What assessments evaluate use of hands in infants? A literature review

Selecting assessment tools to characterize upper limb function of children with cerebral palsy: A mega-review of systematic reviews

AIM

A mega-review of published systematic reviews without restriction on year of publication was implemented to summarize available assessment tools of upper limb (UL) function in children with Cerebral Palsy (CP).

METHOD

A multi-prong search strategy was used to identify 12 systematic literature reviews for inclusion in the mega-review. Included reviews were coded by descriptive analyses, which included methodological and reported measurement property description. Methodological quality of the selected systematic reviews was evaluated with the AMSTAR-2. We synthetized the measurement properties of the revised assessment tools and their coverage within the International Classification of Functioning, Disability and Health (ICF) domains.

RESULTS

The 12 systematic reviews addressed 84 assessment tools. Systematic reviews' methodological quality varied between critically low to moderate. Suggested assessment tools covered ICF domains of body structure and function, and activities and participation. Measurement property data analysis was based mostly on reliability and validity.

INTERPRETATION

Based on the findings of the mega-review, the ABILHAND-Kids, Assisting Hand Assessment (AHA) and Melbourne Assessment of Unilateral Upper Limb Function (MUUL) are the most suitable tools to evaluate children between 6 and 12 years of age with unilateral CP.

Hammersmith Infant Neurological Examination Clinical Use to Recommend Therapist Assessment of Functional Hand Asymmetries

PURPOSE

To determine whether asymmetry scores derived from the Hammersmith Infant Neurological Examination (HINE) can provide cutoff scores for recommending in-depth assessment of upper extremity functional deficits by therapists using the Hand Assessment for Infants (HAI).

METHODS

Observational study in a clinical laboratory with the HINE and the HAI administered concurrently to 101 infants 3 to 12 months corrected age developing typically or atypically. Predictive value of HINE asymmetry scores for atypical HAI was determined.

RESULTS

Total HINE asymmetry scores of 4 or greater had 100% sensitivity and 88% or greater specificity for identifying infants with an asymmetric HAI score of 3 or greater point difference between hands.

CONCLUSIONS

For infants receiving a total HINE asymmetry score of 4 or greater, referral to therapists for HAI assessment may be beneficial to precisely evaluate function and determine the need for targeted upper extremity interventions.

Measuring Early Problem-Solving in Young Children with Motor Delays: A Validation Study

AIM

There is a lack of evidence-based tools for measuring problem-solving in young children with motor delays. The purpose of this study was to evaluate the construct validity and responsiveness of the Assessment of Problem-Solving in Play.

METHODS

125 young children (10.72, SD 2.62 months) with mild, moderate, and severe motor delays were assessed with the Bayley Scales of Infant and Toddler Development, Third Edition Cognitive Scale and the Assessment of Problem-Solving in Play up to 4 times over 12 months. The baseline and change over time assessment scores were compared.

RESULTS

The Assessment of Problem-Solving in Play was strongly, positively correlated with the Bayley Scales of Infant and Toddler Development, Third Edition Cognitive Scale raw scores at baseline (r=.83, p<.001) and for changes in scores across time (r=.64, p<.001). On average, participants demonstrated positive change in problem-solving scores across time. Participants with severe motor delay scored lower at baseline and changed less as compared to other participants.

CONCLUSIONS

Results provide evidence for the construct validity and responsiveness of the Assessment of Problem-Solving in Play scores in quantifying problem-solving in young children with motor delays 7-27 months of age.

Psychometric Properties of Assessments of Cognition in Infants With Cerebral Palsy or Motor Impairment: A Systematic Review

Objective

Approximately 50% of people with cerebral palsy have a cognitive impairment. However, many tools used to assess cognition in infants require almost normal fine motor ability, and thus may not accurately reflect cognitive abilities of infants with cerebral palsy or other motor impairments. This systematic review aimed to evaluate the psychometric properties of cognitive assessment tools for infants aged 0-24 months with motor impairments and to make recommendations about the most appropriate cognitive assessment tools for the purpose of discrimination, prediction, and evaluation.

Method

A systematic review was conducted. CINAHL, Embase, ERIC, Medline, PsycINFO, and SCOPUS databases were searched to identify studies reporting on 1 or more psychometric properties of a standardized cognitive assessment tool or questionnaire in a sample/subsample of infants with motor impairment. Of the 4,480 articles reviewed, 9 assessment tools were identified in 20 publications, which met our inclusion criteria. Articles were appraised using the COnsensus-based Standards for the selection of health Measurement INstruments to assess study rigor. The GRADE framework was applied to develop recommendations for clinical practice.

Results

The Mayes Motor-Free Compilation, Fagan Test of Infant Intelligence, and Bayley-III Low Motor/Vision have predictive and/or discriminative utility in this population. The Mullen Scales of Early Learning was the only tool with psychometric research available examining responsivity to change.

Conclusions

Assessment tools with low-motor/motor-free accommodations have greater accuracy in estimating cognitive abilities of infants with motor impairment than conventional norm-referenced tests. There, however, remains a significant paucity of research in this area.

Using accelerometry for measurement of motor behavior in children: Relationship of real-world movement to standardized evaluation

BACKGROUND

When detected, children with asymmetrical motor impairment are referred for therapeutic interventions to maximize the child's ability to reach their health and developmental potential. Referal is dependent on standardized evaluation, which rarely examines upper extremity (UE) function within the context of real-world activity. Accelerometry provides an efficient method to objectively measure movement in children. The purpose of this study was to compare accelerometry to clinical assessment, specifically the Melbourne Assessment of Unilateral Upper Limb Function-2 (MA-2).

METHODS

A total of 52 children between 1-17 years of age with asymmetrical motor deficits and age matched controls participated in this study. Participants wore bilateral accelerometers for 4 x 25 h. The use ratio (UR) and mono-arm use index (MAUI) were calculated to quantify asymmetrical impairment. The Melbourne Assessment of Unilateral Upper Limb Function-2 (MA-2) was administered and compared to accelerometry variables.

RESULTS

The UR and MAUI were significantly different in children with and without deficits. The MAUI was significantly correlated with all domains of the MA-2: accuracy (r = 0.44, p = 0.026); fluency (r = 0.52, p = 0.006); dexterity (r = 0.53, p = 0.005); and range of motion (r = 0.49, p = 0.011).

CONCLUSIONS

Our findings suggest a relationship between real-world movement and clinical evaluation.

Hand Assessment for Infants: normative reference values

AIM

To create normative reference values for unilateral and bilateral use of the hands, using the Hand Assessment for Infants (HAI), a newly developed criterion-referenced assessment measuring hand use in infants aged 3 months to 12 months at risk of cerebral palsy (CP).

METHOD

In total, 489 HAI assessments of typically developing infants (243 females, 246 males), aged 3 months to 10 months (mean 6mo 14d [SD 2mo 5d]), were collected in Italy and Sweden. Normative growth curves based on mean and SDs were created, as well as skill acquisition curves for each test item. Correlation to age and differences between groups based on sex and nationality, as well as differences between the right and the left hand, were investigated.

RESULTS

The growth curves showed a steady increase in mean value and a decrease in SD over age. There were no differences between groups based on sex or nationality. There was a negligible mean difference (0.1 raw score) between the right and left hands.

INTERPRETATION

HAI normative reference values are now available, which can assist in identifying deviating hand use for each month of age, as well as a side difference between hands in infants at risk of CP.

WHAT THIS PAPER ADDS

A Hand Assessment for Infants (HAI) result greater than 2SD below the mean indicates atypical hand use. Skill acquisition curves describe the age at which typically developing infants master the HAI items. Most typically developing infants do not demonstrate asymmetry in hand use.

Treatment response prediction of rehabilitation program in children with cerebral palsy using radiomics strategy: protocol for a multicenter prospective cohort study in west China

Background

Cerebral palsy (CP) is a major cause of chronic childhood disability worldwide, causing activity limitation as well as impairments in sensation, cognition, and communication. Leveraging biomarkers to establish individualized predictions of future treatment responses will be of great value. We aim to develop and validate a model that can be used to predict the individualized treatment response in Children with CP.

Methods

A multicenter prospective cohort study will be conducted in 4 hospitals in west China. One hundred and thirty children with CP will be recruited and undergo clinical assessment using the Peabody Developmental Motor Scales, Manual Ability Classification System (MACS), Hand Assessment for Infants (HAI), Assisting Hand Assessment (AHA), and Gross Motor Function Classification System (GMFCS). The data collected will include MRI image, clinical status, and socioeconomic status. The clinical information and MRI features extracted using radiomics strategy will be combined for exploratory analysis. The accuracy, sensitivity, and specificity of the model will be assessed using multiple modeling methodologies. Internal and external validation will be used to evaluate the performance of the radiomics model.

Discussion

We hypothesized that the findings from this study could provide a critical step towards the prediction of treatment response in children with CP, which could also complement other biomarkers in the development of precision medicine approaches for this severe disorder.

Trial registration

The study was registered with clinicaltrials.gov (NCT02979743).

Early prediction of unilateral cerebral palsy in infants with asymmetric perinatal brain injury - Model development and internal validation

BACKGROUND

Early diagnosis of unilateral cerebral palsy is important after asymmetric perinatal brain injury (APBI). Our objective is to estimate the risk of unilateral cerebral palsy (UCP) in infants with APBI during the first months of life using neuroimaging and clinical assessment.

PATIENTS AND METHODS

Prognostic multivariable prediction modeling study including 52 infants (27 males), median gestational age 39.3 weeks with APBI from Sweden (n = 33) and the Netherlands (n = 19).

INCLUSION CRITERIA

(1) neonatal MRI within one month after term equivalent age (TEA), (2) Hand Assessment for Infants (HAI) between 3.5 and 4.5 months of (corrected) age. UCP was diagnosed ≥24 months of age. Firth regression with cross-validation was used to construct and internally validate the model to estimate the risk for UCP based on the predictors corticospinal tract (CST) and basal ganglia/thalamus (BGT) involvement, contralesional HAI Each hand sum score (EaHS), gestational age and sex.

RESULTS

UCP was diagnosed in 18 infants (35%). Infants who developed UCP more often had involvement of the CST and BGT on neonatal MRI and had lower contralesional HAI EaHS compared to those who did not develop UCP. The final model showed excellent accuracy for UCP prediction between 3.5 and 4.5 months (area under the curve, AUC = 0.980; 95% CI 0.95-1.00).

CONCLUSIONS

Combining neonatal MRI, the HAI, gestational age and sex accurately identify the prognostic risk of UCP at 3.5-4.5 months in infants with APBI.

[Long term outcome of perinatal stroke]

Neonatal Arterial Ischemic Stroke (NAIS) affects 6-17 newborns on 100 000-birth term neonates, most of these children keeping long-term motor and cognitive impairments. Based on a literature review, the objectives of this paper are to describe motor and cognitive outcomes after a NAIS and to propose a consensual monitoring of these children to improve their management. About 30 % of children after a NAIS will develop a unilateral cerebral palsy requiring a management by a team with expertise in physical medicine and rehabilitation. Unlike adults, especially after a left NAIS, children will not present aphasia but between 50 and 90 % will present disorders of speech and language in expression and/or reception. After NAIS, the global intellectual efficiency is usually preserved except when the size of the lesion is very important or when severe epilepsy occurs. Several studies are also in favor of vulnerability in visuospatial functions. To quantify impairments, activity limitations and participation restrictions resulting from this NAIS, early and at least yearly evaluations with reliable tools must be carried out systematically until puberty. A multidisciplinary team with a longitudinal follow-up, in all the different developmental dimensions, must conduct these evaluations in term of motor skills, cognitive impairment, behavior, autonomy, quality of life, and participation. Consequences on family functioning need to be evaluate in order to help children and family coping with this event.

Feasibility trial of an early therapy in perinatal stroke (eTIPS)

BACKGROUND

Perinatal stroke (PS) affects up to 1/2300 infants and frequently leads to unilateral cerebral palsy (UCP). Preterm-born infants affected by unilateral haemorrhagic parenchymal infarction (HPI) are also at risk of UCP. To date no standardised early therapy approach exists, yet early intervention could be highly effective, by positively influencing processes of activity-dependent plasticity within the developing nervous system including the corticospinal tract. Our aim was to test feasibility and acceptability of an "early Therapy In Perinatal Stroke" (eTIPS) intervention, aiming ultimately to improve motor outcome.

METHODS

Design: Feasibility trial, North-East England, August 2015-September 2017. Participants were infants with PS or HPI, their carers and therapists. The intervention consisted of a parent-delivered lateralised therapy approach starting from term equivalent age and continuing until 6 months corrected age. The outcome measures were feasibility (recruitment and retention rates) and acceptability of the intervention (parental questionnaires including the Warwick-Edinburgh Mental Wellbeing Scale (WEBWMS), qualitative observations and in-depth interviews with parents and therapists). We also reviewed clinical imaging data and undertook assessments of motor function, including the Hand Assessment for Infants (HAI). Assessments were also piloted in typically developing (TD) infants, to provide further information on their ease of use and acceptability.

RESULTS

Over a period of 18 months we screened 20 infants referred as PS/HPI: 14 met the inclusion criteria and 13 took part. At 6 months, 11 (85%) of those enrolled had completed the final assessment. Parents valued the intervention and found it acceptable and workable. There were no adverse events related to the intervention. We recruited 14 TD infants, one of whom died prior to undertaking any assessments and one of whom was subsequently found to have a condition affecting neurodevelopmental progress: thus, data for 12 TD infants was analysed to 6 months. The HAI was well tolerated by infants and highly valued by parents. Completion rates for the WEBWMS were high and did not suggest any adverse effect of engagement in eTIPS on parental mental wellbeing.

CONCLUSION

The eTIPS intervention was feasible to deliver and acceptable to families. We plan to investigate efficacy in a multicentre randomised controlled trial.

TRIAL REGISTRATION

ISRCTN12547427 (registration request submitted 28/05/2015; retrospectively registered, 30/09/2015).

NICU Graduates: The Role of the Allied Health Team in Follow-Up

Infants who graduate from the neonatal intensive care unit, including those infants born preterm and/or with brain injury, are at increased risk of long-term neurodevelopmental impairments. The developmental allied health team, consisting of physical therapy, occupational therapy, and speech pathology, is crucial in early evaluation of gross motor, fine motor, feeding, and language development. Surveillance of neurodevelopment in the first year of life is essential to ensure early detection of specific developmental delays and impairments, and to ensure timely referral for early intervention. Early intervention is not only important in optimizing long-term outcomes for the child, but it also plays an important role in enhancing the parent-child relationship and parental well-being. In this review, we discuss the role of the developmental allied health team in the follow-up of high-risk infants, identify key assessment tools used in early neurodevelopmental surveillance, and provide recommendations regarding referral to intervention programs to optimize child and family outcomes. [Pediatr Ann. 2018;47(4):e165-e171.].

Coaching in early physical therapy intervention: the COPCA program as an example of translation of theory into practice

Background: Coaching is en vogue in pediatric physiotherapy, but often applied rather unspecific and undefined. Methods: This paper aims to describe coaching in early physiotherapy intervention, taking the specific coaching approach of the family-centered program "COPing with and CAring for infants with special needs" (COPCA) as a case in point. Results: The theoretical underpinnings of coaching in COPCA, including a meta-model, family-centered practice, the Neuronal Group Selection Theory and the goal-oriented coaching approach, are discussed. Next, the translation of theory into practical ingredients for coaching of families of a child with special needs is presented. The latter includes the appreciation of family autonomy and attitudes, and the creativity to ask specific questions to support the families in making their own decisions to promote their child's development during daily care-giving routines. Conclusion: It is concluded that the approach of coaching is demanding for both families and pediatric physiotherapists. It requires an active role of the family members in the intervention process and for therapists that they incorporate the attitude of a coach that largely differs from the attitude of the traditional therapist. For families and pediatric physiotherapists appreciating these changes in attitude, COPCA's coaching offers a promising form of early intervention. Implications for rehabilitation We recommend the implementation of the promising approach of goal-oriented and solution-focused coaching in pediatric rehabilitation and/or early intervention. We recommend applying coaching methods that are based on explicit theoretical background and clinical knowledge. We recommend formal training in coaching before professionals apply coaching in pediatric rehabilitation and/or early intervention.

The effectiveness of Baby-CIMT in infants younger than 12 months with clinical signs of unilateral-cerebral palsy; an explorative study with randomized design

AIM

To explore the effectiveness of baby-CIMT (constraint-induced movement therapy) and baby-massage for improving the manual ability of infants younger than 12 months with unilateral cerebral palsy (CP).

METHOD

Infants eligible for inclusion were 3-8 months old with asymmetric hand function and at high risk of developing unilateral CP. Thirty-seven infants were assigned randomly to receive baby-CIMT or baby-massage. At one year of age 31 children were diagnosed with unilateral CP, 18 (8 boys, 6.1±1.7months) of these had received baby-CIMT and 13 (8 boys, 5.0±1.6months) baby-massage. There were two 6-week training periods separated by a 6-week pause. The Hand Assessment for Infants (HAI), Assisting Hand Assessment (AHA), the Parenting Sense of Competence Scale (PSCS) and a questionnaire concerning feasibility were applied.

RESULTS

There was improvement in the "Affected hand score" of HAI from median 10 (6;13 IQR) to 13 (7;17 IQR) raw score in the baby-CIMT group and from 5 (4;11 IQR) to 6 (3;12 IQR) for baby-massage with a significant between group difference (p=0.041). At 18-month of age, the median AHA score were 51 (38;72 IQR) after baby-CIMT (n=18) compared to 24 (19;43 IQR) baby-massage (n=9). The PSCS revealed an enhanced sense of competence of being a parent among fathers in the baby-CIMT group compared to fathers in the baby-massage (p=0.002). Parents considered both interventions to be feasible.

CONCLUSION

Baby-CIMT appears to improve the unimanual ability of young children with unilateral CP more than massage.

Development of the Hand Assessment for Infants: evidence of internal scale validity

AIM

The aim of this study was to develop a descriptive and evaluative assessment of upper limb function for infants aged 3 to 12 months and to investigate its internal scale validity for use with infants at risk of unilateral cerebral palsy.

METHOD

The concepts of the test items and scoring criteria were developed. Internal scale validity and aspects of reliability were investigated on the basis of 156 assessments of infants at 3 to 12 months corrected age (mean 7.2mo, SD 2.5) with signs of asymmetric hand use. Rasch measurement model analysis and non-parametric statistics were used.

RESULTS

The new test, the Hand Assessment for Infants (HAI), consists of 12 unimanual and five bimanual items, each scored on a 3-point rating scale. It demonstrated a unidimensional construct and good fit to the Rasch model requirements. The excellent person reliability enabled person separation to six significant ability strata. The HAI produced an interval-level measure of bilateral hand use as well as unimanual scores of each hand, allowing a quantification of possible asymmetry expressed as an asymmetry index.

INTERPRETATION

The HAI can be considered a valid assessment tool for measuring bilateral hand use and quantifying side difference between hands among infants at risk of developing unilateral cerebral palsy.

WHAT THIS PAPER ADDS

The Hand Assessment for Infants (HAI) measures the use of both hands and quantifies a possible asymmetry of hand use. HAI is valid for infants at 3 to 12 months corrected age at risk of unilateral cerebral palsy.

REACH: study protocol of a randomised trial of rehabilitation very early in congenital hemiplegia

OBJECTIVES

Congenital hemiplegia is the most common form of cerebral palsy (CP). Children with unilateral CP show signs of upper limb asymmetry by 8 months corrected age (ca) but are frequently not referred to therapy until after 12 months ca. This study compares the efficacy of infant-friendly modified constraint-induced movement therapy (Baby mCIMT) to infant friendly bimanual therapy (Baby BIM) on upper limb, cognitive and neuroplasticity outcomes in a multisite randomised comparison trial.

METHODS AND ANALYSIS

150 infants (75 in each group), aged between 3 and 6 months ca, with asymmetric brain injury and clinical signs of upper extremity asymmetry will be recruited. Children will be randomised centrally to receive equal doses of either Baby mCIMT or Baby BIM. Baby mCIMT comprises restraint of the unimpaired hand using a simple restraint (eg, glove, sock), combined with intensive parent implemented practice focusing on active use of the impaired hand in a play-based context. In contrast, Baby BIM promotes active play requiring both hands in a play-based context. Both interventions will be delivered by parents at home with monthly home visits and interim telecommunication support by study therapists. Assessments will be conducted at study entry; at 6, 12 months ca immediately postintervention (primary outcome) and 24 months ca (retention). The primary outcome will be the Mini-Assisting Hand Assessment. Secondary outcomes include the Bayley Scale for Infant and Toddler Development (cognitive and motor domains) and the Hand Assessment of Infants. A subset of children will undertake MRI scans at 24 months ca to evaluate brain lesion severity and brain (re)organisation after intervention.

ETHICS AND DISSEMINATION

Full ethical approvals for this study have been obtained from the relevant sites. The findings will be disseminated in peer-reviewed publications.

TRIAL REGISTRATION NUMBER

Australian and New Zealand Clinical Trials Registry: ACTRN12615000180516, Pre results.

Multiprofessional evaluation in clinical practice: establishing a core set of outcome measures for children with cerebral palsy

AIM

To develop a national consensus on outcome measures that define functional ability in children with cerebral palsy (CP) according to the International Classification of Functioning, Disability and Health (ICF) framework.

METHOD

The project started in 2008 in neuropaediatric units of two university hospitals and one outpatient clinic. Each professional group selected representatives to be knowledge brokers for their own specialty. Based on the evidence, expert opinion, and the ICF framework, multiprofessional teams selected the most valid measures used in clinical practice (2009-2010). Data from 269 children with CP were analysed, classified by the Gross Motor Function Classification System, Manual Ability Classification System, and Communication Function Classification System, and evaluated.

RESULTS

The process aimed at improving and unifying clinical practice in Finland through a national consensus on the core set of measures. The selected measures were presented by professional groups, and consensus was reached on the recommended core set of measures to be used in all hospitals treating children with CP in Finland.

INTERPRETATION

A national consensus on relevant and feasible measures is essential for identifying differences in the effectiveness of local practices, and for conducting multisite intervention studies. This project showed that multiprofessional rehabilitation practices can be improved through respect for and inclusion of everyone involved.

Infant constraint induced movement therapy: Lessons learned from clinical implementation

Current evidence supports the efficacy of pediatric constraint induced movement therapy (CIMT) for toddlers and children but little has been published about its use in early intervention with children eighteen months and younger. This paper and case report describes the clinical experience of developing and executing a modified pediatric CIMT intervention with infants under 18 months old. This is an emerging area of practice that is showing positive trends with initial cases.

Development, and construct validity and internal consistency of the Grasp and Reach Assessment of Brisbane (GRAB) for infants with asymmetric brain injury

INTRODUCTION

Infants with asymmetric brain injury (asymBI) are at high risk of Unilateral Cerebral Palsy (UCP). The Grasp and Reach Assessment of Brisbane (GRAB) was developed to detect asymmetries in unimanual/bimanual upper limb (UL) reach and grasp behaviours in infants with asymBI. This study reports the development of the GRAB and evaluates its construct validity and internal consistency.

MATERIAL AND METHODS

Prospective study of twenty four infants with asymBI and twenty typically developing (TD) infants at 18 weeks corrected age (C.A.) in a structured play session. Three different coloured toys were presented at the midline in a block design of six 30-s trials of toy presentation, separated by five 30-s trials of no toy presentation. The number and duration of: (i) unimanual contacts; (ii) unimanual grasps; (iii) bimanual midline grasps; and (iv) duration of other unimanual behaviours (e.g. prehensile movements and transport phase) were measured. An Asymmetry Index (AI) was calculated to determine asymmetries between ULs. Possible AI values ranged from 0 to 100%, indicating proportion of toy presentation time that unimanual behaviours were asymmetric between ULs. Internal consistency of both the Time Phase (TP) and Toy Colour Phase (TCP) test items were determined by calculating Cronbach's alpha coefficients. Each assessment occasion was split into six TPs and two TCPs; whereby one TP comprised one 30-s trial of one toy presentation and one TCP comprised two 30-s trials of the same toy presentation.

RESULTS

For TP, seven out of nine unimanual behaviours and two out of three bimanual behaviours demonstrated strong internal consistency (Cronbach's alpha coefficients 0.72-0.89). No unimanual activity demonstrated the strongest IC (0.89). For TCP, six out of nine unimanual behaviours demonstrated strong IC (0.73-0.82). Number of unimanual contacts and duration of unimanual prehensile movements demonstrated the strongest IC (0.82). Duration of unimanual contribution to hands at midline and duration of bimanual midline behaviour demonstrated the weakest IC for both TP and TCP (0.46-0.50). For unimanual contacts, the asymBI group were more asymmetric between ULs (mean AI=50%) compared to the TD group (mean AI=30%). For unimanual grasps, both groups were similarly asymmetric (both mean AI=40%). The TD group were almost twice as likely to demonstrate bimanual grasps as the asymBI group (incidence rate ratio IRR 1.9, 95% CI 1.4 to 2.5, p<0.001). Infants with asymBI were less likely to use the impaired UL compared to the unimpaired UL for grasping (IRR 0.6, 95% CI 0.5 to 0.8, p<0.001); and used the impaired UL for a shorter proportion of time compared to the unimpaired UL for grasping (mean difference -9.1%, 95% CI -16.6 to -1.7, p=0.02).

CONCLUSIONS

The GRAB is a criterion-referenced research measure that detects and quantifies the presence or absence of unimanual and bimanual reach and grasp behaviours at 18 weeks C.A. in infants at risk of UCP. The GRAB demonstrated moderate to strong construct validity and strong IC within an assessment occasion. There was no toy preference or warm-up effect for TP or TCP for either group; confirming that the GRAB is a consistent measure across toy presentations within an assessment occasion. In this study, the GRAB identified that infants with asymBI demonstrated a paucity of bimanual grasping compared to TD infants; and demonstrated asymmetric unimanual grasping between ULs at 18 weeks C.A.

Outcome measures evaluating hand function in children with bilateral cerebral palsy: a systematic review

AIM

To review outcome measures used to evaluate hand function, with emphasis on manual capacity and performance, in children with bilateral cerebral palsy (CP), to describe the content and measurement properties of such measures, and to investigate the quality of the studies that have examined these properties.

METHOD

Embase, MEDLINE, PubMed, and CINAHL were searched. The COSMIN-criteria (COnsensus-based Standards for the selection of health Measurement INstruments) were used to assess the quality of studies and the Terwee criteria were used to assess the result of the studies.

RESULTS

Five hand function measures were identified from 16 papers. The strongest level of evidence for aspects of validity and reliability was found for the Melbourne Assessment 2, assessing unimanual capacity, and for the questionnaire ABILHAND-Kids, assessing perceived manual ability in daily activities. However, evidence for the responsiveness of these measures is missing.

INTERPRETATION

Further high-quality studies providing evidence for responsiveness, as well as for additional aspects of validity and reliability of the Melbourne Assessment 2 and the ABILHAND-Kids, are needed. Furthermore, there is a need to develop appropriate outcome measures evaluating how children with bilateral CP use their hands when handling objects in bimanual tasks.

Grading and Quantification of Upper Extremity Function in Children with Spasticity

The World Health Organization's International Classification of Functioning, Disability and Health (ICF) provides an ideal framework within which to conceptualize grading and quantification of upper extremity function for children with spasticity. In this article the authors provide an overview of assessments and classification tools used to (1) understand upper extremity function associated with spasticity and the factors that contribute to dysfunction, (2) guide the selection of appropriate interventions, (3) identify specific muscles to target using surgical interventions and botulinum toxin-A injections, and (4) measure the outcomes of upper extremity interventions. Assessments of upper extremity function are briefly described and categorized as to whether they (1) measure children's best ability or actual performance in daily life, (2) are clinician administered or are a child/proxy report, (3) assist in planning intervention and/or measuring outcomes, and (4) evaluate unimanual or bimanual ability. In addition, measures of spasticity and hypertonicity, and classifications of static and dynamic upper extremity postures are summarized.

Improvements in bimanual hand function after baby-CIMT in two-year old children with unilateral cerebral palsy: A retrospective study

The common assumption that early-onset intensive intervention positively affects motor development has rarely been investigated for hand function in children with unilateral cerebral palsy (CP). This retrospective study explored the possible impact of baby constraint-induced movement therapy (baby-CIMT) on hand function at two years of age. We hypothesized that baby-CIMT in the first year of life would lead to better bimanual hand use at two years of age than would not receiving baby-CIMT. The Assisting Hand Assessment (AHA) was administered at age 21 months (SD 2.4 months) in 72 children with unilateral CP, 31 of who received baby-CIMT. When dividing the children into four functional levels based on AHA, the proportional distribution differed between the groups in favour of baby-CIMT. Logistic regression analysis indicated that children in the baby-CIMT group were more likely than were children in the no baby-CIMT group to have a high functional level, even when controlling for the effect of brain lesion type (OR 5.83, 95% CI 1.44-23.56, p = 0.001). However, no difference was found between groups in the odds of having a very low functional level (OR 0.31, 95% CI 0.08-1.17, p = 0.084). The result shows that baby-CIMT at early age can have a positive effect. Children who received baby-CIMT were six times more likely to have a high functional level at two years of age than were children in the no baby-CIMT group.

Efficacy of baby-CIMT: study protocol for a randomised controlled trial on infants below age 12 months, with clinical signs of unilateral CP

Background

Infants with unilateral brain lesions are at high risk of developing unilateral cerebral palsy (CP). Given the great plasticity of the young brain, possible interventions for infants at risk of unilateral CP deserve exploration. Constraint-induced movement therapy (CIMT) is known to be effective for older children with unilateral CP but is not systematically used for infants. The development of CIMT for infants (baby-CIMT) is described here, as is the methodology of an RCT comparing the effects on manual ability development of baby-CIMT versus baby-massage. The main hypothesis is that infants receiving baby-CIMT will develop manual ability in the involved hand faster than will infants receiving baby-massage in the first year of life.

Method and design

The study will be a randomised, controlled, prospective parallel-group trial. Invited infants will be to be randomised to either the baby-CIMT or the baby-massage group if they: 1) are at risk of developing unilateral CP due to a known neonatal event affecting the brain or 2) have been referred to Astrid Lindgren Children’s Hospital due to asymmetric hand function. The inclusion criteria are age 3–8 months and established asymmetric hand use. Infants in both groups will receive two 6-weeks training periods separated by a 6-week pause, for 12 weeks in total of treatment. The primary outcome measure will be the new Hand Assessment for Infants (HAI) for evaluating manual ability. In addition, the Parenting Sense of Competence scale and Alberta Infant Motor Scale will be used. Clinical neuroimaging will be utilized to characterise the brain lesion type. To compare outcomes between treatment groups generalised linear models will be used.

Discussion

The model of early intensive intervention for hand function, baby-CIMT evaluated by the Hand Assessment for Infants (HAI) will have the potential to significantly increase our understanding of how early intervention of upper limb function in infants at risk of developing unilateral CP can be performed and measured.

Trial registration

SFO-V4072/2012, 05/22/2013