What is the threshold dose of upper limb training for children with cerebral palsy to improve function? A systematic review

Joystick-Operated Ride-On Toy Navigation Training for Children With Hemiplegic Cerebral Palsy: A Pilot Study

IMPORTANCE

Children with hemiplegic cerebral palsy (HCP) require intensive task-oriented training to make meaningful gains in affected upper extremity (UE) motor function.

OBJECTIVE

To evaluate the acceptability and utility of single joystick-operated ride-on toy (ROT) navigation training incorporated into a modified constraint-induced movement therapy (CIMT) camp for children with HCP.

DESIGN

Single group pretest-posttest design.

SETTING

Three-wk structured CIMT camp.

PARTICIPANTS

Eleven children with HCP between ages 3 and 14 yr.

INTERVENTION

Children received group-based CIMT for 6 hr/day, 5 days/wk, for 3 wk. As part of camp activities, children also received ROT navigation training for 20 to 30 min/day, 5 days/wk, for 3 wk.

OUTCOMES AND MEASURES

We assessed children's acceptance of ROT training by monitoring adherence and evaluating child engagement (affect and attention) during training sessions. The effects of ROT training combined with other camp activities on children's affected UE motor function were also assessed with the standardized Quality of Upper Extremity Skills Test (QUEST) and training-specific measures of ROT maneuvering accuracy.

RESULTS

Children demonstrated high levels of training adherence, positive affect, and task-appropriate attention across weeks. Positive engagement during ROT sessions was correlated with independent navigation. We also found medium- to large-sized improvements in QUEST scores and toy-maneuvering capabilities after the combined program.

CONCLUSIONS AND RELEVANCE

Our pilot data support the use of joystick-operated ROTs as child-friendly therapy adjuncts that can be incorporated into intensive UE training programs to improve adherence and motivation in therapy programs, boost treatment dosing, and promote affected UE motor function in children with HCP. Plain-Language Summary: This pilot study offers promising evidence that supports the use of modified single joystick-operated ride-on toys (ROTs) for children with hemiplegic cerebral palsy (HCP). The study used ROTs as one of several interventions that were part of a constraint-induced movement therapy (CIMT) camp program for children with HCP. The ROTs boosted children's motivation, their engagement with and adherence to training, and their practice in using their affected upper extremity (UE) for goal-directed activities in their natural settings. ROTs are accessible, age-appropriate, and easy-to-use devices for both occupational therapy clinicians and families to encourage children to use their affected UEs by challenging their perceptual, motor-planning, problem-solving, and movement-control skills in an enjoyable and engaging way. ROTs can be used within and outside conventional rehabilitation settings.

Co-designing complex therapy interventions with parents as partners in the care of children with cerebral palsy: An Experience-based Co-design study in England

BACKGROUND

Parents of children with hemiplegic cerebral palsy are increasingly involved in therapy intervention delivery. Enhancing the ways that parents are supported in delivery is key to optimising outcomes. This study aimed to refine an existing programme in England to better support parents partnering in their child's intervention delivery.

METHODS AND PROCEDURES

Experience-based Co-design (EBCD) fostered collaboration between parents and therapists to identify shared improvement priorities and develop solutions. The study included eighteen interviews and sixteen co-design meetings involving twenty parents and eight therapists in total. Intervention development followed the MRC Framework for developing and evaluating complex interventions.

OUTCOMES AND RESULTS

Themes from parent and therapist interviews informed priority setting for the co-design work. Three key shared priorities emerged a) accessing rehabilitation; b) fostering partnership and c) parent learning. Aligned with these priorities, three mixed parent and therapist co-design teams produced a) a parent booklet; an education outline for healthcare professionals; b) partnership principles; adaptations to intervention logbooks c) an online parent education session.

CONCLUSIONS AND IMPLICATIONS

Engaging parents and therapists in a structured co-design process using EBCD yielded innovative interventions supporting parents in delivering therapy for children with hemiplegia. This collaborative approach is anticipated to enhance programme implementation and effectiveness.

Fast and Fun: A Pilot Feasibility Study Using Dual Joystick-Operated Ride-on Toys for Upper Extremity Rehabilitation in Children with Hemiplegia

AIM

Our study investigates the feasibility and utility of implementing a dual joystick-operated ride-on-toy navigation training (RNT) program within a 3-week intensive camp based on principles of modified constraint-induced movement therapy and bimanual training, to improve upper extremity (UE) function in children with unilateral cerebral palsy (UCP).

METHODS

We employed a single-group pretest posttest, mixed methods study design. Eleven 4-to-10-year-old children with UCP received RNT as part of camp activities. Sessions required children to use both arms together for navigation and completing gross and fine motor UE challenges. We collected exit questionnaires from children, caregivers, and clinicians to assess the feasibility, acceptance, enjoyment, and perceived efficacy of RNT. Videos of training sessions were coded using Datavyu behavioral coding software to assess children's facial expressions and affective states, indicative of their level of engagement during intervention sessions.

RESULTS

We found high levels of child engagement during RNT sessions based on video data and stakeholder feedback. The RNT program was smoothly integrated into the camp. Stakeholders acknowledged the highly motivating nature of RNT. When combined with other camp activities, the program led to stakeholder-reported improvements in bimanual skills and spontaneous daily use of the affected UE.

CONCLUSIONS

Our pilot study provides promising evidence for using joystick-operated ride-on toys as engaging therapy adjuncts. Our findings call for future studies to systematically assess the efficacy of these devices in improving UE function among children with UCP.

Child-led goal setting and evaluation tools for children with a disability: A scoping review

AIM

To examine child-led goal setting and evaluation tools and approaches for children with a disability or developmental delay.

METHOD

Six databases were searched for studies that included population (children aged less than 18 years with disability or developmental delay); construct (child-led goal setting tool or approach); and context (developmental therapy or rehabilitation). The utility of tools and approaches across the goal setting and evaluation process was investigated using abductive content analysis.

RESULTS

Fifty articles met the inclusion criteria. Three approaches and four tools for child-led goal setting and evaluation were identified. No studies reported the clinimetric properties of tools specifically for child self-respondents. Qualitative analysis revealed six distinct goal phases in which tools and approaches were used, which were synthesized into a new framework for child-led goal setting and evaluation titled DECIDE: Direct children to goal setting; Elicit goal topics and priorities; Construct a goal statement; Indicate baseline goal performance; Develop an action plan to address the goal; and Evaluate goal progress after the intervention.

INTERPRETATION

Children actively participated in goal setting and evaluation across six DECIDE goal phases. Further clinimetric information is required to support use of goal setting and evaluation tools with child self-respondents. Future research should emphasize the development of multi-phase goal setting tools and approaches for diverse populations of children.

Is more always better? Effectiveness of constraint-induced movement therapy in children with high-risk or unilateral cerebral palsy (0-6 years): Systematic review and meta-analysis

BACKGROUND

While constraint-induced movement therapy is strongly recommended as an intervention for infants with unilateral cerebral palsy, the optimal dosage remains undefined. This systematic review aims to identify the most effective level of intensity of constraint-induced movement therapy to enhance manual function in infants at high risk of asymmetric brain lesions or unilateral cerebral palsy diagnosis.

METHODS

This systematic review with meta-analysis encompassed a comprehensive search across four electronic databases to identify articles that met the following criteria: randomised controlled trials, children aged 0-6 with at high risk or with unilateral cerebral palsy, and treatment involving constraint-induced movement therapy for upper limb function. Studies with similar outcomes were pooled by calculating the standardised mean difference score for each subgroup, and subgroups were stratified every 30 h of total intervention dosage (30-60, 61-90, >90 h). Risk of bias was assessed with Cochrane Collaboration's tool.

RESULTS

Seventeen studies were included. Meta-analyses revealed significant differences among subgroups. The 30-60 h subgroup showed a weak effect for spontaneous use of the affected upper limb during bimanual performance, grasp function, and parents' perception of how often children use their affected upper limb. Additionally, this subgroup demonstrated a moderate effect for the parents' perception of how effectively children use their affected upper limb.

CONCLUSIONS

Using a dosage ranging from 30 to 60 h when applying a constraint-induced movement therapy protocol holds promise as the most age-appropriate and cost-effectiveness approach for improving upper limb functional outcomes and parent's perception.

Effects of a highly intensive balance therapy camp in children with developmental coordination disorder - An intervention protocol

BACKGROUND

Children with Developmental Coordination Disorder (DCD) often (<87 %) experience postural control problems, impacting all levels of the International Classification of Functioning, Disability and Health (ICF) including their daily participation, self-esteem and mental health. Due to the multisystemic nature of postural control, comprehensive therapy should target all systems which is currently not the case. Highly intensive therapy is effective and commonly used in pediatric populations, but has not been explored yet to train postural control in children with DCD.

AIMS

To investigate the effects of a highly intensive functional balance therapy camp at all ICF levels in children with DCD.

METHODS AND PROCEDURES

The effects on postural control, muscle activity, brain alterations, self-perceived competence, self-identified goals, gross motor activities and participation are evaluated. Participants are assessed pre- and post-intervention, including a 3 months follow-up. Forty-eight children with DCD, aged 6-12 years old, receive 40 h of comprehensive balance training. This intervention is fun, individually tailored, targets all postural control systems, implements different motor learning strategies and includes both individual and group activities.

CONCLUSION

Novel insights into the effects of a highly intensive comprehensive balance therapy camp designed for children with DCD will be gained at all levels of the ICF.

A Pilot Feasibility Study on the Use of Dual-Joystick-Operated Ride-on Toys in Upper Extremity Rehabilitation for Children with Unilateral Cerebral Palsy

Children with unilateral cerebral palsy (UCP) require task-oriented practice several hours per week to produce meaningful gains in affected upper extremity (UE) motor function. Clinicians find it challenging to provide services at the required intensity and sustain child engagement. This pilot study assessed the acceptance and utility of a child-friendly program using dual-joystick-operated ride-on toys incorporated into an intensive UE rehabilitation camp. Eleven children with UCP between four and 10 years received ride-on-toy navigation training for 20-30 min/day, five days/week, for three weeks as part of camp programming. We report session adherence and percent time children spent in task-appropriate attention/engagement across sessions. The overall effects of camp programming on children's motor function were assessed using the Shriner's Hospital Upper Extremity Evaluation (SHUEE) from pretest to posttest and using training-specific measures of bimanual UE use and navigational accuracy. Children showed excellent adherence and sustained task-appropriate engagement across sessions. The combined program led to improved navigational accuracy (p-values ≤ 0.007) as well as spontaneous affected UE use during bimanual activities outside the training context (p < 0.001). Our pilot study provides promising evidence for using modified, commercially available ride-on toys to incentivize rehabilitation and boost repetitive, task-oriented UE practice among children with UCP.

Pairing taVNS and CIMT is feasible and may improve upper extremity function in infants

In this study we combined non-invasive transcutaneous auricular vagal nerve stimulation (taVNS) with 40 h of constraint induced movement therapy (CIMT) in infants. All infants completed the full intervention with no adverse events. Therapists were able to maintain high treatment fidelity and reported high ratings for ease of use and child tolerance. Preliminary results show promising gains on motor outcomes: Mean QUEST increase 19.17 (minimal clinically important difference, MCID 4.89); Mean GMFM increase 13.33 (MCID 1%-3%). Infants also exceeded expectations on Goal Attainment Scores (+1). Early data is promising that taVNS paired with intensive motor CIMT is feasible, reliable, and safe in young infants with hemiplegia, and may help harness activity-dependent plasticity to enhance functional movement.

Reporting Completeness of Intensity-, Dose-, and Dosage-Related Items in Active Pediatric Upper Limb Neurorehabilitation Trials: A Systematic Review

OBJECTIVE

To analyze the reporting completeness of the TIDieR items 8-12, in particular intensity, dose, and dosage, in active pediatric upper limb neurorehabilitation trials.

DATA SOURCES

We searched PubMed Central, Scopus, CINAHL, OTseeker, and Web of Science for eligible publications.

STUDY SELECTION

We included publications analyzing active pediatric upper limb neurorehabilitation interventions and assessed the reporting completeness of 11 items for each intervention and control group.

DATA EXTRACTION

Two raters independently screened titles and abstracts and selected the publications using the RYYAN platform. We unblinded the results after the raters had completed their selection and resolved the disagreements by discussion. We used the same procedures to review the full texts.

DATA SYNTHESIS

We included 52 randomized controlled trials with 65 intervention and 48 control groups. Authors did not report all 11 items in any of the study groups. The overall reporting completeness varied between 1% (intensity) to 95% (length of the intervention). The reporting completeness of the TIDieR items ranged from 2% (modifications) to 64% (when and how much). We found no significant differences in the reporting completeness between the intervention and control groups.

CONCLUSIONS

Information essential for dose-response calculations is often missing in randomized controlled trials of pediatric upper limb neurorehabilitation interventions. Reporting completeness should be improved, and new measures to accurately quantify intensity should be discussed and developed.

An Exploration of the Effectiveness of Different Intensity Protocols of Modified Constraint-Induced Therapy in Stroke: A Systematic Review

Purpose

To examine the effectiveness of different modified Constraint-Inuced Therapy (mCIMT) protocol intensities on upper extremity motor function in adults with hemiplegia.

Methods

A search was conducted in PubMed, Scopus, EBSCO, and Cochrane Library for articles published between April 2010 and December 2021. Only randomized controlled trials (RCTs) were included. Studies were excluded if they used a sample of less than five, mCIMT in combination with other therapy, and/or if they were not written in English. Methodologic quality was assessed using the Cochrane collaboration risk of bias tool-2.

Results

Thirty-six RCTs with a total of 721 participants were included. Most researchers followed a moderate to low protocol intensity in terms of total treatment time and moderate to high intensity with regard to restriction time. Almost all of the upper limb motor function measures showed statistically significant improvements (p < .05) after mCIMT, irrespective of the protocol's intensity, but there was lack of high-quality studies. Statistically significant improvements did not always translate to clinical importance.

Conclusions

Low-intensity CIMT protocols may result in comparable improvements to more intensive ones but caution has to be taken when drawing conclusions due to high risk of bias studies.

Effects of a 12 week community-based high-level mobility programme on sustained participation in physical activity by adolescents with cerebral palsy: a single subject research design study

PURPOSE

To assess if a high-level mobility programme (HLMP) can promote sustained participation in physical activity by adolescents with cerebral palsy.

METHODS

Eight adolescents with cerebral palsy, Gross Motor Function Classification System levels I-II, 11-16 years, participated in 24 community-based group HLMP sessions across 12 weeks. Participants set attendance, involvement, and physical performance goals, completed activity diaries over 58 weeks and undertook physical capacity tests. Measures of activity frequency and diversity (attendance) and involvement level were collected weekly across baseline (4-6 weeks), intervention (12 weeks), and nine months follow-up (including Covid lockdown).

RESULTS

Median attendance was 23 of 24 HLMP sessions. Attendance goal/s attainment was highest during COVID lockdown. Involvement goals were consistently attained throughout all phases. Physical performance goal/s attainment was highest during intervention phase but reduced during nine months follow-up. Frequency of participation in physical activities varied greatly across study phases (range 0-33 episodes/week) with stable variety of activities and generally high 'involvement.' During the intervention, seven participants improved physical capacity and six maintained, or increased, the gains six months later.

CONCLUSION

Most participants improved physical capacity post-intervention but only some had sustained attendance and involvement in physical activity, highlighting the complexity of physical activity participation.

Activity based restorative therapy considerations for children: medical and therapeutic perspectives for the pediatric population

Well-established scientific evidence demonstrates that activity is essential for the development and repair of the central nervous system, yet traditional rehabilitation approaches target muscles only above the lesion as a means of compensation. Activity-Based Rehabilitation (ABR) represents an evolving paradigm shift in neurorehabilitation targeting activation of the neuromuscular system below the lesion. Based on activity-dependent plasticity, ABR offers high intensity activation of the nervous system to optimize the capacity for recovery, while working to offset the chronic complications that occur as a result of neurologic injury. Treatment focus shifts from compensatory training to promotion of restoration of function with special emphasis on normalizing sensory cues and movement kinematics. ABR in children carries special considerations for a developing nervous system and the focus is not just restoring functions but advancing functions in line with typical development. Application of activity-based interventions includes traditional rehabilitation strategies at higher intensity and frequency than in traditional models, including locomotor training, functional electrical stimulation, massed practice, and task specific training, applied across the continuum of care from early intervention to the chronic condition.

A Tailorable Robotic Hand Orthosis to Support Children with Neurological Hand Impairments: a Case Study in a Child's Home

Neurological disorders such as traumatic brain injuries (TBI) can lead to hand impairments in children, negatively impacting their quality of life. Fully wearable robotic hand orthoses (RHO) have been proposed to actively support children and promote the use of the impaired limb in daily life. Here we report a case study on the feasibility of using the pediatric RHO PEXO for assistance at home in a 13- year-old child with hand impairment after TBI. The size and functionalities of the RHO were first fully tailored to the child's needs. We trained the child and their parent on independently using the RHO before taking it home for a period of two weeks. The use of the RHO improved hand ability. Additionally, the tailoring and training benefited the unimanual capacity (Box and Block Test score +2 after tailoring) and bimanual performance (Assisting Hand Assessment score +4) of the child with PEXO. Further, it increased device acceptance by the child and the parent. The child used PEXO at home for 76 minutes distributed over three days during eating and drinking tasks. Personal and environmental factors caused the moderate use. No adverse events or safety-related issues occurred. This study highlights the value of tailoring an assistive RHO and, for the first time, demonstrates the feasibility of home use of a pediatric RHO by children with neurological hand impairments.

Defining, quantifying, and reporting intensity, dose, and dosage of neurorehabilitative interventions focusing on motor outcomes

Introduction

Determining the minimal amount of therapy needed for positive neurorehabilitative outcomes is important for optimizing active treatment interventions to improve motor outcomes. However, there are various challenges when quantifying these relationships: first, several consensuses on the definition and usage of the terms intensity, dose, and dosage of motor interventions have been proposed, but there seems to be no agreement, and the terms are still used inconsistently. Second, randomized controlled trials frequently underreport items relevant to determining the intensity, dose, and dosage of the interventions. Third, there is no universal measure to quantify therapy intensity accurately. This "perspectives" paper aims to increase awareness of these topics among neurorehabilitation specialists.

Defining quantifying and reporting

We searched the literature for definitions of intensity, dose, and dosage and adapted the ones we considered the most appropriate to fit the needs of neurorehabilitative interventions. Furthermore, we suggest refining the template for intervention description and replication (TIDieR) to enhance the reporting of randomized controlled trials. Finally, we performed a systematic literature search to provide a list of intensity measures and complemented these with some novel candidate measures.

Discussion

The proposed definitions of intensity, dose, and dosage could improve the communication between neurorehabilitation specialists and the reporting of dose and dosage in interventional studies. Quantifying intensity is necessary to improve our understanding of the minimal intensity, dose, and dosage of therapy needed to improve motor outcomes in neurorehabilitation. We consider the lack of appropriate intensity measures a significant gap in knowledge requiring future research.

Understanding a videogame home intervention for children with hemiplegia: a mixed methods multi-case study

Introduction

Access to rehabilitation therapies is a salient and growing issue for children with cerebral palsy (CP) and their families, motivating interest in home-based interventions. Bootle Blast is a low-cost, movement-tracking videogame that can be used at home to encourage upper limb (UL) functional exercise tailored to each child's abilities and therapy goals. The study objectives were to: 1) Establish the extent to which children achieve their self-directed play-time goal over a 12-week intervention, 2) Measure changes in UL motor outcomes, and 3) Explore participants' experiences of using Bootle Blast at home.

Methods

Mixed methods case series study of four children with hemiplegic cerebral palsy (HCP), each with a participating parent. Participants played Bootle Blast at home for 12 weeks. Study assessments occurred at baseline, post-intervention and four week follow up. A post-intervention interview explored participants' experiences. Game-logs provided play time and progress data.

Results

Three of four participants (8-13 yrs., Manual Ability Classification Level I-II) completed the intervention. One dropped out at week 6. Play-time goals were achieved in most weeks, with two of four children surpassing their overall intervention goals. Outcomes varied across the three participants, however consistent improvements were observed on the Canadian Occupational Performance Measure and the Box and Blocks Test. Inductive analysis generated four main themes: 1) Intrinsic motivators fostered play engagement, 2) Virtual play for real-world gains, 3) Therapy on demand (at home), and 4) Shifting the onus from the parent to the game. Integration of qualitative and quantitative data was important for interpreting play patterns/usage and clinical outcomes.

Discussion

This mixed methods study describes a novel videogaming intervention designed for home-rehabilitation for children with HCP and provides preliminary evidence to guide future study design and research.

Clinical Trial Registration

[https://clinicaltrials.gov/ct2/show/NCT04009031?recrs=h&cond=Cerebral+Palsy&cntry=CA&city=Toronto&draw=2&rank=1], identifier [NCT04009031].

Efficacy of Constraint-Induced Movement Therapy Versus Bimanual Intensive Training on Motor and Psychosocial Outcomes in Children With Unilateral Cerebral Palsy: A Randomized Trial

IMPORTANCE

Emerging research has demonstrated that constraint-induced movement therapy (CIMT) and bimanual intensive training (BIT) show promising effectiveness for children with unilateral cerebral palsy (UCP). Considering that neurorehabilitative programs have always been designed with long training periods, psychosocial outcomes have received scarce attention and thus have not been investigated sufficiently.

OBJECTIVE

To compare the efficacy of CIMT and BIT with 36-hr interventional dosages for both motor and psychosocial outcomes.

DESIGN

Randomized trial.

SETTING

Community.

PARTICIPANTS

Forty-eight children with UCP, ages 6 to 12 yr.

INTERVENTION

Both CIMT and BIT delivered via individual intervention for 2.25 hr/day, twice a week, for 8 wk.

OUTCOMES AND MEASURES

The Melbourne Assessment 2, Pediatric Motor Activity Log-Revised, Bruininks-Oseretsky Test of Motor Proficiency, ABILHAND-Kids measure, and Parenting Stress Index-Short Form were administrated at pretreatment, midterm, posttreatment, and 6 mo after intervention. An engagement questionnaire for investigating the child's engagement in the intervention was used to collect the perspectives of the children and the parents weekly.

RESULTS

Children with UCP who received either CIMT or BIT achieved similar motor improvements. The only difference was that CIMT yielded larger improvements in frequency and quality of use of the more affected hand at the 6-mo follow-up. Similar child engagement and parental stress levels were found in the two groups.

CONCLUSIONS AND RELEVANCE

This study comprehensively compared the efficacy of motor and psychosocial outcomes for 36-hr dosages of CIMT and BIT. The promising findings support the clinical efficacy and feasibility of the proposed protocols. What This Article Adds: The core therapeutic principle of CIMT (i.e., remind the child to use the more affected hand) may be more easily duplicated by parents. Parents may have overestimated their child's engagement and given relatively higher scores; therefore, occupational therapists should also consider the opinions of the children themselves.

Evidence for Using ACQUIRE Therapy in the Clinical Application of Intensive Therapy: A Framework to Guide Therapeutic Interactions

Intensive therapies have become increasingly popular for children with hemiparesis in the last two decades and are specifically recommended because of high levels of scientific evidence associated with them, including multiple randomized controlled trials and systematic reviews. Common features of most intensive therapies that have documented efficacy include: high dosages of therapy hours; active engagement of the child; individualized goal-directed activities; and the systematic application of operant conditioning techniques to elicit and progress skills with an emphasis on success-oriented play. However, the scientific protocols have not resulted in guiding principles designed to aid clinicians with understanding the complexity of applying these principles to a heterogeneous clinical population, nor have we gathered sufficient clinical data using intensive therapies to justify their widespread clinical use beyond hemiparesis. We define a framework for describing moment-by-moment therapeutic interactions that we have used to train therapists across multiple clinical trials in implementing intensive therapy protocols. We also document outcomes from the use of this framework during intensive therapies provided clinically to children (7 months-20 years) from a wide array of diagnoses that present with motor impairments, including hemiparesis and quadriparesis. Results indicate that children from a wide array of diagnostic categories demonstrated functional improvements.

Evidence-based management and motor rehabilitation of cerebral palsy children and adolescents: a systematic review

Background

Evidence regarding the management of several aspects of cerebral palsy improved in recent years. Still, discrepancies are reported in clinical practice. Italian professionals and stakeholders expressed the need of setting up updated, evidenced-based, shared statements, to address clinical practice in cerebral palsy rehabilitation. The objective of the present study was to provide an updated overview of the state of knowledge, regarding the management and motor rehabilitation of children and young people with cerebral palsy, as the framework to develop evidence-based recommendations on this topic.

Methods

Guidelines and systematic reviews were searched, relative to evidence-based management and motor treatment, aimed at improving gross motor and manual function and activities, in subjects with cerebral palsy, aged 2-18 years. A systematic search according to the Patients Intervention Control Outcome framework was executed on multiple sites. Independent evaluators provided selection and quality assessment of the studies and extraction of data.

Results

Four guidelines, 43 systematic reviews, and three primary studies were included. Agreement among guidelines was reported relative to the general requirements of management and motor treatment. Considering the subject's multidimensional profile, age and developmentally appropriate activities were recommended to set individual goals and interventions. Only a few approaches were supported by high-level evidence (i.e., bimanual therapy and constraint-induced movement therapy to enhance manual performance). Several task-specific active approaches, to improve gross motor function and gait, were reported (mobility and gait training, cycling, backward gait, and treadmill), based on low-level evidence. Increasing daily physical activity and countering sedentary behavior were advised. Based on the available evidence, non-invasive brain stimulation, virtual reality, action-observation therapy, hydrotherapy, and hippotherapy might be complementary to task or goal-oriented physical therapy programs.

Conclusion

A multiple-disciplinary family-centered evidence-based management is recommended. All motor rehabilitation approaches to minors affected by cerebral palsy must share the following fundamental characteristics: engaging active involvement of the subject, individualized, age and developmentally appropriate, goal-directed, skill-based, and preferably intensive and time-limited, but suitable for the needs and preferences of the child or young person and their family, and feasible considering the implications for themselves and possible contextual limitations.

Home-based virtual reality-enhanced upper limb training system in children with brain injury: a randomized controlled trial

Background

Rehabilitation of upper limb function can be challenging in children with brain lesion. Recent virtual reality (VR) rehabilitation may be an additional treatment option in pediatric rehabilitation.

Objectives

To assess the feasibility and effectiveness of a home-based VR-enhanced rehabilitation program with wearable multi-inertial measurement unit (IMU) sensors on upper limb functions in children with brain injury.

Methods

This multicenter single blind randomized controlled trial included 40 children with cerebral palsy (CP) or static brain injury. Subjects were randomized 1:1 to experimental and control group. Both the groups maintained the same therapeutic content and dose of occupational therapy during the intervention period. The experimental group performed additional training at home using the VR-enhanced program for at least 30 min/day, 5 days/week, for 6 weeks. VR training consisted of daily activities or games promoting wrist and forearm articular movements using wearable IMU sensors. The Melbourne Assessment of Unilateral Upper Limb Function-version 2 (MA2), Upper Limb Physician's Rating Scale (ULPRS), Pediatric Evaluation of Disability Inventory-computer adaptive test (PEDI-CAT), computerized 3D motion analysis, and user satisfaction survey were performed. Mann-Whitney U test was used to compare treatment effects between groups, and Friedman and Wilcoxon signed-rank tests were used to compare pre and post intervention.

Results

Overall 35 children (15 in VR group and 20 in control group) completed the protocol. In the experimental group, an average VR training time was 855 min. The accuracy of motion measured by MA2, segmental movements by ULPRS, daily living capability and social cognitive function by PEDI-CAT, movement time and shoulder movement pattern by motion analysis showed significant improvements. However, there were no significant differences in any of the functional outcome measures compared to the control group. All the children and parents reported positive experiences.

Conclusions

Home-based VR training though it had limited impact on improving upper limb function, it could help improve social cognitive function, movement pattern, and efficiency in children with brain injury and could be an effective means of extending clinical therapy to the home.

Clinical Trial Registration

CRIS.nih.go.kr: identifier KCT0003172.

Outcomes Associated with a Single Joystick-Operated Ride-on-Toy Navigation Training Incorporated into a Constraint-Induced Movement Therapy Program: A Pilot Feasibility Study

Our research aims to evaluate the utility of joystick-operated ride-on-toys (ROTs) as therapeutic adjuncts to improve upper extremity (UE) function in children with hemiplegic cerebral palsy (HCP). This study assessed changes in affected UE use and function following a three-week ROT navigation training incorporated into an existing constraint-induced movement therapy (CIMT) camp in 11 children (3-14 years old) with HCP. We report changes in scores on the standardized Shriners Hospital Upper Extremity Evaluation (SHUEE) from pretest-to-posttest and changes from early-to-late sessions in percent time spent by the affected arm in: (a) "moderate-to-vigorous activity", "light activity" and "no activity" bouts based on accelerometer data and (b) "independent", "assisted", and "no activity" bouts based on video data. We also explored relationships between standardized measures and training-specific measures of affected UE activity. We found small-to-medium improvements in the SHUEE scores. Between 90 and 100% of children also showed medium-to-large improvements in affected UE activity from early-to-late sessions using accelerometers and small improvements via video-based assessments. Exploratory analyses suggested trends for relationships between pretest-posttest and training-specific objective and subjective measures of arm use and function. Our pilot data suggest that single joystick-operated ROTs may serve as motivating, child-friendly tools that can augment conventional therapies such as CIMT to boost treatment dosing, promote affected UE movement practice during real-world navigation tasks, and ultimately improve functional outcomes in children with HCP.

Kindy Moves: the feasibility of an intensive interdisciplinary programme on goal and motor outcomes for preschool-aged children with neurodisabilities requiring daily equipment and physical assistance

OBJECTIVES

To determine the feasibility of an intensive interdisciplinary programme in improving goal and motor outcomes for preschool-aged children with non-progressive neurodisabilities. The primary hypothesis was that the intervention would be feasible.

DESIGN

A single group feasibility study.

SETTING

An Australian paediatric community therapy provider.

PARTICIPANTS

Forty children were recruited. Inclusion criteria were age 2-5 years with a non-progressive neurodisability, Gross Motor Function Classification System (GMFCS) levels III-V or equivalent, and goals relating to mobility, communication and upper limb function. Exclusion criteria included orthopaedic surgery in the past 6 months, unstable hip subluxation, uncontrolled seizure disorder or treadmill training in the past month.

INTERVENTION

A goal-directed programme of three 2-hour sessions per week for 4 weeks (24 hours total). This consisted of treadmill and overground walking, communication practice, and upper limb tasks tailored by an interdisciplinary team.

PRIMARY AND SECONDARY OUTCOME MEASURES

Limited-efficacy measures from preintervention (T1) to postintervention (T2) and 4-week follow-up (T3) included the Goal Attainment Scaling (GAS), Canadian Occupational Performance Measure (COPM), Gross Motor Function Measure (GMFM-66) and 10-Metre Walk Test (10MWT). Acceptability, demand, implementation and practicality were also explored.

RESULTS

There were improvements at T2 compared with T1 for all limited-efficacy measures. The GAS improved at T2 (mean difference (MD) 27.7, 95% CI 25.8 to 29.5) as well as COPM performance (MD 3.2, 95% CI 2.8 to 3.6) and satisfaction (MD 3.3, 95% CI 2.8 to 3.8). The GMFM-66 (MD 2.3, 95% CI 1.0 to 3.5) and 10MWT (median difference -2.3, 95% CI -28.8 to 0.0) improved at T2. Almost all improvements were maintained at T3. Other feasibility components were also demonstrated. There were no adverse events.

CONCLUSIONS

An intensive interdisciplinary programme is feasible in improving goal and motor outcomes for preschool children with neurodisabilities (GMFCS III-V or equivalent). A randomised controlled trial is warranted to establish efficacy.

TRIAL REGISTRATION NUMBER

ACTRN12619000064101.

Development of Hand Use with and Without Intensive Training Among Children with Unilateral Cerebral Palsy in Scandinavia

AIM

To describe hand use development in children with unilateral cerebral palsy who did/did not participate in constraint-induced movement therapy (CIMT) before 7 years of age.

METHOD

The study included 334 participants (18 months-12 years) who were assessed with 1,565 Assisting Hand Assessments (AHAs) and categorized into no intensive training (NIT), CIMT (18 months-7 years), and Baby-CIMT (<18 months) groups.

RESULTS

AHA performance at 18 months (AHA-18) was positively associated with development regardless of training. The CIMT group had lower AHA-18 performance than the NIT group (p = .028), but higher stable limit (p = .076). The age when 90% of development was reached was highest in the CIMT group (p = .014). Although non-significant, the Baby-CIMT group had higher mean curve than NIT and CIMT combined (AHA-18 p = .459, limit p = .477).

CONCLUSION

The CIMT group improved more over time than the NIT group. Intensive training extended the window of development, and Baby-CIMT might promote early development.

Harnessing neuroplasticity to improve motor performance in infants with cerebral palsy: a study protocol for the GAME randomised controlled trial

INTRODUCTION

Cerebral palsy (CP) is the most common physical disability of childhood worldwide. Historically the diagnosis was made between 12 and 24 months, meaning data about effective early interventions to improve motor outcomes are scant. In high-income countries, two in three children will walk. This evaluator-blinded randomised controlled trial will investigate the efficacy of an early and sustained Goals-Activity-Motor Enrichment approach to improve motor and cognitive skills in infants with suspected or confirmed CP.

METHODS AND ANALYSIS

Participants will be recruited from neonatal intensive care units and the community in Australia across four states. To be eligible for inclusion infants will be aged 3-6.5 months corrected for prematurity and have a diagnosis of CP or 'high risk of CP' according to the International Clinical Practice Guideline criteria. Eligible participants whose caregivers consent will be randomly allocated to receive usual care or weekly sessions at home from a GAME-trained study physiotherapist or occupational therapist, paired with a daily home programme, until age 2. The study requires 150 participants per group to detect a 0.5 SD difference in motor skills at 2 years of age, measured by the Peabody Developmental Motor Scales-2. Secondary outcomes include gross motor function, cognition, functional independence, social-emotional development and quality of life. A within-trial economic evaluation is also planned.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Sydney Children's Hospital Network Human Ethics Committee in April 2017 (ref number HREC/17/SCHN/37). Outcomes will be disseminated through peer-reviewed journal publications, presentations at international conferences and consumer websites.

TRIAL REGISTRATION NUMBER

ACTRN12617000006347.

Multisensory Stimulation and Priming (MuSSAP) in 4-10 Months Old Infants with a Unilateral Brain Lesion: A Pilot Randomised Clinical Trial

Aim

To explore the effect of an Early Intensive-Upper Limb intervention (EI-UL) compared to EI-UL with integrated Multisensory Stimulation And Priming (MuSSAP) training on improving manual ability in infants with a unilateral brain lesion.

Method

A pilot randomised clinical trial with pre- and postintervention and follow-up measurements (T0, T1, and T2) was conducted. Sixteen infants with a unilateral brain lesion (corrected age is 4-10 months) received home-based intervention with video coaching. Eight infants received EI-UL and eight infants received EI-UL with integrated MuSSAP training. Primary outcome was the Hand Assessment for Infants (HAI) score. Additionally, effects were explored on initiation of goal-directed movements in both groups and on attention in the EI-UL with integrated MuSSAP training group.

Results

No significant group differences in HAI scores were found. Overall, HAI 'Affected hand score' increased between T0 and T1 (p = 0.001, Cohen's d = 1.04) and between T0 and T2 (p < 0.001, Cohen's d = 1.28); and the HAI 'Both Hands Measure' increased between T0 and T1 (p < 0.001, Cohen's d = 1.72) and between T0 and T2 (p < 0.001, Cohen's d = 1.81). At the start of the intervention, six infants (three in both groups) did not demonstrate initiation of goal-directed contralesional upper limb movements. During the intervention one infant receiving EI-UL and all three infants receiving EI-UL with integrated MuSSAP training started to initiate goal-directed movements.

Conclusion

The results suggest manual ability of infants with unilateral brain lesion improved with both interventions. We hypothesize that the integrated MuSSAP training may facilitate attention and initiation of contralesional upper limb goal-directed movements. This trial is registered with NCT05533476).

Feasibility of family-directed home-based bimanual intensive therapy combined with modified constraint induced movement therapy (h-BITmCI) in very low and low bimanual functional level: A brief report

OBJECTIVE

To examine the feasibility of a home-based hybrid Bimanual-Intensive-Therapy combined with modified Constraint-Induced-Movement-Therapy (h-BITmCI) in children with spastic unilateral cerebral palsy (SUCP) with low and very low bimanual functional level.

METHODS

A single-group of 10 children aged 5-8 years old, performed the hybrid home Bimanual-Intensive-Therapy (BIT, 80 hours) combined with modified Constraint-Induced-Movement-Therapy (mCIMT, 20 hours): h-BITmCI. Thus, Bimanual Functional Performance (BFP), Quality of Life (QoL) and expectations from families were measured through the Assisting Hand Assessment, (AHA), Pediatric Quality of Life Inventory, for Cerebral Palsy, (PedsQL^TM v. 3.0, CP) and a specific questionnaire for families for baseline period (week 0), during the treatment phase (week 4 and week 8) and after the intervention (week 10). Repeated measures ANOVA analysis (with post hoc test correction) was used for the BFP and QoL, with a confidence interval (CI) of 95% and with p value <.008 considered statistically significant.

RESULTS

Ten children completed the study with an average of 77-hours-BIT and 17-hours-mCIMT. None of the participants dropped out of the study during the follow-up process, and the parents' expectations were fulfilled, indicating high caregiver compliance. During the first 80 hours of BIT, a mean increase of 3.7 AHA units was obtained for the BFP (p = 1.00) and 1.64 points in the QoL (p = 1.00). Clinically relevant changes were observed in the last two weeks (20 hours mCIMT) with a mean increase of 10.6 AHA units in BFP and 6.29 points in QoL (p < .001).

CONCLUSIONS

h-BITmCI protocol is feasible to be performed at home with the family's involvement, obtaining the greatest improvements after 100 hours of both therapies. Thus, mCIMT would be a relevant condition to increase the affected upper limb functionality, rather than the dosage used to obtain clinically relevant changes.

Does bimanual task training benefit manual ability and hand function of children with bilateral spastic cerebral palsy?

PURPOSE

Sixty percent of children with bilateral cerebral palsy have impaired hand function. The study's purpose was to examine the benefits of bimanual task practice on the manual ability and hand function of children with bilateral spastic cerebral palsy.

METHODS

In this pre-post study design, 18 children with bilateral spastic cerebral palsy with an average age of 11.5 (+/-1.9) years, Manual Ability Classification System levels I-III and Bimanual Fine Motor Function levels I-III participated in bimanual task practice of upper extremities. The task practice included clay activities, paper manipulation and activities of daily needs. The children underwent 45-minute training sessions 3 times a week over 6 weeks. The outcome measures were ABILHAND-Kids, Quality of Upper Extremity Skills Test and grip strength.

RESULTS

Post-training, a mean change of 6.44 logits in ABILHAND-Kids, 11 points on the Quality of Upper Extremity Skills Test, and 3.3 and 3.1 kilograms grip strength in the dominant and nondominant hands respectively were observed with a statistical significance (p <  0.05).

CONCLUSION

Bimanual task training might be beneficial in improving manual ability, hand function and grip strength in children with bilateral spastic cerebral palsy.

Rehabilitation Evidence-Based Decision-Making: The READ Model

Evidence-based practice is the foundation of rehabilitation for maximizing client outcomes. However, an unacceptably high number of ineffective or outdated interventions are still implemented, leading to sub-optimal outcomes for clients. This paper proposes the Rehabilitation Evidence bAsed Decision-Making (READ) Model, a decision-making algorithm for evidence-based decision-making in rehabilitation settings. The READ Model outlines a step-by-step layered process for healthcare professionals to collaboratively set goals, and to select appropriate interventions. The READ Model acknowledges the important multi-layered contributions of client's preferences and values, family supports available, and external environmental factors such as funding, availability of services and access. Healthcare professionals can apply the READ Model to choose interventions that are evidence-based, with an appropriate mode, dose, and with regular review, in order to achieve client's goals. Two case studies are used to demonstrate application of the READ Model: cerebral palsy and autism spectrum disorder. The READ Model applies the four central principles of evidence-based practice and can be applied across multiple rehabilitation settings.

Experiences of patients who had a stroke and rehabilitation professionals with upper limb rehabilitation robots: a qualitative systematic review protocol

INTRODUCTION

Emerging evidence suggests that robotic devices for upper limb rehabilitation after a stroke may improve upper limb function. For robotic upper limb rehabilitation in stroke to be successful, patients' experiences and those of the rehabilitation professionals must be considered. Therefore, this review aims to synthesise the available evidence on experiences of patients after a stroke with rehabilitation robots for upper limb rehabilitation and the experiences of rehabilitation professionals with rehabilitation robots for upper limb stroke rehabilitation.

METHODS AND ANALYSIS

Database search will include MEDLINE (Ovid), EMBASE (Elsevier), Cochrane CENTRAL, PsycINFO, Scopus, Web of Science, IEEE and CINAHL (EBSCOhost). Grey literature from Open Grey, PsyArXiv, bioRxiv, medRxiv and Google Scholar will also be searched. Qualitative studies or results from mixed-method studies that include adult patients after a stroke who use upper limb rehabilitation robots, either supervised by rehabilitation professionals or by patients themselves, at any stage of their rehabilitation and/or stroke professionals who use upper limb rehabilitation robots will be included. Robotic upper limb rehabilitation provided by students, healthcare assistants, technicians, non-professional caregivers, family caregivers, volunteer caregivers or other informal caregivers will be excluded. Articles published in English will be considered regardless of date of publication. Studies will be screened and critically appraised for methodological quality by two independent reviewers. A standardised tool from JBI System for the Unified Management, Assessment and Review of Information for data extraction, the meta-aggregation approach for data synthesis and the ConQual approach for confidence evaluation will be followed.

ETHICS AND DISSEMINATION

As this systematic review is based on previously published research, no informed consent or ethical approval is required. It is anticipated that this systematic review will highlight the experiences of patients after a stroke and perceived facilitators and barriers for rehabilitation professionals on this topic, which will be disseminated through peer-reviewed publications and national and international conferences.

PROSPERO REGISTRATION NUMBER

CRD42022321402.

Intervenções para promover função física de crianças e jovens com paralisia cerebral: diretriz internacional de prática clínica

OBJETIVO

Fornecer recomendações de intervenções para promoção da função física de crianças e jovens com paralisia cerebral.

MÉTODO

Um painel de especialistas priorizou perguntas e desfechos importantes para o paciente. Usando o Grading of Recommendations Assessment, Development and Evaluation (GRADE), o painel avaliou a certeza das evidências e fez recomendações, com consultoria de especialistas internacionais e consumidores.

RESULTADOS

A diretriz compreende 13 recomendações (informadas por três revisões sistemáticas, 30 estudos randomizados e cinco estudos pré‐pós). Para alcance de objetivos funcionais, recomenda‐se que a intervenção inclua objetivos escolhidos pelo cliente, prática completa da tarefa em ambientes da vida real, suporte para empoderar as famílias e uma abordagem em equipe. Idade, habilidade e preferências da criança/família precisam ser consideradas. Para melhora da habilidade da marcha, recomenda‐se marcha no solo, que pode ser complementada com treinamento em esteira. Várias abordagens podem facilitar os objetivos relacionados ao uso das mãos: terapia bimanual, terapia de contensão induzida, treino direcionado a objetivos e abordagens cognitivas. Para auto‐cuidado, prática da tarefa completa, combinada com recursos assistivos podem aumentar a independência e reduzir a sobrecarga do cuidador. A participação em objetivos de lazer pode combinar prática da tarefa completa com estratégias direcionadas para barreiras ambientais, pessoais e sociais.

INTERPRETAÇÃO

Intervenção para promoção da função de crianças e jovens com paralisia cerebral precisa incluir objetivos escolhidos pelo cliente e a prática da tarefa completa dos objetivos. Os clínicos devem considerar as preferências da criança/família, idade e habilidade ao selecionarem intervenções específicas.

Neurodevelopmental Therapy for Cerebral Palsy: A Meta-analysis

BACKGROUND AND OBJECTIVE

Bobath therapy, or neurodevelopmental therapy (NDT) is widely practiced despite evidence other interventions are more effective in cerebral palsy (CP). The objective is to determine the efficacy of NDT in children and infants with CP or high risk of CP.

METHODS

Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Embase, and Medline were searched through March 2021. Randomized controlled trials comparing NDT with any or no intervention were included. Meta-analysis was conducted with standardized mean differences calculated. Quality was assessed by using Cochrane Risk of Bias tool-2 and certainty by using Grading of Recommendations Assessment, Development, and Evaluation.

RESULTS

Of 667 records screened, 34 studies (in 35 publications, 1332 participants) met inclusion. Four meta-analyses were conducted assessing motor function. We found no effect between NDT and control (pooled effect size 0.13 [-0.20 to 0.46]), a moderate effect favoring activity-based approaches (0.76 [0.12 to 1.40]) and body function and structures (0.77 [0.19 to 1.35]) over NDT and no effect between higher- and lower-dose NDT (0.32 [-0.11 to 0.75]). A strong recommendation against the use of NDT at any dose was made. Studies were not all Consolidated Standards of Reporting Trials-compliant. NDT versus activity-based comparator had considerable heterogeneity (I2 = 80%) reflecting varied measures.

CONCLUSIONS

We found that activity-based and body structure and function interventions are more effective than NDT for improving motor function, NDT is no more effective than control, and higher-dose NDT is not more effective than lower-dose. Deimplementation of NDT in CP is required.

Interventions to improve physical function for children and young people with cerebral palsy: international clinical practice guideline

AIM

To provide recommendations for interventions to improve physical function for children and young people with cerebral palsy.

METHOD

An expert panel prioritized questions and patient-important outcomes. Using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methods, the panel assessed the certainty of evidence and made recommendations, with international expert and consumer consultation.

RESULTS

The guideline comprises 13 recommendations (informed by three systematic reviews, 30 randomized trials, and five before-after studies). To achieve functional goals, it is recommended that intervention includes client-chosen goals, whole-task practice within real-life settings, support to empower families, and a team approach. Age, ability, and child/family preferences need to be considered. To improve walking ability, overground walking is recommended and can be supplemented with treadmill training. Various approaches can facilitate hand use goals: bimanual therapy, constraint-induced movement therapy, goal-directed training, and cognitive approaches. For self-care, whole-task practice combined with assistive devices can increase independence and reduce caregiver burden. Participation in leisure goals can combine whole-task practice with strategies to address environmental, personal, and social barriers.

INTERPRETATION

Intervention to improve function for children and young people with cerebral palsy needs to include client-chosen goals and whole-task practice of goals. Clinicians should consider child/family preferences, age, and ability when selecting specific interventions.

Are they really motor learning therapies? A scoping review of evidence-based, task-focused models of upper limb therapy for children with unilateral cerebral palsy

PURPOSE

To identify the specific motor learning (ML) theories underpinning evidence-based, task-focused upper limb models of therapy for children with unilateral cerebral palsy; and to document the strategies used in the operationalisation of these theories.

MATERIAL AND METHOD

This scoping review searched for relevant studies using eight electronic databases. A list of 68 ML strategies and accompanying definitions was developed for data extraction. Three classifications; adequate, inadequate or not described were used to rate the description of ML strategies. A corresponding colour-coding system was used to provide a visual summary.

RESULTS

There is a limited description of the ML theories and strategies used to operationalise these theories in existing models of evidence-based upper limb therapy. Of 103 therapy protocols included, only 24 explicitly described the guiding ML theory. When described, there was significant variation in the underlying theories, leading to significantly different focus and content of therapy. Of the 68 ML strategies, only three were adequately described.

CONCLUSIONS

To support treatment fidelity and the implementation of evidence-based, task-focused models of upper limb therapy in clinical practice, future research needs to provide explicit details about the underlying theories and strategies used in the operationalisation of these theories.Implications for rehabilitationEvidence-based models of upper limb therapy purport to be based on motor learning theory, however, most provide a very limited description of the theories and strategies used.Dosage of practice is only one element that is specific to a therapy approach and other elements guided by the principles of type of task and type of feedback should be considered.To support the implementation of evidence-based approaches in clinical practice, and improve treatment fidelity, it is important for researchers to define the theories that guide therapy approaches and explicitly describe the strategies used to operationalise these theories.

Daily Outpatient Physical Therapy for a Toddler With a Neurodegenerative Disease: A Case Report

PURPOSE

This case report highlights the potential value of delivering a high-dose physical therapy (PT) intervention for a child with a neurodegenerative disease. We include developmental outcomes for a 23-month-old toddler with biallelic TBCD gene mutations following daily outpatient PT.

SUMMARY OF KEY POINTS

The child had clinical improvements in gross and fine motor, cognition, expressive and receptive language, socioemotional, and adaptive behavior function as determined through Goal Attainment Scaling, Gross Motor Function Measure, and Bayley Scales of Infant and Toddler Development following daily PT intervention.

STATEMENT OF CONCLUSION AND RECOMMENDATIONS FOR CLINICAL PRACTICE

High-dose outpatient PT may be beneficial for a child with a neurodegenerative disease at some time frames. In selected cases, if the neurodegenerative disease slowly progresses, high-dose PT may be a treatment option to promote motor change.

Childhood stroke

Stroke is an important cause of neurological morbidity in children; most survivors have permanent neurological deficits that affect the remainder of their life. Stroke in childhood, the focus of this Primer, is distinguished from perinatal stroke, defined as stroke before 29 days of age, because of its unique pathogenesis reflecting the maternal-fetal unit. Although approximately 15% of strokes in adults are haemorrhagic, half of incident strokes in children are haemorrhagic and half are ischaemic. The causes of childhood stroke are distinct from those in adults. Urgent brain imaging is essential to confirm the stroke diagnosis and guide decisions about hyperacute therapies. Secondary stroke prevention strongly depends on the underlying aetiology. While the past decade has seen substantial advances in paediatric stroke research, the quality of evidence for interventions, such as the rapid reperfusion therapies that have revolutionized arterial ischaemic stroke care in adults, remains low. Substantial time delays in diagnosis and treatment continue to challenge best possible care. Effective primary stroke prevention strategies in children with sickle cell disease represent a major success, yet barriers to implementation persist. The multidisciplinary members of the International Pediatric Stroke Organization are coordinating global efforts to tackle these challenges and improve the outcomes in children with cerebrovascular disease.

Feasibility of High Repetition Upper Extremity Rehabilitation for Children with Unilateral Cerebral Palsy

AIMS

In pediatric upper extremity rehabilitation, feasible repetition rates are unknown. Our objectives were to examine repetition rates during rehabilitation and their impact on outcomes.

METHODS

Children with unilateral cerebral palsy due to perinatal stroke (n = 55, median 10 y 7 mo, 30 males) received Constraint-Induced Movement Therapy (CIMT) followed by Bimanual Therapy, each for 5 days. Repetitions were documented during one-on-one therapy (1.5 h/day). Outcomes included the Assisting Hand Assessment (AHA), Jebsen Taylor Test of Hand Function (JTTHF), and Box and Block Test (BBT). Means and standard deviations for motor outcomes and frequencies for repetition rates were calculated. Factors associated with repetition rates and outcome change were explored using standard linear regression.

RESULTS

Repetitions/hour averaged 365 ± 165 during CIMT and 285 ± 103 during Bimanual Therapy. Higher repetition rates were associated with higher baseline function by older age, a main effect of younger age, and improving motor skill (p < .05). Higher repetition rates corresponded with improvement of the AHA and BBT (p < .05, standardized ß = 0.392, 0.358).

CONCLUSIONS

Results suggest high repetition therapy is feasible in school-aged children with perinatal stroke, albeit with high individual variability. Multiple associations between repetition rates and baseline function and change point to the clinical importance of this measurable and potentially modifiable factor.

Effects of Dynamic Suit Orthoses on the Spatio-Temporal Gait Parameters in Children with Cerebral Palsy: A Systematic Review

Dynamic suit orthoses (DSO) are currently used as a complementary treatment method in children with Cerebral Palsy (cwCP). The aim of this review was to assess the effects of interventions with DSO on the altered spatio-temporal gait parameters (STGPs) in cwCP. An electronic search was conducted in the Web of Science, Scopus, PEDro, Cochrane Library, MEDLINE/PubMed, and CINAHL databases up to July 2021. We included a total of 12 studies, which showed great heterogeneity in terms of design type, sample size, and intervention performed (two employed a Therasuit, three employed the Adeli suit, three employed Theratogs, one employed elastomeric tissue dynamic orthosis, one employed a full-body suit, one employed external belt orthosis, and one employed dynamic orthosis composed of trousers and T-shirt). The Cochrane collaboration’s tool and the Checklist for Measuring Study Quality were used to assess the risk of bias and the methodological quality of the studies. It was variable according to the Checklist for Measuring Study Quality, and it oscillated between eight and 23. The studies of higher methodological quality showed significant post-intervention changes in walking speed (which is the most widely evaluated parameter), cadence, stride length, and step length symmetry. Although the evidence is limited, the intervention with DSO combined with a programme of training/physical therapy seems to have positive effects on the STGPs in cwCP, with the functional improvements that it entails. Despite the immediate effect after one session, a number of sessions between 18 and 60 is recommended to obtain optimum results. Future studies should measure all STGPs, and not only the main ones, such as gait speed, in order to draw more accurate conclusions on the functional improvement of gait after the use of this type of intervention.

Kindy Moves: a protocol for establishing the feasibility of an activity-based intervention on goal attainment and motor capacity delivered within an interdisciplinary framework for preschool aged children with cerebral palsy

INTRODUCTION

Preschool aged children with cerebral palsy (CP) and like conditions are at risk of performing below their peers in key skill areas of school readiness. Kindy Moves was developed to support school readiness in preschool aged children with CP and like conditions that are dependent on physical assistance and equipment throughout the day. The primary aims are to determine the feasibility of motor-based interventions that are functional and goal directed, adequately dosed and embedded into a play environment with interdisciplinary support to optimise goal-driven outcomes.

METHODS AND ANALYSIS

Forty children with CP and like conditions aged between 2 and 5 years with a Gross Motor Function Classification System (GMFCS) level of III-V or equivalent, that is, dependent on physical assistance and equipment will be recruited in Western Australia. Participants will undertake a 4-week programme, comprised three, 2-hour sessions a week consisting of floor time, gross motor movement and play (30 min), locomotor treadmill training (30 min), overground walking in gait trainers (30 min) and table-top activities (30 min). The programme is group based with 3-4 children of similar GMFCS levels in each group. However, each child will be supported by their own therapist providing an interdisciplinary and goal directed approach. Primary outcomes of this feasibility study will be goal attainment (Goal Attainment Scale) and secondary outcomes will include Canadian Occupational Performance Measure, 10 metre walk test, Children's Functional Independence Measure, Sleep Disturbance Scale, Infant and Toddler Quality of Life Questionnaire, Peabody Developmental Motor Scale and Gross Motor Function Measure. Outcomes will be assessed at baseline, post intervention (4 weeks) and retention at the 4-week follow-up.

ETHICS AND DISSEMINATION

Ethical approval was obtained from Curtin University Human Ethics Committee (HRE2019-0073). Results will be disseminated through published manuscripts in peer-reviewed journals, conference presentations and public seminars for stakeholder groups.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12619000064101p).

Improvements in Upper Extremity Function Following Intensive Training Are Independent of Corticospinal Tract Organization in Children With Unilateral Spastic Cerebral Palsy: A Clinical Randomized Trial

Background/Objectives: Intensive training of the more affected upper extremity (UE) has been shown to be effective for children with unilateral spastic cerebral palsy (USCP). Two types of UE training have been particularly successful: Constraint-Induced Movement Therapy (CIMT) and Bimanual training. Reorganization of the corticospinal tract (CST) early during development often occurs in USCP. Prior studies have suggested that children with an ipsilateral CST controlling the affected UE may improve less following CIMT than children with a contralateral CST. We tested the hypothesis that improvements in UE function after intensive training depend on CST laterality.

Study Participants and Setting: Eighty-two children with USCP, age 5 years 10 months to 17 years, University laboratory setting.

Materials/Methods: Single-pulse transcranial magnetic stimulation (TMS) was used to determine each child's CST connectivity pattern. Children were stratified by age, sex, baseline hand function and CST connectivity pattern, and randomized to receive either CIMT or Bimanual training, each of which were provided in a day-camp setting (90 h). Hand function was tested before, immediately and 6 months after the intervention with the Jebsen-Taylor Test of Hand Function, the Assisting Hand Assessment, the Box and Block Test, and ABILHAND-Kids. The Canadian Occupational Performance Measure was used to track goal achievement and the Pediatric Evaluation of Disability Inventory was used to assess functioning in daily living activities at home.

Results: In contrast to our hypothesis, participants had statistically similar improvements for both CIMT and Bimanual training for all measures independent of their CST connectivity pattern (contralateral, ipsilateral, or bilateral) (p < 0.05 in all cases).

Conclusions/Significance: The efficacy of CIMT and Bimanual training is independent of CST connectivity pattern. Children with an ipsilateral CST, previously thought to be maladaptive, have the capacity to improve as well as children with a contralateral or bilateral CST following intensive CIMT or Bimanual training.

Clinical Trial Registration:www.ClinicalTrials.gov, identifier NCT02918890.

Physical ACTivity in Survivorship (PACTS): study protocol for a randomized controlled trial evaluating a goal-directed therapeutic exercise program in pediatric posterior fossa brain tumor survivors

BACKGROUND

Posterior fossa brain tumors (PFBT) are the most common solid tumor in children. Recent increases in survival rates are encouraging; however, survivors may experience a plethora of disease- and treatment-related complications that can persist into adulthood. Therapeutic exercise interventions have been shown to improve quality of survivorship in other pediatric cancer diagnoses. There is also evidence that goal-directed interventions are effective at improving motor activities, function, and self-care in children with complex health conditions. Yet, there is currently no evidence on the efficacy of goal-directed therapeutic exercise in pediatric PFBT survivors. The Physical ACTivity in Survivorship (PACTS) study aims to investigate the effects of a novel goal-directed therapeutic exercise program on cardiorespiratory fitness and physical activity-related goal attainment in pediatric survivors of PFBT.

METHOD

PFBT survivors, aged five to 17 years, who underwent surgery at least 12 months earlier and completed radiation therapy and/or chemotherapy at least 6 months prior will be recruited from the Queensland Children's Hospital (Brisbane, Australia) (target n = 48). Following baseline assessment, participants are randomized into either the intervention or usual care group. The intervention group will receive weekly individualized, goal-directed exercise therapy delivered face-to-face for 12 weeks, along with an accompanying home-based program (three sessions per week). Outcomes will be assessed at baseline, immediately post-intervention, and at 6- and 12-months post-intervention. The primary outcomes are cardiorespiratory fitness (Peak VO2) and physical activity-related goal attainment. Secondary outcomes are cardiorespiratory endurance, high-level mobility skills, functional muscle strength, habitual physical activity, gait, balance, quality of life, fatigue, participation, perceived movement skill competence and parameters of body composition.

DISCUSSION

PACTS is the first study to investigate the efficacy of goal-directed therapeutic exercise in children with PFBT and provide evidence needed to inform clinical practice recommendations for managing quality of survivorship in PFBT survivors.

TRIAL REGISTRATION

ACTRN12619000841178 .

Advancing Stroke Recovery Through Improved Articulation of Nonpharmacological Intervention Dose

Dose articulation is a universal issue of intervention development and testing. In stroke recovery, dose of a nonpharmaceutical intervention appears to influence outcome but is often poorly reported. The challenges of articulating dose in nonpharmacological stroke recovery research include: (1) the absence of specific internationally agreed dose reporting guidelines; (2) inadequate conceptualization of dose, which is multidimensional; and (3) unclear and inconsistent terminology that incorporates the multiple dose dimensions. To address these challenges, we need a well-conceptualized and consistent approach to dose articulation that can be applied across stroke recovery domains to stimulate critical thinking about dose during intervention development, as well as promote reporting of planned intervention dose versus actually delivered dose. We followed the Design Research Paradigm to develop a framework that guides how to articulate dose, conceptualizes the multidimensional nature and systemic linkages between dose dimensions, and provides reference terminology for the field. Our framework recognizes that dose is multidimensional and comprised of a duration of days that contain individual sessions and episodes that can be active (time on task) or inactive (time off task), and each individual episode can be made up of information about length, intensity, and difficulty. Clinical utility of this framework was demonstrated via hypothetical application to preclinical and clinical domains of stroke recovery. The suitability of the framework to address dose articulation challenges was confirmed with an international expert advisory group. This novel framework provides a pathway for better articulation of nonpharmacological dose that will enable transparent and accurate description, implementation, monitoring, and reporting, in stroke recovery research.

Single-centre parental survey of paediatric rehabilitation services for children with cerebral palsy

Cerebral palsy (CP) is the most common childhood motor disability. The dose of usual care for rehabilitation therapies is unknown. The purpose of this study was to describe current dosage of rehabilitation services for children with CP recruited from a paediatric hospital system in the USA. 96 children with CP were included in this cross-sectional survey. Parents reported frequency, intensity, time and type of therapy services. Weekly frequency was the most common. Children with CP received 0.9-1.2 hours/month of each discipline in the educational setting and 1.5-2.0 hours/month in the clinical setting, lower than the recommendations for improvements in motor skills.

"Help Me to Improve my Own Priorities!": A Feasibility Study of an Individualized Intensive Goal Training for Adolescents with Cerebral Palsy

AIM

To investigate the feasibility and the preliminary effects of an individualized intensive goal training for adolescents with cerebral palsy (CP).

METHODS

Twelve adolescents with CP (12-17 years old, MACS II-III, GMFCS I-IV) identified functional goals to be practiced three hours/day, five days/week, for two weeks. The feasibility aspects included the participant's adherence (i.e., daily logs), the adequacy of the instruments used, and the participant's satisfaction with the intervention (i.e., structured questionnaire). Outcome measures included the Canadian Occupational Performance Measure (COPM), Pediatric Evaluation of Disability Inventory (PEDI) (self-care; mobility), Children Helping Out: Responsibilities, Expectations and Supports (CHORES), Participation and Environment Measure-Children and Youth (PEM-CY) (home) and Box and Blocks Test (BBT). Assessments were conducted one month and two days before the intervention, immediately and three months after the intervention. Friedman tests were used to test time-related differences in the outcome measures.

RESULTS

All adolescents completed and reported satisfaction with the proposed intervention. Significant improvements were observed in performance and satisfaction (COPM), in functional skills and caregiver assistance in self-care and in the performance of household tasks. There were no significant differences in mobility skills, independence in mobility or household tasks, home participation, or manual dexterity.

CONCLUSION

The intensive training was feasible and promoted improvements in functional goals and daily functioning of adolescents with CP.