±3,29), com diagnóstico de PC, níveis I e II no GMFCS. O autoconceito foi avaliado com a Escala Infantil de Autoconceito Piers-Harris, o equilíbrio por meio do domínio quociente motor 3 da Escala de Desenvolvimento Motor. Para avaliação do desempenho motor foi utilizado o quociente motor geral, e as pontuações dos jogos avaliaram o sucesso adaptativo no ambiente virtual. A intervenção aconteceu durante oito semanas, sendo duas sessões semanais de 45 minutos cada. Foram utilizados quatro jogos ativos com demandas de equilíbrio, coordenação motora, saltos, agachamentos e deslocamento lateral do corpo. O teste de Wilcoxon foi usado para verificar as diferenças pré e pós-intervenção. Constatou-se diferença após a intervenção nos domínios: ansiedade, intelectual, popularidade, aparência física, satisfação, felicidade, equilíbrio, desempenho motor, e pontuação dos jogos. Conclui-se que a RV pode influenciar na forma com que essas crianças se enxergam quanto ao autoconceito, equilíbrio, desempenho motor geral e sucesso adaptativo, ajudando os profissionais a desenvolver formas de terapia que possam melhorar tais aspectos.

Hand-Arm Bimanual Intensive Therapy Improves Prefrontal Cortex Activation in Children With Hemiplegic Cerebral Palsy

PURPOSE

To determine the changes in the prefrontal cortical (PFC) activation following hand-arm bimanual intensive therapy (HABIT) in children with hemiplegic cerebral palsy (HCP).

METHODS

Nine children with HCP and 15 children who were developing typically participated in the study. Children with HCP received 50 hours of HABIT. We assessed pre- and post-HABIT PFC activation using functional near-infrared spectroscopy neuroimaging. Bimanual coordination and motor task performance were assessed using the Assisting Hand Assessment (AHA), the average number of shapes matched, the shape matching errors, the reaction time, the 9-hole peg test, and the box and blocks test.

RESULTS

The PFC activation decreased following HABIT and became similar to what was seen in the children who were developing typically. Post-HABIT PFC activation improvements paralleled with the improvements seen in the AHA and the behavioral outcomes.

CONCLUSION

HABIT potentially improves the PFC's involvement in the action planning of the upper extremity movements in children with HCP.

A randomized controlled trial to compare two methods of constraint-induced movement therapy to improve functional ability in the affected upper limb in pre-school children with hemiplegic cerebral palsy: CATCH TRIAL

OBJECTIVE

To determine the feasibility and short-term efficacy of caregiver-directed constraint-induced movement therapy to improve upper limb function in young children with hemiplegic cerebral palsy.

DESIGN

Randomized controlled trial with masked assessment.

SETTING

Community paediatric therapy services.

SUBJECTS

Pre-school children with hemiplegic cerebral palsy.

INTERVENTIONS

Caregiver-directed constraint-induced movement therapy administered using either 24-hour short-arm restraint device (prolonged) or intermittent holding restraint during therapy (manual).

MAIN MEASURES

Primary measures include Assisting Hand Assessment (AHA) at 10 weeks. Secondary measures include adverse events, Quality of Upper Extremity Skills Test and Pediatric Quality of Life Inventory. Feasibility measures include recruitment, retention, data completeness and adherence.

RESULTS

About 62/81 (72%) of eligible patients in 16 centres were randomized (prolonged restraint n = 30; manual restraint n = 32) with 97% retention at 10 weeks. The mean change at 10 weeks on the AHA logit-based 0-100 unit was 9.0 (95% confidence interval (CI): 5.7, 12.4; P < 0.001) for prolonged restraint and 5.3 (95% CI: 1.3, 9.4; P = 0.01) for manual restraint with a mean group difference of 3.7 (95% CI: -1.5, 8.8; P = 0.156) (AHA smallest detectable difference = 5 units). No serious related adverse events were reported. There were no differences in secondary outcomes. More daily therapy was delivered with prolonged restraint (60 vs 30 minutes; P < 0.001). AHA data were complete at baseline and 10 weeks.

CONCLUSION

Caregiver-directed constraint-induced movement therapy is feasible and associated with improvement in upper limb function at 10 weeks. More therapy was delivered with prolonged than with manual restraint, warranting further testing of this intervention in a longer term trial.

Effective Site for the Application of Extracorporeal Shock-Wave Therapy on Spasticity in Chronic Stroke: Muscle Belly or Myotendinous Junction

OBJECTIVE

To compare the effect of extracorporeal shock-wave therapy (ESWT) applied at the muscle belly and myotendinous junction on spasticity in the upper and lower limbs of chronic stroke patients.

METHODS

Of the 151 patients, a total of 80 patients with stroke-induced spasticity on the elbow flexor and 44 patients on the knee flexor were enrolled for a prospective, randomized clinical trial. The patients were divided into control, muscle belly, and myotendinous junction groups, and a total of three ESWT sessions (0.068-0.093 mJ/mm², 1,500 shots) were conducted at one per week. A Modified Ashworth Scale (MAS) and Modified Tardieu Scale (MTS) were collected at the baseline and at 1 week after each session.

RESULTS

After interventions, the MAS and MTS of both the belly and the junction groups showed positive effects from the ESWT on spasticity in the elbow and knee flexors, but the control group did not. The results also tended to improve after each session until the entire intervention was completed. However, there was no significant difference between the belly and junction groups.

CONCLUSION

ESWT could be effective for treating chronic spasticity after stroke when applied to muscle belly or myotendinous junction.

Community-Based Rehabilitation to Improve Stroke Survivors' Rehabilitation Participation and Functional Recovery

OBJECTIVE

The aim of this study was to evaluate the effectiveness of a community-based rehabilitation appropriate technique (CRAT) intervention program in increasing rehabilitation participation and improving functional recovery of stroke survivors.

DESIGN

This study followed a quasi-experimental design. In each of 5 centers servicing approximately 50,000 individuals, 2 communities were designated as either the intervention or control community. A CRAT intervention program, including 2-year rehabilitation education and 3-month CRAT treatment, was regularly implemented in the intervention communities, whereas there was no special intervention in the control community. Two sampling surveys, at baseline and after intervention, were administered to evaluate the rehabilitation activity undertaken. In intervention communities, stroke survivor's motor function, daily activity, and social activity were evaluated pretreatment and posttreatment, using the Fugl-Meyer Motor Function Assessment, Barthel index, and Social Functional Activities Questionnaire.

RESULTS

The proportion of individuals participating in rehabilitation-related activity was increased significantly (P < 0.05) in intervention communities, as compared with control communities. In intervention communities, the patients' Fugl-Meyer Motor Function Assessment, Barthel index, and Social Functional Activities Questionnaire scores were significantly improved after rehabilitation (P < 0.05) across all ages and disease courses, except for the FAQ scores in patients younger than 50 years (P > 0.05).

CONCLUSIONS

Community-based rehabilitation appropriate technique increases rehabilitation participation rates and enhances motor function, daily activity, and social activity of stroke survivors.

Augmented effects of EMG biofeedback interfaced with virtual reality on neuromuscular control and movement coordination during reaching in children with cerebral palsy

BACKGROUND

The purpose of the present study was to compare therapeutic effects of an electromyography (EMG) biofeedback augmented by virtual reality (VR) and EMG biofeedback alone on the triceps and biceps (T:B) muscle activity imbalance and elbow joint movement coordination during a reaching motor taskOBJECTIVE: To compare therapeutic effects of an electromyography (EMG) biofeedback augmented by virtual reality (VR) and EMG biofeedback alone on the triceps and biceps muscle activity imbalance and elbow joint movement coordination during a reaching motor task in normal children and children with spastic cerebral palsy (CP).

METHODS

18 children with spastic CP (2 females; mean±standard deviation = 9.5 ± 1.96 years) and 8 normal children (3 females; mean ± standard deviation = 9.75 ± 2.55 years) were recruited from a local community center. All children with CP first underwent one intensive session of EMG feedback (30 minutes), followed by one session of the EMG-VR feedback (30 minutes) after a 1-week washout period. Clinical tests included elbow extension range of motion (ROM), biceps muscle strength, and box and block test. EMG triceps and biceps (T:B) muscle activity imbalance and reaching movement acceleration coordination were concurrently determined by EMG and 3-axis accelerometer measurements respectively. Independent t-test and one-way repeated analysis of variance (ANOVA) were performed at p < 0.05.

RESULTS

The one-way repeated ANOVA was revealed to be significantly effective in elbow extension ROM (p = 0.01), biceps muscle strength (p = 0.01), and box and block test (p = 0.03). The one-way repeated ANOVA also revealed to be significantly effective in the peak triceps muscle activity (p = 0.01). However, one-way repeated ANOVA produced no statistical significance in the composite 3-dimensional movement acceleration coordination data (p = 0.12).

CONCLUSIONS

The present study is a first clinical trial that demonstrated the superior benefits of the EMG biofeedback when augmented by virtual reality exercise games in children with spastic CP. The augmented EMG and VR feedback produced better neuromuscular balance control in the elbow joint than the EMG biofeedback alone.

Home-based Nintendo Wii training to improve upper-limb function in children ages 7 to 12 with spastic hemiplegic cerebral palsy

This pilot study compared a Nintendo Wii intervention to single-joint resistance training for the upper limb in children ages 7 to 12 with spastic hemiplegic cerebral palsy (CP). Children were randomized to Wii training (n= 3), or resistance training (n= 3) and trained at home for 6 weeks. Pre, post and 4-week follow-up measures were collected. Outcome measures were the Melbourne Assessment (MA2), and ABILHAND-Kids, and grip strength. Compliance, motivation and feasibility of each intervention was explored using daily logbook responses and questionnaires. Descriptive statistics were used. Three children improved in the MA2, two of which were in the Wii training group. Improvements in the ABILHAND-Kids were minimal for all participants. Grip strength improvements were observed in 3 participants, two of which were in the resistance training group. The Wii training group reported higher compliance and more consistently positive responses to motivation and feasibility questions. Therefore, Wii training may be an effective home-based rehabilitation strategy, and is worth exploring in a larger trial. Implications of Wii training in the context of motivation theory are discussed.

A microcosting study of the surgical correction of upper extremity deformity in children with spastic cerebral palsy

OBJECTIVE

Determine healthcare costs of upper-extremity surgical correction in children with spastic cerebral palsy (CP).

METHOD

This cohort study included 39 children with spastic CP who had surgery for their upper extremity at a Dutch hospital. A retrospective cost analysis was performed including both hospital and rehabilitation costs. Hospital costs were determined using microcosting methodology. Rehabilitation costs were estimated using reference prices.

RESULTS

Hospital costs averaged €6813 per child. Labor (50%), overheads (29%), and medical aids (15%) were important cost drivers. Rehabilitation costs were estimated at €3599 per child.

CONCLUSIONS

Surgery of the upper extremity is an important contributor to the healthcare costs of children with CP. Our study shows that labor is the most important cost driver for hospital costs, owing to the multidisciplinary approach and patient-specific treatment plan. A remarkable finding was the substantial amount of rehabilitation costs.

Practice-based evidence from a clinical cohort that received pediatric constraint- induced movement therapy

PURPOSE

Constraint-Induced Movement Therapy (CIMT) is now designated a highly efficacious treatment for children with cerebral palsy, based on rigorous clinical trials. Yet virtually no evidence confirms that these moderate to large size effects can be replicated in clinical practice for a more heterogeneous clinical population. Thus there is a need to collect and report treatment outcome data based on actual clinical practice as a critical next step for implementation.

METHODS

This study presents results from a prospective study conducted on a clinical cohort of 88 children, 18 months to 12 years old (M = 55 months, SD = 5 months), who received high-intensity CIMT known as ACQUIREc. The children varied in severity and etiology of their hemiparesis and a subset was diagnosed with asymmetric quadriparesis.

RESULTS

Pre- to post-CIMT assessments confirmed highly significant and clinically meaningful changes based on both parental report (Pediatric Motor Activity Log, p< 0.0001) and standardized measures (The Assisting Hand Assessment, p= 0.04).

CONCLUSIONS

Clinical practice of high-intensity CIMT (120 hours in 4 weeks) with full-time casting of the less-impaired upper extremity produced benefits of comparable magnitude to those from rigorous randomized controlled trials (RCTs). Therapists were highly trained and actively monitored. Children across a wide range of etiologies and severity levels realized positive outcomes.

Factors Influencing Occupational Therapists' Clinical Decision Making for Clients with Upper Limb Performance Dysfunction following Brain Injury

Occupational therapists make clinical decisions to help clients with upper limb performance dysfunction following brain injury to achieve their goals. Although occupational therapy services have traditionally been separated for paediatric and adult populations, it has been proposed that a common process can be used to make clinical decisions for children and adults with upper limb performance dysfunction following brain injury.

This study compared the factors that influenced the clinical decisions of experienced occupational therapists who worked with either children or adults with upper limb performance dysfunction after brain injury to determine if the clinical decision-making process was common for all clients with brain injury. Eleven occupational therapists with experience in working with clients with brain injury participated in two focus groups. Six had experience in working with children and five in working with adults. The discussions were audiotaped, transcribed and analysed using NUD*IST Version 4 data management software.

The intrinsic or client-related factors identified as influencing clinical decision making were the client's condition, personal attributes and occupational performance needs. The extrinsic factors were related both to the therapist (knowledge of ‘feel’, experience, treatment preferences, confidence and personal convictions and beliefs) and to the environment (context of service provision and organisational culture and constraints). The consistency in the factors identified across different caseloads appeared to indicate that a common protocol would be suitable for guiding clinical decision making for both children and adults with varying patterns and intensity of upper limb performance dysfunction. Further research is needed to determine the clinical usefulness of such a protocol and the consistency of client outcomes following its use.

Effects of robotic therapy on upper-extremity function in children with cerebral palsy: A systematic review

OBJECTIVE

To systematically examine the effects of robotic therapy on upper extremity (UE) function in children with cerebral palsy (CP).

METHODS

A systematic literature search was conducted in Pubmed, CINAHL, Cochrane, PsychInfo, TRIP, and Web of Science up to July 2013. Studies of children with CP, using robotic therapy and measures of UE were included.

RESULTS

Nine articles using three different robotic systems were included. Of these, seven were case studies. Overall, robotic therapy showed the potential effects as all studies reported at least one positive outcome: a moderate effect in improving reaching duration, smoothness, or decreased muscle tone, and a small to large effect in standardized clinical assessment (e.g. Fugl-Meyer).

CONCLUSION

This review confirms the potential for robotic therapy to improve UE function in children with CP. However, the paucity of group design studies summons the need for more rigorous research before conclusive recommendations can be made.

Effects of botulinum toxin type A on upper limb function in children with cerebral palsy: a systematic review

Objective: To evaluate whether botulinum toxin type A injections improve upper limb function in children with cerebral palsy.

Methods: An extensive search was carried out in PUBMED, CINAHL, PICARTA, EMBASE, PEDRO and the Cochrane Controlled Trials Register. Controlled and uncontrolled studies were included and evaluated on the basis of a best evidence synthesis.

Results: Twelve out of 645 identified studies were included: three randomized controlled trials (RCTs) ( n = 64) of high methodological quality, and nine uncontrolled studies ( n = 107) of sufficient methodological quality. In one of the three RCTs a short-term, significant decrease of spasticity was found in favour of the botulinum toxin type A group, which was supported by five of the seven uncontrolled studies that also measured spasticity. In one RCT significant changes in range of motion were reported for wrist and thumb extension. This finding was supported by two out of seven uncontrolled studies. One RCT reported a significant improvement in activities after one month, according to the Quality of Upper Extremity Skills Test and the Pediatric Evaluation Disability Inventory, whereas five out of the nine uncontrolled studies reported an improvement in functional activities.

Conclusion: Insufficient evidence is found for the effects of botulinum toxin type A injections to reduce spasticity or to increase range of motion and upper limb function in children with cerebral palsy. Besides differences in treatment goals, the lack of evidence is mainly due to the use of invalid assessment instruments and insufficient statistical power to demonstrate treatment effects.

Selective Control of the Upper Extremity Scale: validation of a clinical assessment tool for children with hemiplegic cerebral palsy

AIM

The ability to determine the relationship between selective motor control and upper extremity function in children with unilateral cerebral palsy (CP), and to measure the functional outcome and efficacy of interventions designed to improve selective motor control, has been limited by the lack of an objective, validated tool. The primary objective of this study is to describe the development of a clinical tool entitled Selective Control of the Upper Extremity Scale (SCUES), and present evidence of its validity and reliability.

METHOD

Content validity was established through an expert panel (eight clinicians, mean and median of 17y of clinical experience, range 2-30y). Intra- and interrater reliability was determined by six occupational therapists who scored 10 participant studies. Construct validity of the SCUES was established by comparison to the spontaneous functional analysis section of the Shriners Hospitals Upper Extremity Evaluation, the Manual Ability Classification System, and the Box and Block test for 25 children with unilateral CP.

RESULTS

The content validity ratio values were greater than 0 (indicating >50% agreement) for 33 of the 34 items (97%), and equal or greater than 0.5 (indicating ≥75% agreement) for 26 of the 34 items (76%). Intrarater reliability was excellent (intraclass correlation coefficient [ICC] >0.75) for all segments and joints of the affected extremity. Interrater reliability was excellent for all segments and joints of the affected extremity except the shoulder (ICC=0.72). The SCUES was strongly correlated with the SHUEE (Spearman's rho=0.69, p=0.003). The SCUES was not correlated with the Manual Ability Classification System (rho=-0.24, p=0.369) or the Box and Block test (rho=0.47, p=0.066).

INTERPRETATION

Psychometric analysis of the SCUES revealed comparable validity to other accepted video-based clinical assessment tools for the upper extremity in children with CP.

Development of an EMG-ACC-Based Upper Limb Rehabilitation Training System

This paper focuses on the development of an upper limb rehabilitation training system designed for use by children with cerebral palsy (CP). It attempts to meet the requirements of in-home training by taking advantage of the combination of portable accelerometers (ACC) and surface electromyography (SEMG) sensors worn on the upper limb to capture functional movements. In the proposed system, the EMG-ACC acquisition device works essentially as wireless game controller, and three rehabilitation games were designed for improving upper limb motor function under a clinician's guidance. The games were developed on the Android platform based on a physical engine called Box2D. The results of a system performance test demonstrated that the developed games can respond to the upper limb actions within 210 ms. Positive questionnaire feedbacks from twenty CP subjects who participated in the game test verified both the feasibility and usability of the system. Results of a long-term game training conducted with three CP subjects demonstrated that CP patients could improve in their game performance through repetitive training, and persistent training was needed to improve and enhance the rehabilitation effect. According to our experimental results, the novel multi-feedback SEMG-ACC-based user interface improved the users' initiative and performance in rehabilitation training.

Younger Children with Cerebral Palsy Respond Better Than Older Ones to Therapist-Based Constraint-Induced Therapy at Home on Functional Outcomes and Motor Control

AIMS

To examine the differences in efficacy of home-based constraint-induced therapy (CIT) on functional outcomes and motor control in two age groups of children with cerebral palsy (CP).

METHODS

Twenty-three children with spastic unilateral CP receiving 4-week home-based CIT by a therapist were divided into younger (6-8 years; n = 11) and older (9-12 years; n = 12) groups. The home-based CIT involved intensive functional training of the more affected upper-limb while restraining the less affected upper-limb. The outcome measures were Peabody Developmental Motor Scale-2nd edition (PDMS-2) that was being used in a modified way, Functional Independence Measure for Children (WeeFIM), and reach-to-grasp kinematic parameters, including reaction time (RT), normalized movement time (MT), normalized movement units (MUs), peak velocity (PV), and maximum grip aperture (MGA). The outcome measures were assessed at baseline, 4-weeks (post-treatment), 3- and 6-months (follow-up).

RESULTS

The younger group showed greater changes in visual motor integration skills and RT at all post-tests after intervention than the older group. Groups had comparable changes on any other measures.

CONCLUSIONS

Younger children with CP responded better to home-based CIT on some areas of upper-limb functions and reach-to-grasp motor control strategies than older children.

Resting State and Diffusion Neuroimaging Predictors of Clinical Improvements Following Constraint-Induced Movement Therapy in Children With Hemiplegic Cerebral Palsy

The aim was to identify neuroimaging predictors of clinical improvements following constraint-induced movement therapy. Resting state functional magnetic resonance and diffusion tensor imaging data was acquired in 7 children with hemiplegic cerebral palsy. Clinical and magnetic resonance imaging (MRI) data were acquired at baseline and 1 month later following a 3-week constraint therapy regimen. A more negative baseline laterality index characterizing an atypical unilateral sensorimotor resting state network significantly correlated with an improvement in the Canadian Occupational Performance Measure score (r = -0.81, P = .03). A more unilateral network with decreased activity in the affected hemisphere was associated with greater improvements in clinical scores. Higher mean diffusivity in the posterior limb of the internal capsule of the affect tract correlated significantly with improvements in the Jebsen-Taylor score (r = -0.83, P = .02). Children with more compromised networks and tracts improved the most following constraint therapy.

Effect of a Home-Based Virtual Reality Intervention for Children with Cerebral Palsy Using Super Pop VR Evaluation Metrics: A Feasibility Study

Objective. The purpose of this pilot study was to determine whether Super Pop VR, a low-cost virtual reality (VR) system, was a feasible system for documenting improvement in children with cerebral palsy (CP) and whether a home-based VR intervention was effective. Methods. Three children with CP participated in this study and received an 8-week VR intervention (30 minutes × 5 sessions/week) using the commercial EyeToy Play VR system. Reaching kinematics measured by Super Pop VR and two fine motor tools (Bruininks-Oseretsky Test of Motor Proficiency second edition, BOT-2, and Pediatric Motor Activity Log, PMAL) were tested before, mid, and after intervention. Results. All children successfully completed the evaluations using the Super Pop VR system at home where 85% of the reaches collected were used to compute reaching kinematics, which is compatible with literature using expensive motion analysis systems. Only the child with hemiplegic CP and more impaired arm function improved the reaching kinematics and functional use of the affected hand after intervention. Conclusion. Super Pop VR proved to be a feasible evaluation tool in children with CP.

Sensory Feedback Training for Improvement of Finger Perception in Cerebral Palsy

Purpose. To develop and to test a feedback training system for improvement of tactile perception and coordination of fingers in children and youth with cerebral palsy. Methods. The fingers of 7 probands with cerebral palsy of different types and severity were stimulated using small vibration motors integrated in the fingers of a hand glove. The vibration motors were connected through a microcontroller to a computer and to a response 5-button keyboard. By pressing an appropriate keyboard button, the proband must indicate in which finger the vibration was felt. The number of incorrect responses and the reaction time were measured for every finger. The perception and coordination of fingers were estimated before and after two-week training using both clinical tests and the measurements. Results. Proper functioning of the developed system in persons with cerebral palsy was confirmed. The tactile sensation of fingers was improved in five of seven subjects after two weeks of training. There was no clear tendency towards improvement of selective use of fingers. Conclusion. The designed feedback system could be used to train tactile perception of fingers in children and youth with cerebral palsy. An extensive study is required to confirm these findings.

Upper limb function evaluation scales for individuals with cerebral palsy: a systematic review

[Purpose] The aim of the present study was to perform a systematic review of the literature on the scales and methods most often used for the evaluation of upper limb function in individuals with cerebral palsy. [Materials and Methods] Searches were conducted in the Medline, PEDro, Lilacs, Scielo, and PubMed databases. The following inclusion criteria were used for the selection of articles: randomized controlled study, evaluation of upper limb function in individuals with cerebral palsy, and publication between 2006 and 2014. The methodological quality of the articles was evaluated using the PEDro evidence scale. [Results] Five articles met the inclusion criteria and achieved 6 points or higher on the PEDro scale of methodological quality. [Conclusion] The studies analyzed used different evaluation scales, but no consensus has been reached thus far on which scale is the most appropriate. Thus, further studies are needed to establish an adequate method for the evaluation of upper limb function in individuals with cerebral palsy.

Evaluation of cortical plasticity in children with cerebral palsy undergoing constraint-induced movement therapy based on functional near-infrared spectroscopy

Sensorimotor cortex plasticity induced by constraint-induced movement therapy (CIMT) in six children (10.2±2.1 years old) with hemiplegic cerebral palsy was assessed by functional near-infrared spectroscopy (fNIRS). The activation laterality index and time-to-peak/duration during a finger-tapping task and the resting-state functional connectivity were quantified before, immediately after, and 6 months after CIMT. These fNIRS-based metrics were used to help explain changes in clinical scores of manual performance obtained concurrently with imaging time points. Five age-matched healthy children (9.8±1.3 years old) were also imaged to provide comparative activation metrics for normal controls. Interestingly, the activation time-to-peak/duration for all sensorimotor centers displayed significant normalization immediately after CIMT that persisted 6 months later. In contrast to this improved localized activation response, the laterality index and resting-state connectivity metrics that depended on communication between sensorimotor centers improved immediately after CIMT, but relapsed 6 months later. In addition, for the subjects measured in this work, there was either a trade-off between improving unimanual versus bimanual performance when sensorimotor activation patterns normalized after CIMT, or an improvement occurred in both unimanual and bimanual performance but at the cost of very abnormal plastic changes in sensorimotor activity.

Chemodenervation for treatment of limb spasticity following spinal cord injury: a systematic review

STUDY DESIGN

Systematic review.

OBJECTIVES

To systematically review the literature on chemodenervation with botulinum toxin (BoNT) or phenol/alcohol for treatment of limb spasticity following spinal cord injury (SCI).

SETTING

British Columbia, Canada.

METHODS

EMBASE, MEDLINE, CINAHL, Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials were searched for English language studies published up until March 2014. Studies were assessed for eligibility and quality by two independent reviewers.

RESULTS

No controlled trials were identified. A total of 19 studies were included: 9 involving BoNT and 10 involving phenol/alcohol. Owing to the clinically diverse nature of the studies, meta-analysis was deemed inappropriate. The studies produced level 4 and level 5 evidence that chemodenervation with BoNT or alcohol/phenol can lead to improvement in outcome measurements classified in the body structure and function, as well as activity domains of the International Classification of Functioning, Disability and Health framework. The Modified Ashworth Scale (MAS) was the most commonly used outcome measure. All six studies on BoNT and three of the four studies on phenol/alcohol measuring MAS reported a decrease in at least one point. An improvement in MAS was not always associated with improvement in function. The effect of phenol/alcohol has the potential to last beyond 6 months; study follow-up did not occur beyond this time point.

CONCLUSION

Chemodenervation with BoNT or phenol/alcohol may improve spasticity and function in individuals with SCI. However, there is a lack of high-quality evidence and further research is needed to confirm the efficacy of these interventions.