Psychometric properties of a revised version of the Assisting Hand Assessment (Kids-AHA 5.0)

Infant Modified Constraint-Induced Movement Therapy Paired With Neuromuscular Electrical Stimulation: A Feasibility Study

PURPOSE

To determine the feasibility of modified constraint-induced movement therapy (mCIMT) paired with neuromuscular electrical stimulation (NMES) for infants with asymmetrical hand function (AHF).

METHODS

Five infants received an experimental ABA design: (A1) 3 weeks of our Standard AHF Care, (B) 3 weeks mCIMT-NMES, and (A2) 3 weeks of our Standard AHF Care. Parents tracked key data in a daily log, and infants were assessed 4 times using the Hand Assessment for Infants and Peabody Developmental Motor Scale-2.

RESULTS

There was a high level of participant enrollment, visit frequency adherence, and compliance with the treatment protocol. No adverse events were reported. Mean Hand Assessment for Infants Both Hands measure scores changed more after mCIMT-NMES than after our Standard AHF Care.

CONCLUSIONS

mCIMT-NMES is a feasible early intervention for infants with AHF at risk for unilateral cerebral palsy. A future study in a larger sample should examine the efficacy of mCIMT-NMES in this population.

The relation between visual functions, functional vision, and bimanual function in children with unilateral cerebral palsy

BACKGROUND

Accurate visual information is needed to guide and perform efficient movements in daily life.

AIMS

To investigate the relation between visual functions, functional vision, and bimanual function in children with unilateral cerebral palsy (uCP).

METHODS AND PROCEDURES

In 49 children with uCP (7-15 y), we investigated the relation between stereoacuity (Titmus Stereo Fly test), visual perception (Test of Visual Perceptual Skills), visuomotor integration (Beery Buktenica Test of Visual-Motor Integration) and functional vision (Flemish cerebral visual impairment questionnaire) with bimanual dexterity (Tyneside Pegboard Test), bimanual coordination (Kinarm exoskeleton robot, Box opening task), and functional hand use (Children's Hand-use Experience Questionnaire; Assisting Hand Assessment) using correlations (rs) and elastic-net regularized regressions (d).

OUTCOMES AND RESULTS

Visual perception correlated with bimanual coordination (rs=0.407-0.436) and functional hand use (rs=0.380-0.533). Stereoacuity (rs=-0.404), visual perception (rs=-0.391 to -0.620), and visuomotor integration (rs=-0.377) correlated with bimanual dexterity. Functional vision correlated with functional hand use (rs=-0.441 to -0.458). Visual perception predicted bimanual dexterity (d=0.001-0.315), bimanual coordination (d=0.004-0.176), and functional hand use (d=0.001-0.345), whereas functional vision mainly predicted functional hand use (d=0.001-0.201).

CONCLUSIONS AND IMPLICATIONS

Visual functions and functional vision are related to bimanual function in children with uCP highlighting the importance of performing extensive visual assessment to better understand children's difficulties in performing bimanual tasks.

WHAT THIS PAPER ADDS

Previous findings showed that up to 62 % of children with unilateral cerebral palsy (uCP) present with visual impairment, which can further compromise their motor performance. However, the relation between visual and motor function has hardly been investigated in this population. This study makes a significant contribution to the literature by comprehensively investigating the multi-level relation between the heterogenous spectrum of visual abilities and bimanual function in children with uCP. We found that mainly decreased visual perception was related to decreased bimanual dexterity, bimanual coordination, and functional hand use while impairments in functional vision were only related to decreased functional hand use. Additionally, elastic-net regression models showed that visual assessments can predict bimanual function in children with uCP, however, effect sizes were only tiny to small. With our study, we demonstrated a relation between visual functions and bimanual function in children with uCP. These findings suggest the relevance of thoroughly examining visual functions in children with uCP to identify the presence of visual impairments that may further compromise their bimanual function.

Association between upper limb clinical tests and accelerometry metrics for arm use in daily life in children with unilateral cerebral palsy

PURPOSE

To evaluate the association between upper-limb (UL) clinical tests and UL accelerometry-derived metrics in children with unilateral Cerebral Palsy (CP).

METHODS

In this cross-sectional study, twenty children with unilateral CP and Manual Ability Classification System level I-III were included. Outcomes of the Assisting Hand Assessment, Box and Block-Test and accelerometry metrics were collected in the clinical setting and in daily life. UL asymmetry index (i.e., the ratio between the well-functioning UL and the affected UL use) was evaluated in different physical activity levels and relative use of UL was evaluated during daily living. Spearman's correlation was used to determine the association between UL clinical tests and accelerometry metrics in a clinical setting and in daily life.

RESULTS

The strongest negative association was between the Assisting Hand Assessment units and accelerometry metrics during the sedentary time in daily life (rs = -0.64). The asymmetries between ULs were highest during the child's sedentary time (asymmetry index: 45.15) compared to when the child was in light (asymmetry index: 23.97) or higher intensity physical activity (asymmetry index: 13.39). The children used both ULs simultaneously for 44% of the time during daily life.

CONCLUSION

Accelerometry metrics may provide additional objective information to clinical tests by quantifying the amount of UL movements and the amount of asymmetry between the upper limbs in daily life.

Validation and reliability of Arabic version of Children's Hand-use Experience Questionnaire (CHEQ) for children with hemiparetic cerebral palsy

The aim was to assess validation and reliability of Arabic version of Children's Hand-use Experience Questionnaire (CHEQ) for children with hemiparetic cerebral palsy (HCP). Ninety-nine children aged 6-18 years diagnosed with HCP participated in the study. The CHEQ was used to evaluate the hand-use experiences of children with cerebral palsy (CP). In the expert opinion questionnaire, the average percentage score of agreement on grasp efficacy was 91.5%. The highest percentage (93.3%) was for time taken. Agreement on CHEQ ranged from 91.5 to 93.3% indicating that the content validity of the prototype is supported by the expert ratings. Fitting indices showed that the one-factor structure of the CHEQ has a good and acceptable fit in children with HCP aged 6-18 years. All factor loads of the CHEQ items were greater than 0.7 and significant. Cronbach's alpha coefficient in this study was 0.921, thus showing that the questionnaire had high internal consistency.

A systematic review of instrumented assessments for upper limb function in cerebral palsy: current limitations and future directions

INTRODUCTION

Recently, interest in quantifying upper limb function in cerebral palsy has grown. However, the lack of reference tasks and protocols, have hindered the development of quantified movement analysis in clinical practice. This study aimed to evaluate existing instrumented assessments of upper limb function in cerebral palsy, with a focus on their clinical applicability, to identify reasons for the lack of adoption and provide recommendations for improving clinical relevance and utility.

METHODS

A systematic review was conducted by a multidisciplinary team of researchers and clinicians (Prospero CRD42023402382). PubMed and Web of Science databases were searched using relevant keywords and inclusion/exclusion criteria.

RESULTS

A total of 657 articles were initially identified, and after the selection process, 76 records were included for analysis comprising a total of 1293 patients with cerebral palsy. The quality assessment of the reviewed studies revealed a moderate overall quality, with deficiencies in sample size justification and participant information. Optoelectronic motion capture systems were predominantly used in the studies (N = 57/76). The population mainly consisted of individuals with spastic cerebral palsy (834/1293) with unilateral impairment (N = 1092/1293). Patients with severe functional impairment (MACS IV and V) were underrepresented with 3.4% of the 754 patients for whom the information was provided. Thirty-nine tasks were used across the articles. Most articles focused on unimanual activities (N = 66/76) and reach or reach and grasp (N = 51/76). Bimanual cooperative tasks only represented 3 tasks present in 4 articles. A total of 140 different parameters were identified across articles. Task duration was the most frequently used parameter and 23% of the parameters were used in only one article.

CONCLUSION

Further research is necessary before incorporating quantified motion analysis into clinical practice. Existing protocols focus on extensively studied populations and rely on costly equipment, limiting their practicality. Standardized unimanual tasks provide limited insights into everyday arm use. Balancing methodological requirements and performance evaluation flexibility is a challenge. Exploring the correlation between outcome parameters and therapeutic guidance could facilitate the integration of quantified movement assessment into treatment pathways.

Does somatosensory discrimination therapy alter sensorimotor upper limb function differently compared to motor therapy in children and adolescents with unilateral cerebral palsy: study protocol for a randomized controlled trial

BACKGROUND

Besides motor impairments, up to 90% of the children and adolescents with unilateral cerebral palsy (uCP) present with somatosensory impairments in the upper limb. As somatosensory information is of utmost importance for coordinated movements and motor learning, somatosensory impairments can further compromise the effective use of the impaired upper limb in daily life activities. Yet, intervention approaches specifically designated to target these somatosensory impairments are insufficiently investigated in children and adolescents with uCP. Therefore, the aim of this randomized controlled trial (RCT) is to compare the effectiveness of somatosensory discrimination therapy and dose-matched motor therapy to improve sensorimotor upper limb function in children and adolescents with uCP, who experience somatosensory impairments in the upper limb. We will further explore potential behavioral and neurological predictors of therapy response.

METHODS

A parallel group, evaluator-blinded, phase-II, single-center RCT will be conducted for which 50 children and adolescents with uCP, aged 7 to 15 years, will be recruited. Participants will be randomized to receive 3 weekly sessions of 45 minutes of either somatosensory discrimination therapy or upper limb motor therapy for a period of 8 weeks. Stratification will be performed based on age, manual ability, and severity of tactile impairment at baseline. Sensorimotor upper limb function will be evaluated at baseline, immediately after the intervention and after 6 months follow-up. The primary outcome measure will be bimanual performance as measured with the Assisting Hand Assessment. Secondary outcomes include a comprehensive test battery to objectify somatosensory function and measures of bimanual coordination, unimanual motor function, and goal attainment. Brain imaging will be performed at baseline to investigate structural brain lesion characteristics and structural connectivity of the white matter tracts.

DISCUSSION

This protocol describes the design of an RCT comparing the effectiveness of somatosensory discrimination therapy and dose-matched motor therapy to improve sensorimotor upper limb function in children and adolescents with uCP. The results of this study may aid in the selection of the most effective upper limb therapy, specifically for children and adolescents with tactile impairments.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT06006065). Registered on August 8, 2023.

Self-care and hand function in preschool children with unilateral or bilateral cerebral palsy: A cross-sectional study

AIMS

To describe self-care capabilities among children with cerebral palsy (CP) and explore associations between self-care and hand function for children with unilateral cerebral palsy (UCP) and children with bilateral cerebral palsy (BCP) separately.

METHOD

Cross-sectional data on self-care capabilities (Pediatric Evaluation of Disability Inventory, PEDI), manual abilities (Manual Ability Classification System, MACS) and hand use during bimanual performance (Assisting Hand Assessment, AHA; Both Hands Assessment, BoHA) were retrieved from the Norwegian Quality and Surveillance Registry for Cerebral Palsy (NorCP). Eighty-seven children with CP (UCP, n = 61, mean age 4 years 1 month, SD 1 year 3 months, range 56) or BCP (n = 26, mean age 4 years 4 months, SD 1 year, range 41), classified at MACS level I (n = 26), II (n = 40) or III (n = 21), were included.

RESULTS

No significant differences in self-care capabilities were found between children with UCP and children with BCP. Analysis of variance showed significant differences in self-care between MACS levels for the whole group. No significant differences in self-care between MACS levels were observed for children with UCP (p = 0.36), but significant differences were found for those with BCP (p < 0.001). Whereas a small correlation (r = 0.3) between PEDI and AHA scores was found for children with UCP, a large correlation (r = 0.6) was found for those with BCP. Children with BCP with symmetric hand use during bimanual performance (BoHA) had higher PEDI scores than children with asymmetric hand use.

CONCLUSION

Though children with UCP and children with BCP who were classified at MACS I-III exhibited similar self-care capabilities, the limited hand use seems to contribute differently between the two groups. The two different measures of hand use exhibit different associations with self-care capabilities for young children with UCP and BCP, respectively, and illustrate the need to treat UCP and BCP as two distinct groups, each requiring tailored interventions according to their specific needs.

Constraint-induced movement therapy versus bimanual intensive therapy in children with hemiplegia showing low/very low bimanual functional performance: A randomized clinical trial

INTRODUCTION

Children with infantile hemiplegia with low or very low bimanual functional performance have great impediments to spontaneously use their affected upper limb, which affects their performance of day-to-day activities and their quality of life.

OBJECTIVE

To determine whether the order of application and the dose of modified constraint-induced movement therapy within a combined (hybrid) protocol influences the results of bimanual functional performance of the affected upper limb and the quality of life of children with congenital hemiplegia (5 to 8 years old) with low/very low bimanual functional performance.

DESIGN

Single-blinded randomized controlled trial.

PARTICIPANTS

Twenty-one children with congenital hemiplegia (5 to 8 years old) were recruited from two public hospitals and an infantile hemiplegia association in Spain.

INTERVENTIONS

The experimental group (n = 11) received 100 hours of intensive therapies for the affected upper limb: 80 hours of modified constraint-induced movement therapy and 20 hours of bimanual intensive therapy. The control group (n = 10) received the same dose with 80 hours of bimanual intensive therapy and 20 hours of modified constraint-induced movement therapy. The protocol was provided 2 hours per day, 5 days per week, for 10 weeks.

OUTCOME MEASURES

The primary outcome was bimanual functional performance, measured with the Assisting Hand Assessment, and the second outcome was quality of life, measured with the Pediatric Quality of Life Inventory Cerebral-Palsy module (PedsQL v. 3.0, CP module). Four assessments were performed: Weeks 0, 4, 8, and 10.

RESULTS

The experimental group obtained an increase of 22 assisting hand assessment (AHA) units at week 8 with the application of modified constraint-induced movement, in contrast with the control group, which obtained an increase of 3.7 AHA units after bimanual intensive therapy. At week 10, the control group showed its greatest increase in bimanual functional performance, with 10.6 AHA units after modified constraint-induced movement therapy. Regarding quality of life, the greatest improvement occurred after modified constraint-induced movement, with 13.1 points in the experimental group (80 hours) and 6.3 points in the control group (20 hours). The protocol interaction was statistically significant for bimanual functional performance (p = .018) and quality of life (p = .09).

CONCLUSIONS

Modified constraint-induced movement therapy is more beneficial than bimanual intensive therapy for improving upper limb functioning and quality of life in children with congenital hemiplegia showing low/very low bimanual performance.

CLINICALTRIALS

GOV IDENTIFIER

NCT03465046.

In-depth quantification of bimanual coordination using the Kinarm exoskeleton robot in children with unilateral cerebral palsy

BACKGROUND

Robots have been proposed as tools to measure bimanual coordination in children with unilateral cerebral palsy (uCP). However, previous research only examined one task and clinical interpretation remains challenging due to the large amount of generated data. This cross-sectional study aims to examine bimanual coordination by using multiple bimanual robotics tasks in children with uCP, and their relation to task execution and unimanual performance.

METHODS

The Kinarm exoskeleton robot was used in 50 children with uCP (mean age: 11 years 11 months ± 2 years 10 months, Manual Ability Classification system (MACS-levels: l = 27, ll = 16, lll = 7)) and 50 individually matched typically developing children (TDC). All participants performed three tasks: object-hit (hit falling balls), ball-on-bar (balance a ball on a bar while moving to a target) and circuit task (move a cursor along a circuit by making horizontal and vertical motions with their right and left hand, respectively). Bimanual parameters provided information about bimanual coupling and interlimb differences. Differences between groups and MACS-levels were investigated using ANCOVA with age as covariate (α < 0.05, [Formula: see text]). Correlation analysis (r) linked bimanual coordination to task execution and unimanual parameters.

RESULTS

Children with uCP exhibited worse bimanual coordination compared to TDC in all tasks (p ≤ 0.05, [Formula: see text] = 0.05-0.34). The ball-on-bar task displayed high effect size differences between groups in both bimanual coupling and interlimb differences (p < 0.001, [Formula: see text] = 0.18-0.36), while the object-hit task exhibited variations in interlimb differences (p < 0.001, [Formula: see text] = 0.22-0.34) and the circuit task in bimanual coupling (p < 0.001, [Formula: see text] = 0.31). Mainly the performance of the ball-on-bar task (p < 0.05, [Formula: see text] = 0.18-0.51) was modulated by MACS-levels, showing that children with MACS-level lll had worse bimanual coordination compared to children with MACS-level l and/or II. Ball-on-bar outcomes were highly related to task execution (r = - 0.75-0.70), whereas more interlimb differences of the object-hit task were moderately associated with a worse performance of the non-dominant hand (r = - 0.69-(- 0.53)).

CONCLUSION

This study gained first insight in important robotic tasks and outcome measures to quantify bimanual coordination deficits in children with uCP. The ball-on-bar task showed the most discriminative ability for both bimanual coupling and interlimb differences, while the object-hit and circuit tasks are unique to interlimb differences and bimanual coupling, respectively.

The assisting hand assessment for children and youth with brachial plexus birth injury: a study of validity and item hierarchy of AHA-Plex

OBJECTIVE

Functional assessments that focus on activity performance and that produce valid outcome measures for people with brachial plexus birth injury are lacking. The primary aim of this study was to re-evaluate the internal scale validity of the Assisting Hand Assessment specifically for children and adolescents with brachial plexus birth injury. Two further aims were investigating whether the scale could be shortened for this group while maintaining psychometric quality, and exploring and presenting its item difficulty hierarchy.

DESIGN

A cross-sectional psychometric study.

SUBJECTS

A convenience sample of 105 children and adolescents (aged 18 months to 18 years, mean 6 years, 7 months, standard deviation (SD) 4 years, 4 months) from Sweden, Norway, and the Netherlands with brachial plexus birth injury.

METHODS

Participants were assessed with the Assisting Hand Assessment. Data were analysed with Rasch measurement analysis.

RESULTS

The 20 Assisting Hand Assessment items together measured a unidimensional construct with high reliability (0.97) and the 4-level rating scale functioned well. Item reduction resulted in 15 items with good item fit, unidimensionality, reliability and acceptable targeting.

CONCLUSION

Assisting Hand Assessment for people with brachial plexus birth injury, called AHA-Plex, has 15 items and good internal scale validity. A unique item hierarchy for people with brachial plexus birth injury is presented.

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.

Design and Use of a 3D-Printed Dynamic Upper Extremity Orthosis for Children With Cerebral Palsy and Severe Upper Extremity Involvement: A Pilot Study

IMPORTANCE

Children with cerebral palsy (CP) and severe hand impairment have limited options for upper extremity (UE) orthoses.

OBJECTIVE

To (1) design and fabricate a customized low-cost, functional, three-dimensional (3D) printed dynamic upper extremity orthosis (DUEO) and (2) examine, using a comprehensive evaluation, the effect of the orthosis on the UE function of children with unilateral UE CP, Manual Ability Classification System (MACS) Levels III to V.

DESIGN

Pilot study. Assessments were performed pretreatment and immediately posttreatment.

SETTING

Hospital-based outpatient occupational therapy department.

PARTICIPANTS

Five patients, ages 13 to 17 yr, with CP and unilateral UE involvement MACS Levels III to V.

INTERVENTION

Custom forearm thumb opponens orthosis and the DUEO were designed and fabricated by a multidisciplinary team for use during eight 1-hr occupational therapy sessions targeting bimanual UE training.

OUTCOMES AND MEASURES

Pretreatment and posttreatment assessments included the Assisting Hand Assessment (AHA), Melbourne Assessment 2 (MA-2), Pediatric Motor Activity Log-Revised (PMAL-R), and the Pediatric Quality of Life Inventory: CP Module (PedsQL:CP).

RESULTS

All participants had higher posttreatment scores on at least one measure. Four had minimal clinically important differences (MCID) on the AHA. Three met MCID criteria on MA-2 subtests (one negative change). Four demonstrated improvement on the PMAL-R (one participant achieved an MCID score), and three reported improvements in more than one PedsQL:CP domain.

CONCLUSIONS AND RELEVANCE

This novel 3D-printed device, in combination with occupational therapy, shows promising evidence that children who score in lower MACS levels can show gains in UE function. What This Article Adds: This study demonstrates that a customized, 3D-printed dynamic orthosis, in combination with occupational therapy intervention, can facilitate UE function in children with severe hand impairment.

Consensus-Based Evaluation of Outcome Measures in Pediatric Stroke Care: A Toolkit

Following a pediatric stroke, outcome measures selected for monitoring functional recovery and development vary widely. We sought to develop a toolkit of outcome measures that are currently available to clinicians, possess strong psychometric properties, and are feasible for use within clinical settings. A multidisciplinary group of clinicians and scientists from the International Pediatric Stroke Organization comprehensively reviewed the quality of measures in multiple domains described in pediatric stroke populations including global performance, motor and cognitive function, language, quality of life, and behavior and adaptive functioning. The quality of each measure was evaluated using guidelines focused on responsiveness and sensitivity, reliability, validity, feasibility, and predictive utility. A total of 48 outcome measures were included and were rated by experts based on the available evidence within the literature supporting the strengths of their psychometric properties and practical use. Only three measures were found to be validated for use in pediatric stroke: the Pediatric Stroke Outcome Measure, the Pediatric Stroke Recurrence and Recovery Questionnaire, and the Pediatric Stroke Quality of Life Measure. However, multiple additional measures were deemed to have good psychometric properties and acceptable utility for assessing pediatric stroke outcomes. Strengths and weaknesses of commonly used measures including feasibility are highlighted to guide evidence-based and practicable outcome measure selection. Improving the coherence of outcome assessment will facilitate comparison of studies and enhance research and clinical care in children with stroke. Further work is urgently needed to close the gap and validate measures across all clinically significant domains in the pediatric stroke population.

Assisting hand use and self-care bimanual performance of children with unilateral spastic cerebral palsy

AIM

To examine the relationship between assisting hand use in bimanual activities and children's self-care activities and task performance.

METHOD

We retrospectively analysed daily functioning (Pediatric Evaluation of Disability Inventory [PEDI]) and bimanual performance (Assisting Hand Assessment [AHA]) data from the assessment of 112 children (mean age: 8 years 10 months [SD 2 years 1 month], range 3 years 7 months-17 years 4 months; 66 males, 46 females) with unilateral spastic cerebral palsy (CP). We used Rasch analysis to examine the relationship between individual item scores from the AHA and the self-care items (functional skills, caregiver assistance) from the PEDI.

RESULTS

Most self-care functional skills and caregiver-assisted tasks were located on the middle of the unidimensional continuum. These items showed similar levels of difficulty as the items from the AHA related to the effective coordination of two hands, appropriate pace, and use of the assisting hand to stabilize and release objects, as well as variations in arm movements.

INTERPRETATION

The distribution of the PEDI self-care and AHA items along the unidimensional continuum illustrates the relationship between assisting hand use and self-care bimanual performance. Interpretation of the items' locations on the hierarchical unidimensional continuum may be helpful to therapists' clinical reasoning and suggest intervention goals to improve the hand function and daily functioning of children with unilateral spastic CP. Such an application needs further investigation.

Exploring structural connectomes in children with unilateral cerebral palsy using graph theory

We explored structural brain connectomes in children with spastic unilateral cerebral palsy (uCP) and its relation to sensory-motor function using graph theory. In 46 children with uCP (mean age = 10 years 7 months ± 2 years 9 months; Manual Ability Classification System I = 15, II = 16, III = 15) we assessed upper limb somatosensory and motor function. We collected multi-shell diffusion-weighted, T1-weighted and T2-FLAIR MRI and identified the corticospinal tract (CST) wiring pattern using transcranial magnetic stimulation. Structural connectomes were constructed using Virtual Brain Grafting-modified FreeSurfer parcellations and multi-shell multi-tissue constrained spherical deconvolution-based anatomically-constrained tractography. Graph metrics (characteristic path length, global/local efficiency and clustering coefficient) of the whole brain, the ipsilesional/contralesional hemisphere, and the full/ipsilesional/contralesional sensory-motor network were compared between lesion types (periventricular white matter (PWM) = 28, cortical and deep gray matter (CDGM) = 18) and CST-wiring patterns (ipsilateral = 14, bilateral = 14, contralateral = 12, unknown = 6) using ANCOVA with age as covariate. Using elastic-net regularized regression we investigated how graph metrics, lesion volume, lesion type, CST-wiring pattern and age predicted sensory-motor function. In both the whole brain and subnetworks, we observed a hyperconnectivity pattern in children with CDGM-lesions compared with PWM-lesions, with higher clustering coefficient (p = [<.001-.047], η p 2 $$ {\eta}_p^2 $$ =[0.09-0.27]), characteristic path length (p = .003, η p 2 $$ {\eta}_p^2 $$ =0.19) and local efficiency (p = [.001-.02], η p 2 $$ {\eta}_p^2 $$ =[0.11-0.21]), and a lower global efficiency with age (p = [.01-.04], η p 2 $$ {\eta}_p^2 $$ =[0.09-0.15]). No differences were found between CST-wiring groups. Overall, good predictions of sensory-motor function were obtained with elastic-net regression (R²  = .40-.87). CST-wiring pattern was the strongest predictor for motor function. For somatosensory function, all independent variables contributed equally to the model. In conclusion, we demonstrated the potential of structural connectomics in understanding disease severity and brain development in children with uCP.

Assessing time processing ability and daily time management in persons with dementia: Psychometric properties of three instruments

INTRODUCTION

Persons with dementia experience time-related problems, but there is a lack of instruments evaluating their time processing ability and daily time management. This study aimed to evaluate the psychometric properties of the instruments KaTid®-Senior measuring time processing ability, and Time-S© Senior and Time-Proxy© measuring daily time management for persons with dementia.

METHODS

Persons with dementia (n = 53) and their significant others (n = 49) participated in the study. Rasch analyses were used to evaluate the instruments' rating scale functioning; internal scale validity; person-response validity; unidimensionality; person-separation reliability; and internal consistency. Versions excluding items with poor fit to the Rasch model were also evaluated.

RESULTS

Overall, the Rasch analyses showed acceptable psychometric properties. All instruments met the criteria for unidimensionality and the reliability was good. More challenging items should be added in KaTid-Senior for better targeting of persons with mild dementia. Person-response validity issues in Time-S Senior need to be addressed.

CONCLUSION

The instruments can validly and reliably be used to assess time processing ability and daily time management in persons with dementia in clinical research and healthcare settings. In turn, this can contribute to the development of methods to compensate for impaired time processing ability and daily time management. The assessments can also increase the possibility of early detection of impaired time processing ability and daily time management, thereby facilitating adequate timing of interventions and enhanced occupational performance.

Hand-Arm Bimanual Intensive Training in Virtual Reality: A Feasibility Study

OBJECTIVE

The aim of the study was to evaluate the feasibility of virtual reality (VR) software built using the core concepts of hand-arm bimanual intensive training (HABIT) for improving upper extremity motor function in children with cerebral palsy (CP).

METHODS

Eight children with CP participated in a 10-day, 40-hour HABIT program. Half of the time custom VR software, HABIT-VR was used. The children's motor skills were assessed pre- and postintervention with the Assisting Hand Assessment, Box and Blocks Test, and Nine-Hole Peg Test.

RESULTS

The children had significant and clinically relevant changes in the Assisting Hand Assessment and Box and Blocks Test; however, Nine-Hole Peg Test scores did not change with intervention.

CONCLUSION

These data suggest that combining traditional HABIT strategies with HABIT-VR games improve upper extremity function and gross motor skills but not fine motor skills.

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.

Shall we start? Ready, set, go! Toward early intervention in infants with unilateral cerebral palsy. A randomized clinical trial protocol

BACKGROUND

It is crucial to start an early intervention in unilateral cerebral palsy. Intensive therapies are focused on training based on activities.

OBJECTIVE

The objective of the study was to study the changes in the bimanual functional performance (BFP) after early intensive therapies at home compared with standard care in children with unilateral cerebral palsy from 9 to 18 months of age.

DESIGN

A single-blind comparative effectiveness study will be conducted.

METHODS AND ANALYSIS

Children will be randomized into four groups: infant-mCIMT, infant-BIT, infant-hybrid, and infant standard therapy (control group, CG). Each early intensive protocol will last 50 h and will be applied throughout a 10-week period with the family involvement at home. The main outcomes are BFP measure with mini-Assisting Hand Assessment (mini-AHA) scale, functional goals measure with Goal Attainment Scale (GAS), and satisfaction and expectations on intensive therapy from parents measure through specific questionnaire. Baseline characteristics between groups will be compared using independent t test and Fisher's exact test. Pre- and post-treatment outcomes of standard assessments will be compared using analysis of variance (ANOVA) for parametric and Kruskal-Wallis test for non-parametric variables. The Bonferroni correction is applied for multiple comparisons. An alpha level of p ⩽ 0.05 is considered significant.

DISCUSSION

In relation to other studies that have analyzed intensive therapies, although with fewer intervention groups, it seems that the application of any of the intensive interventions is effective with the applied dose to obtain changes in BFP and increase the spontaneous use of the affected upper limb.

REGISTRATION

ClinicalTrials.gov Identifier: NCT04642872.

Hand Ownership Is Altered in Teenagers with Unilateral Cerebral Palsy

We explored hand ownership in teenagers with unilateral cerebral palsy (UCP) compared with typically developing teenagers. Eighteen participants with UCP and 16 control teenagers participated. We used the rubber hand illusion to test hand ownership (HO). Both affected/non-affected hands (UCP) and dominant/non-dominant hands (controls) were tested during synchronous and asynchronous strokes. HO was assessed by measuring the proprioceptive drift toward the fake hand (as a percentage of arm length) and conducting a questionnaire on subjective HO. Both groups had significantly higher proprioceptive drift in the synchronous stroking condition for both hands. Teenagers with UCP showed a significantly higher proprioceptive drift when comparing their paretic hand (median 3.4% arm length) with the non-dominant hand of the controls (median 1.7% arm length). The questionnaires showed that synchronous versus asynchronous stroking generated a robust change in subjective HO in the control teenagers, but not in the teenagers with UCP. Teenagers with UCP have an altered sense of HO and a distorted subjective experience of HO that may arise from the early dysfunction of complex sensory–motor integration related to their brain lesions. HO may influence motor impairment and prove to be a target for early intervention.

Quantifying intra- and interlimb use during unimanual and bimanual tasks in persons with hemiparesis post-stroke

Background

Individuals with hemiparesis post-stroke often have difficulty with tasks requiring upper extremity (UE) intra- and interlimb use, yet methods to quantify both are limited.

Objective

To develop a quantitative yet sensitive method to identify distinct features of UE intra- and interlimb use during task performance.

Methods

Twenty adults post-stroke and 20 controls wore five inertial sensors (wrists, upper arms, sternum) during 12 seated UE tasks. Three sensor modalities (acceleration, angular rate of change, orientation) were examined for three metrics (peak to peak amplitude, time, and frequency). To allow for comparison between sensor data, the resultant values were combined into one motion parameter, per sensor pair, using a novel algorithm. This motion parameter was compared in a group-by-task analysis of variance as a similarity score (0–1) between key sensor pairs: sternum to wrist, wrist to wrist, and wrist to upper arm. A use ratio (paretic/non-paretic arm) was calculated in persons post-stroke from wrist sensor data for each modality and compared to scores from the Adult Assisting Hand Assessment (Ad-AHA Stroke) and UE Fugl-Meyer (UEFM).

Results

A significant group × task interaction in the similarity score was found for all key sensor pairs. Post-hoc tests between task type revealed significant differences in similarity for sensor pairs in 8/9 comparisons for controls and 3/9 comparisons for persons post stroke. The use ratio was significantly predictive of the Ad-AHA Stroke and UEFM scores for each modality.

Conclusions

Our algorithm and sensor data analyses distinguished task type within and between groups and were predictive of clinical scores. Future work will assess reliability and validity of this novel metric to allow development of an easy-to-use app for clinicians.

Clinical utility of a pediatric hand exoskeleton: identifying users, practicability, and acceptance, and recommendations for design improvement

BACKGROUND

Children and adolescents with upper limb impairments can experience limited bimanual performance reducing daily-life independence. We have developed a fully wearable pediatric hand exoskeleton (PEXO) to train or compensate for impaired hand function. In this study, we investigated its appropriateness, practicability, and acceptability.

METHODS

Children and adolescents aged 6-18 years with functional limitations in at least one hand due to a neurological cause were selected for this cross-sectional evaluation. We characterized participants by various clinical tests and quantified bimanual performance with the Assisting Hand Assessment (AHA). We identified children whose AHA scaled score increased by ≥ 7 points when using the hand exoskeleton and determined clinical predictors to investigate appropriateness. The time needed to don each component and the number of technical issues were recorded to evaluate practicability. For acceptability, the experiences of the patients and the therapist with PEXO were evaluated. We further noted any adverse events.

RESULTS

Eleven children (median age 11.4 years) agreed to participate, but data was available for nine participants. The median AHA scaled score was higher with PEXO (68; IQR: 59.5-83) than without (55; IQR: 37.5-80.5; p = 0.035). The Box and Block test, the Selective Control of the Upper Extremity Scale, and finger extensor muscle strength could differentiate well between those participants who improved in AHA scaled scores by ≥ 7 points and those who did not (sensitivity and specificity varied between 0.75 and 1.00). The median times needed to don the back module, the glove, and the hand module were 62, 150, and 160 s, respectively, but all participants needed assistance. The most critical failures were the robustness of the transmission system, the electronics, and the attachment system. Acceptance was generally high, particularly in participants who improved bimanual performance with PEXO. Five participants experienced some pressure points. No adverse events occurred.

CONCLUSIONS

PEXO is a safe exoskeleton that can improve bimanual hand performance in young patients with minimal hand function. PEXO receives high acceptance. We formulated recommendations to improve technical issues and the donning before such exoskeletons can be used under daily-life conditions for therapy or as an assistive device. Trial registration Not appropriate.

The effectiveness of tele-rehabilitation on improvement of daily living activities in children with cerebral palsy: narrative review

Aim

To investigate the effectiveness of tele-rehabilitation for children diagnosed with unilateral cerebral palsy.

Method

The design of this study is a narrative review. An electronic search was conducted for studies that related to tele-rehabilitation using the following databases: CINAHL, PubMed, MEDLINE, OTSeeker, and PEDro. The data extracted were analyzed by evaluating them according to the key results, limitations, suitability of the methods used to the initial hypothesis, interpretation of the results, and impact of the conclusions in the field.

Results

Out of 139 studies, 3 studies met the inclusion criteria. Further, manual searches of the references of included studies identified 2 more relevant studies. The interventions applied in those studies were web-based multi-modal therapy program using Move-it-to-improve-it (Mitii™), home-based hand-arm bimanual intensive therapy (H-HABIT), and lower-extremity functional training (LIFT). The outcomes were executive functions, occupational performance, activity capacity, dexterity, quality of bimanual hand-use, functional goals, gait capacity, and performance.

Conclusion

Tele-rehabilitation is effective in improving the functions of the upper and lower extremities in daily living activities for children with unilateral cerebral palsy (UCP), aged between 2 to 18 years old, classified to levels I and II in GMFCS and levels I, II, and III in MACS. Webcam and good internet connection are essential requirements to conduct tele-rehabilitation. Children need to be contacted weekly via phone or e-mail for further follow-ups. Additionally, tele-rehabilitation may be considered one of the intervention strategies for patients who live in rural areas.

Hand use development in children with unilateral cerebral palsy

AIM

To describe the development of hand use during bimanual activities among children with unilateral cerebral palsy (CP).

METHOD

A cohort of 166 children (79 females, 87 males; age range 18mo-13y, mean [SD] age at first assessment 37.6mo [20.5mo]) with unilateral CP, registered in the Norwegian CP Follow-up Program with two or more Assisting Hand Assessments (AHAs), were included in this longitudinal study comprising 524 AHAs. Developmental limits and rates were estimated by non-linear mixed effects models and compared between a stable limit model (SLM) and a peak and decline model. Development was described according to Manual Ability Classification System (MACS) levels and AHA performance at 18 months of age (AHA-18).

RESULTS

Children in MACS level I, or in the high AHA-18 group, reached highest limits and had the most rapid development (p<0.001). The developmental trajectories were different between MACS levels I, II, and III and between the high, moderate, and low AHA-18 groups. Seventy-five per cent of the children reached 90% of their estimated limit at 5 years 10 months or earlier. The SLM showed the best model fit (Akaike information criterion: 4008.99).

INTERPRETATION

Most children approached a steady performance limit before 6 years of age. Although children in MACS levels I and II reached 90% of the expected limit at 3 and 4 years respectively, the corresponding age was 8 years for children in MACS level III. The better model fit for the SLM indicates that children with unilateral CP maintain their attained limit of hand use to at least the age of 13 years. What this paper adds Development of hand use between 18 months and 13 years follows a stable-limit pattern. Most children reach a steady limit on the Assisting Hand Assessment before 6 years of age. Manual Ability Classification System levels I, II, and III represent distinct developmental trajectories, level III having a slower rise. Early hand use is an important indicator of future development.

Constraint-Induced Movement Therapy for Cerebral Palsy: A Randomized Trial

OBJECTIVES

With the Children with Hemiparesis Arm and Hand Movement Project (CHAMP) multisite factorial randomized controlled trial, we compared 2 doses and 2 constraint types of constraint-induced movement therapy (CIMT) to usual customary treatment (UCT).

METHODS

CHAMP randomly assigned 118 2- to 8-year-olds with hemiparetic cerebral palsy to one of 5 treatments with assessments at baseline, end of treatment, and 6 months posttreatment. Primary blinded outcomes were the assisting hand assessment; Peabody Motor Development Scales, Second Edition, Visual Motor Integration; and Quality of Upper Extremity Skills Test Dissociated Movement. Parents rated functioning on the Pediatric Evaluation of Disabilities Inventory-Computer Adaptive Test Daily Activities and Child Motor Activity Log How Often scale. Analyses were focused on blinded and parent-report outcomes and rank-order gains across all measures.

RESULTS

Findings varied in statistical significance when analyzing individual blinded outcomes. parent reports, and rank-order gains. Consistently, high-dose CIMT, regardless of constraint type, produced a pattern of greatest short- and long-term gains (1.7% probability of occurring by chance alone) and significant gains on visual motor integration and dissociated movement at 6 months. O'Brien's rank-order analyses revealed high-dose CIMT produced significantly greater improvement than a moderate dose or UCT. All CIMT groups improved significantly more in parent-reported functioning, compared with that of UCT. Children with UCT also revealed objective gains (eg, 48% exceeded the smallest-detectable assisting hand assessment change, compared with 71% high-dose CIMT at the end of treatment).

CONCLUSIONS

CHAMP provides novel albeit complex findings: although most individual blinded outcomes fell below statistical significance for group differences, high-dose CIMT consistently produced the largest improvements at both time points. An unexpected finding concerns shifts in UCT toward higher dosages, with improved outcomes compared with previous reports.

Combined intensive therapies at home in spastic unilateral cerebral palsy with high bimanual functional performance. What do they offer? A comparative randomised clinical trial

Background:

Children with unilateral spastic cerebral palsy (USCP) receive different treatments, including the application of modified constraint induced movement therapy (mCIMT) or bimanual intensive therapy (BIT) to increase affected upper limb functionality. The aim of this study was to compare the effectiveness of two protocols with different proportions and orders of mCIMT/BIT within combined intensive home-therapy in children with USCP (6–8 years old) with high bimanual functional performance, applied by the family.

Methods:

The protocols were performed on 20 children with an average age of 7.12 years [standard deviation (SD): 0.70], allocated to two different combined therapies. The protocols were designed by 100 h of dose for 10 weeks: 80 h of mCIMT followed by 20 h of BIT (mCIMT-B group) and 80 h of BIT followed by 20 h of mCIMT (BIT-mCI group). Bimanual functional performance was measured with Assisting Hand Assessment Scale (AHA) and the affected upper limb-use experience with Children’s Hand-use Experience Questionnaire (CHEQ). Parent satisfaction and expectations with therapy were measured using a specific questionnaire. There were five assessment timepoints (week 0, week 4, week 8, week 10 and week 34).

Results:

There were no statistically significant (p > 0.05) inter- and intra-group changes in the bimanual functional performance of both groups. The affected upper limb-use experience obtained significant changes in BIT-mCI group, with statistically significant differences in the pairwise comparisons between week 0–10 and week 4–10 (p = 0.028) for use of the affected hand and the use of the affected hand to grasp between week 4 and week 8 (p = 0.028). Grasp efficacy and discomfort acquired statistically significant differences only in the BIT-mCI group for pairwise comparisons week 0–week 10/week 4–week 10 (p = 0.035). Although task execution time compared with a typically developing child of the same age obtained statistically significant differences only in the group mCIMT-B for pairwise comparisons week 0–week 8 (p = 0.03), week 0–week 10 (p = 0.03), week 4–week 8 (p = 0.04) and week 4–week 10 (p = 0.03). Family satisfaction and expectations acquired an increase between week 0 and week 10 (p ⩽ 0.02).

Conclusion:

Applying 80 h of BIT for 8 weeks in children with high bimanual functional performance USCP (6–8 years old), executed at home with family involvement would be sufficient to obtain improvements in affected upper limb-use experience, without the need to use combined protocols of 100 h. However, no statistically significant increase in bimanual functional performance would be obtained, with the basal situation of the child being a factor to consider for the execution of mCIMT and BIT.

Registration number and name of trial registry: [ClinicalTrials.gov identifier: NCT03465046]

Tyneside Pegboard Test for unimanual and bimanual dexterity in unilateral cerebral palsy: association with sensorimotor impairment

AIM

We explored the psychometric properties of the recently developed Tyneside Pegboard Test (TPT) for unimanual and bimanual dexterity in children with unilateral cerebral palsy (CP) and investigated the impact of sensorimotor impairments on manual dexterity.

METHOD

In this cross-sectional study, the TPT was assessed in 49 children with unilateral CP (mean age 9y 8mo, SD 1y 11mo, range 6-15y; 30 males, 19 females; 23 with right unilateral CP). All participants additionally underwent a standardized upper limb evaluation at body function and activity level. We investigated: (1) known-group, concurrent, and construct validity and (2) impact of sensorimotor impairments including spasticity, grip force, stereognosis, and mirror movements using analysis of covariance, Spearman's rank correlation (r), and multiple linear regression (R² ) respectively.

RESULTS

TPT outcomes significantly differed according to the Manual Ability Classification System (p<0.001, known-group validity). Relationships were found between the unimanual TPT tasks and the Jebsen-Taylor Hand Function Test (r=0.86-0.88, concurrent validity). Bimanual TPT tasks were negatively correlated with the Assisting Hand Assessment, ABILHAND-Kids, and Children's Hand-use Experience Questionnaire (r=-0.38 to -0.78, construct validity). Stereognosis was the main determinant influencing all tasks (p<0.001, R² =37-50%). Unimanual dexterity was additionally determined by grip strength (p<0.05, R² =8-9%) and mirror movements in the more impaired hand (p<0.05, R² =4-8%). Bimanual dexterity was also explained by mirror movements in the more impaired hand (p<0.01, R² =10-16%) and spasticity (p=0.04, R² =5%).

INTERPRETATION

The TPT is a valid test to measure unimanual and bimanual dexterity in unilateral CP. The results further emphasize the importance of somatosensory impairments in children with unilateral CP. What this paper adds The Tyneside Pegboard Test is valid for measuring unimanual and bimanual dexterity in unilateral cerebral palsy. Children with poorer manual ability show worse unimanual and bimanual dexterity. Stereognosis is the main predictor of both unimanual and bimanual dexterity. Stronger mirror movements in the more impaired hand result in worse bimanual dexterity.

Combined clinic and home-based therapeutic approach for the treatment of bilateral radial deficiency for a young child with Holt-Oram syndrome: A case report

BACKGROUND

Holt-Oram syndrome (HOS) is a rare, genetic condition characterized by the combination of congenital heart defect and hypoplasia in one or both upper extremities. Children with HOS commonly present with varied joint and limb involvement including radial longitudinal deficiency impacting hand function. Evidence-based guidelines regarding orthotic wear and therapeutic techniques are lacking.

PURPOSE

The aim of this case report was to present the results of a long-term occupational therapy program for a patient with HOS pre and postpollicization.

STUDY DESIGN

Case report.

METHODS

A 4-month-old patient with bilateral radial longitudinal deficiencies began outpatient occupational therapy for custom orthosis fabrication and treatment which included long term clinic and home-based intervention. Techniques included passive range of motion, orthosis wear, therapeutic taping, and modified constraint induced movement therapy. Longitudinal assessment of musculoskeletal alignment and functional hand use was performed using goniometry for passive and active range of motion, the Assisting Hand Assessment (AHA), and The Thumb Grasp and Pinch Assessment (T-GAP).

RESULTS

Improvement in passive and active range of motion was achieved as well as improved activity level function as measured by the AHA and T-GAP postpollicization and intervention.

CONCLUSIONS

A combined clinic and home-based therapeutic approach can be effective for children with HOS to improve alignment and function pre and postpollicization to further enhance hand function. Comprehensive, long-term assessment is necessary to fully evaluate and communicate improvement.

Measure of early vision use: initial validation with parents of children with cerebral palsy

PURPOSE

To report initial psychometric evidence on the Measure of Early Vision Use.

METHOD

Data on performance of the Measure of Early Vision Use scale were collected from 100 parents of children with cerebral palsy aged 0-12 years via online survey. Psychometric evaluation included assessment of scale dimensionality using Classical Test Theory and hypothesis testing for evidence of construct validity.

RESULTS

Principal components analysis of the 14-item parent-rated Measure of Early Vision Use revealed one component with an eigenvalue of 9.343, explaining 66.7% of variance; internal consistency was high (Cronbach's α = 0.96). Total scores ranged from 15-56 (Mean 42.8, standard deviation = 10.6). The results support seven pre-defined hypotheses including statistically significant differences in MEVU-total scores between children with and without parent-reported cerebral visual impairment.

CONCLUSIONS

Measure of Early Vision Use is the first assessment tool to describe 'how vision is used' in children with cerebral palsy. Results provide preliminary evidence that the measure comprises a unidimensional construct, sufficient construct validity, and feasibility as a parent-completed online assessment. Findings on internal structure provide foundational evidence and require further testing with Confirmatory Factor Analysis or Rasch Analysis.IMPLICATIONS FOR REHABILITATIONThe Measure of Early Vision Use is a new instrument to describe the use of basic visual abilities and is feasible to use as a parent-completed online questionnaire.The Measure of Early Vision Use is a unidimensional scale with sufficient construct validity to supports its use as a measure of 'how vision is used' without confounding visual ability with the reason why it might be impaired (e.g., cerebral vision impairment, motor limitations, or cognition).There is potential for the Measure of Early Vision Use to support early intervention planning for children with (or at high risk of) cerebral palsy.

Mirror Therapy and Action Observation Therapy to Increase the Affected Upper Limb Functionality in Children with Hemiplegia: A Randomized Controlled Trial Protocol

The movements of the affected upper limb in infantile hemiplegia are slower and clumsy. This leads to a decrease in the use of the affected hand. The visual effect obtained using the mirror box and the observation of actions in another individual can activate the same structural neuronal cells responsible for the execution of these actions. This research will study the affected upper limb functionality in hemiplegia infantile from 6 to 12 years old after the application of two intervention protocols: observation action therapy and mirror therapy combined with observation action therapy. Children with a diagnose of congenital infantile hemiplegia will be recruited to participate in a randomized controlled trial with two intervention protocols during four weeks (1 h per/day; 5 sessions per/week): Mirror Therapy Action Observation (MTAO) or Action Observation Therapy (AOT). The study variables will be: spontaneous use, measured with the Assisting Hand Assessment (AHA); manual ability measured with the Jebsen Taylor Hand Function Test (JTHFT); surface electromyography of the flexors and extensors muscles of the wrist and grasp strength through a grip dynamometer. Four assessments will be performed: At baseline situation, at the end of treatment, 3 and 6 months after treatment (follow-up assessments). This study will study the effects of these therapies on the use of the affected upper limb in children with hemiplegia.

Brain magnetic resonance imaging is a predictor of bimanual performance and executive function in children with unilateral cerebral palsy

AIM

To examine the association between brain magnetic resonance imaging (MRI) characteristics and executive function and bimanual performance in children with unilateral cerebral palsy (CP).

METHOD

Clinical MRI brain scans were classified as: (1) predominant pathological pattern (normal, white matter injury [WMI]; grey matter injury; focal vascular insults [FVI]; malformations; or miscellaneous); and (2) focal lesions (frontal, basal ganglia, and/or thalamus). Assessments included: (1) bimanual performance; (2) unimanual dexterity; and (3) executive function tasks (information processing, attention control, cognitive flexibility, and goal setting) and behavioural ratings (parent).

RESULTS

From 131 recruited children, 60 were ineligible for analysis, leaving 71 children (47 males, 24 females) in the final sample (mean age 9y [SD 2y], 6y-12y 8mo). Brain MRIs were WMI (69%) and FVI (31%); and frontal (59%), thalamic (45%), basal ganglia (37%), and basal ganglia plus thalamic (21%). Bimanual performance was lower in FVI versus WMI (p<0.003), and with frontal (p=0.36), basal ganglia (p=0.032), and thalamic/basal ganglia lesions (p=0.013). Other than information processing, executive function tasks were not associated with predominant pattern. Frontal lesions predicted attention control (p=0.049) and cognitive flexibility (p=0.009) but not goal setting, information processing, or behavioural ratings.

INTERPRETATION

Clinical brain MRI predicts cognitive and motor outcomes when focal lesions and predominate lesion patterns are considered. What this paper adds Early brain magnetic resonance imaging (MRI) predicts bimanual performance and cognitive outcomes. Brain MRI may identify children requiring targeted interventions. Basal ganglia with/without thalamic lesions predicted bimanual performance. Frontal lesions were associated with attention control and cognitive flexibility. Brain MRI predominant patterns predicted motor, not cognitive outcomes, other than information processing.

White matter characteristics of motor, sensory and interhemispheric tracts underlying impaired upper limb function in children with unilateral cerebral palsy

This study explored the role of lesion timing (periventricular white matter versus cortical and deep grey matter lesions) and type of corticospinal tract (CST) wiring pattern (contralateral, bilateral, ipsilateral) on white matter characteristics of the CST, medial lemniscus, superior thalamic radiations and sensorimotor transcallosal fibers in children with unilateral cerebral palsy (CP), and examined the association with upper limb function. Thirty-four children (mean age 10 years 7 months ± 2 years 3 months) with unilateral CP underwent a comprehensive upper limb evaluation and diffusion weighted imaging (75 directions, b value 2800). Streamline count, fractional anisotropy and mean diffusivity were extracted from the targeted tracts and asymmetry indices were additionally calculated. Transcranial magnetic stimulation was applied to assess the CST wiring pattern. Results showed a more damaged CST in children with cortical and deep grey matter lesions (N = 10) and ipsilateral CST projections (N = 11) compared to children with periventricular white matter lesions (N = 24; p < 0.02) and contralateral CST projections (N = 9; p < 0.025), respectively. Moderate to high correlations were found between diffusion metrics of the targeted tracts and upper limb function (r = 0.45-0.72; p < 0.01). Asymmetry indices of the CST and sensory tracts could best explain bimanual performance (74%, p < 0.0001) and unimanual capacity (50%, p = 0.004). Adding lesion timing and CST wiring pattern did not further improve the model of bimanual performance, while for unimanual capacity lesion timing was additionally retained (58%, p = 0.0002). These results contribute to a better understanding of the underlying neuropathology of upper limb function in children with unilateral CP and point towards a clinical potential of tractography.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Cross-cultural adaptation and validation of the Ukrainian version of the ABILHAND-Kids questionnaire

PURPOSE

To develop and cross-culturally validate the Ukrainian version of the ABILHAND-Kids questionnaire by testing its psychometric properties in a sample of Ukrainian children with cerebral palsy.

METHODS

The ABILHAND-Kids questionnaire was translated into Ukrainian, cross-culturally adapted, and administered to 113 parents of children with cerebral palsy. The psychometric properties of the Ukrainian version and its cross-cultural validation were investigated through the Rasch rating scale model.

RESULTS

One major misfit has been found for the item "Rolling up a sleeve of a sweater" that further was removed. The item "Putting on a backpack/schoolbag" was split into gender-specific items, separately for girls and for boys, as it was systematically easier for Ukrainian girls. All remaining items contributed to the definition of a unidimensional measure of manual ability. The internal consistency reliability of the scale was high (R = 0.95). No significant floor (4%) and ceiling effects (5%) were observed. Three major differential item functioning items were found across Belgium and Ukraine, highlighting the need to use the Ukrainian calibration of ABILHAND-Kids in Ukraine.

CONCLUSION

The Ukrainian ABILHAND-Kids questionnaire has good psychometric properties for assessing manual ability in Ukrainian children with cerebral palsy, holding potential to be implemented in clinical practice nationwide.Implications for rehabilitationCerebral palsy impairs manual ability leading to decreased quality of life and participation.Professionals need valid and reliable tools to detect small changes of manual ability during rehabilitation.Metric properties and availability of the Ukrainian version of the ABILHAND-Kids questionnaire make it a useful tool in the assessment of children with cerebral palsy.

Constraint-induced movement therapy in children with unilateral cerebral palsy

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

KEY RESULTS

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

AUTHORS' CONCLUSIONS

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

Interrater Reliability of Activity Questionnaires After an Intensive Motor-Skill Learning Intervention for Children With Cerebral Palsy

OBJECTIVE

To investigate the reliability of parents-reported activity questionnaires after a motor-skill learning intervention for children with cerebral palsy (CP). We hypothesize that the intervention process might influence parental judgment.

DESIGN

Double-blind randomized trial.

SETTING

Conventional therapy was delivered in the usual context while intensive intervention was provided at the Catholic University of Louvain.

PARTICIPANTS

Children with CP (N=41; age range 5-18y, Gross Motor Function Classification System I-IV) were randomized to a control group (CG) (n=21, 2 dropouts) receiving conventional therapy or an intervention group (IG) (n=20) receiving hand-arm bimanual intensive therapy-including lower extremities (HABIT-ILE).

INTERVENTIONS

Conventional therapy (mostly neurodevelopmental) was delivered as ongoing treatment (1-5 times/wk). HABIT-ILE, based on motor-skill learning, was delivered over 2 weeks. All children were assessed at T1 (baseline), T2 (3wk after baseline) and T3 (4mo after baseline).

MAIN OUTCOMES MEASURES

ABILHAND-Kids and ACTIVLIM-CP questionnaires rated by parents (perception) and 2 examiners (videotapes).

RESULTS

Agreement (level/range) between examiners was systematically almost perfect (P≤.001). At baseline, moderate to almost perfect agreement (level/range) was observed between parents and examiners (P≤.001). At T2 and T3, a similar agreement (level/range) was observed for the CG. For the IG, a similar level of agreement was observed, but the range of agreement varied from poor to almost perfect (P≤.001), with parents estimating higher performance measures compared to examiners after intervention. Higher performance was associated with higher satisfaction scores of the child's functional goals at T3.

CONCLUSION

Parents and examiners have a similar perception of the child's performance at baseline and during conventional therapy. Their perceptions are less congruent after a motor-skill learning intervention, probably due to the goal-oriented process of the intervention. Therefore, our results favor the use of blind observations of home-videotaped items after intensive motor-skill learning interventions.

Learning to cope with mirror movements in unilateral spastic cerebral palsy: a brief report

PURPOSE

Mirror movements (MM) in unilateral spastic cerebral palsy (USCP) interfere with many bimanual activities of daily living.

METHODS

Here, we developed a specific bimanual therapeutic regimen, focusing on asymmetric simultaneous movements of the two hands. Twelve children (6-17 years old; complete data available in ten children) with USCP and MM were included.

RESULTS

After three weeks of inpatient rehabilitation, we observed significant improvements for two self-defined bimanual goal activities (Goal Attainment Scaling, Canadian Occupational Performance Measure) and for bimanual performance in general (Assisting Hand Assessment). These improvements were still present 6 months later. In contrast, even immediately after therapy, the severity of MM had not changed.

CONCLUSIONS

Hence, targeted bimanual therapy improved bimanual performance, but did not lead to a reduction of MM. The results of this pilot study might suggest that children with MM benefit more from acquiring strategies to cope with MM than by an active training which aimed to reduce MM.

The development of anticipatory action planning in children with unilateral cerebral palsy

Background Previous studies suggest that compromised bimanual performance experienced by children with unilateral cerebral palsy (CP) is not only due to difficulties in action execution but may also be a result of impaired anticipatory action planning. Aims The effect of age and side of hemiplegia were examined and the relationship between anticipatory action planning, unimanual capacity and bimanual performance was explored. Methods and procedures Using a multi-centre, prospective, cross-sectional observational design, anticipatory action planning was analyzed in 104 children with unilateral cerebral palsy, aged 6-12 years, using the sword task. Outcomes and results Anticipatory action planning did not improve with age in children with unilateral CP, aged between 6-12 years. No differences were found between children with left or right hemiplegia. Finally, anticipatory action planning was not related to unimanual capacity or bimanual performance. Conclusion and implications This study demonstrates anticipatory action planning, measured using the sword task, does not improve with age in children with unilateral CP and is not related to bimanual performance or laterality. Future studies of anticipatory action planning in children with unilateral CP should consider using measures that require effective anticipatory action planning for successful task completion rather than end state comfort.

Upper Limb Function of Children with Unilateral Cerebral Palsy After a Magic-Themed HABIT: A Pre-Post-Study with 3- and 6-Month Follow-Up

Aims: To examine changes in upper limb function, and performance in everyday tasks, for children with unilateral cerebral palsy who participated in a magic-themed hand-arm bimanual intensive therapy (HABIT). Methods: Twenty-eight children participated; mean age 10 y 6 mo (SD 2 y 2 mo), n = 15 male and n = 13 female. Using a single group, pre-and post-test design, the magic-themed HABIT was delivered for 60 hours over 10 days. Bimanual and unimanual hand function were measured using the Assisting Hand Assessment (AHA) and Box and Blocks Test (BBT). Occupational performance was rated using the Canadian Occupational Performance Measure (COPM). Two parent questionnaires explored change in bimanual hand use in everyday activities; ABILHAND-Kids and Children's Hand-use Experience Questionnaire (CHEQ). Assessments were completed pre-, immediately post, 3 months and 6 months after the intervention. Results: Friedman's ANOVA revealed a significant improvement for COPM and CHEQ grasp subscale. Repeated measures ANOVA revealed a significant improvement in BBT, and ABILHAND-Kids, and no significant change for AHA. Conclusions: Children who participated in the magic-themed HABIT experienced improved occupational performance, unimanual skills, and parent ratings of performance in challenging everyday tasks.

Effects of Upper-Extremity Surgery on Manual Performance of Children and Adolescents with Cerebral Palsy: A Multidisciplinary Approach Using Shared Decision-Making

BACKGROUND

Little is known about the effects of upper-extremity surgery on the manual performance of children and adolescents with cerebral palsy (CP). This clinical cohort study describes our experience with patient selection based on multidisciplinary assessment and shared decision-making and the effects of upper-extremity surgery on manual performance and patient-relevant outcomes.

METHODS

All patients (up to 20 years of age) with CP referred to our multidisciplinary team for evaluation for upper-extremity surgery between July 2011 and May 2017 were included. Suitability for upper-extremity surgery was assessed with comprehensive, multidisciplinary screening, and the decision to proceed with surgery was made together with the patient. Individual patient-relevant goals were identified with the Canadian Occupational Performance Measure (COPM); perceived independence in performing bimanual activities at home was assessed with the ABILHAND-Kids tool, and perceived quality of use of the affected hand during daily activities was assessed with a visual analog scale (VAS). The quality of use of the affected hand during bimanual performance was measured with the Assisting Hand Assessment (AHA), and gross manual dexterity was evaluated with the Box and Block Test (BBT). All baseline assessments were repeated at an average of 9 months after the surgery.

RESULTS

Of 66 patients assessed by the multidisciplinary upper-extremity-surgery team, 44 were considered eligible for upper-extremity surgery. Of these patients, 39 (mean age and standard deviation [SD], 14.9 ± 2.10 years, 87% with unilateral CP, and 72% at Manual Ability Classification System [MACS] level II) underwent upper-extremity surgery and were evaluated in the pre-post study. All outcomes improved significantly after upper-extremity surgery, with average improvements of 3.1 ± 1.6 points in the COPM-Performance (COPM-P) score (p < 0.001), 3.3 ± 2.1 points in the COPM-Satisfaction (COPM-S) score (p < 0.001), 1.5 ± 1.2 logits in the ABILHAND score (p < 0.001), 2.4 ± 1.9 cm in the VAS score (p < 0.001), 6.7 ± 4.2 units in the AHA score (p < 0.001), and 2.2 ± 5.0 blocks/minute on the BBT (p = 0.021). The improvement in the COPM-P, COPM-S, ABILHAND, VAS, AHA, and BBT scores was clinically meaningful in 80%, 77%, 55%, 62%, 71%, and 31% of the patients, respectively.

CONCLUSIONS

Careful assessment of eligibility for upper-extremity surgery, based on multidisciplinary screening and shared decision-making, resulted in a clinically relevant improvement in patient-specific functional and/or cosmetic goals and manual performance after upper-extremity surgery in most patients with CP.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Comparison between self-reported and observed locomotion ability scores in patients with stroke: a cross-sectional study

This study aimed to investigate (i) the validity of self-reported scores of locomotion ability in stroke survivors using the ABILOCO-Benin questionnaire, and (ii) the congruence between online Rasch analysis of the ABILOCO-Benin raw scores and a conversion table set along with the questionnaire development. Thirty-five adult poststroke patients [mean age: 52 (SD: 10) years, 60% men] recruited from the rehabilitation department of National University Hospital of Cotonou (Benin), self-reported their locomotion ability, filling out the ABILOCO-Benin questionnaire [self-reported scores (SRS)]. Afterwards, a physical therapist observed and rated the patients' locomotion ability, while they performed each of the 15 items of the questionnaire [performance-based scores (PBS)]. Both raw SRS and PBS were then converted to linear measures using (i) an online Rasch analysis method and (ii) an ordinal-to-interval transformation table. Analyses showed high correlation (intraclass correlation coefficient=0.74, P<0.001) and nonsignificant difference (P=0.778) between SRS and PBS. Linear measures from online Rasch and a conversion table also exhibited high correlation (intraclass correlation coefficient=0.92; P<0.001). However, the difference between online analysis and the conversion table was significant (P=0.022). In conclusion, self-report is a valid method to administer ABILOCO-Benin in stroke patients. The conversion table offers a valid opportunity for quick transfer of raw scores to linear measures. However, the accuracy of linear measures from the conversion table may be slightly affected by missing responses.

The Adult Assisting Hand Assessment Stroke: Psychometric Properties of an Observation-Based Bimanual Upper Limb Performance Measurement

OBJECTIVE

To investigate interrater and intrarater reliability, measurement error, and convergent and discriminative validity of the Adult Assisting Hand Assessment Stroke (Ad-AHA Stroke).

DESIGN

Cross-sectional observational study.

SETTING

A total of 7 stroke rehabilitation centers.

PARTICIPANTS

Stroke survivors (reliability sample: n=30; validity sample: N=118) were included (median age 67y; interquartile range [IQR], 59-76); median time poststroke 81 days (IQR 57-117).

INTERVENTIONS

N/A.

MAIN OUTCOME MEASURES

Ad-AHA Stroke, Action Research Arm Test (ARAT), upper extremity Fugl-Meyer Assessment (UE-FMA). The Ad-AHA Stroke is an observation-based instrument assessing the effectiveness of the spontaneous use of the affected hand when performing bimanual activities in adults poststroke. Reliability of Ad-AHA Stroke was examined using intraclass correlation coefficients (ICCs), Bland-Altman plots, and weighted kappa statistics for reliability on item level. SEM was calculated based on Ad-AHA units. Convergent validity was assessed by calculating Spearman rank correlation coefficients between Ad-AHA Stroke and ARA test and UE-FMA. Comparison of Ad-AHA Stroke scores between subgroups of patients according to hand dominance, neglect, and age evaluated discriminative validity.

RESULTS

Intrarater and interrater agreement showed an ICC of 0.99 (95% confidence interval, 0.99-0.99), an SEM of 2.15 and 1.64 out of 100, respectively, and weighted kappa for item scores were all above 0.79. The relation between Ad-AHA and other clinical assessments was strong (ρ=0.9). Patients with neglect had significantly lower Ad-AHA scores compared to patients without neglect (P=.004).

CONCLUSIONS

The Ad-AHA Stroke captures actual bimanual performance. Therefore, it provides an additional aspect of upper limb assessment with good to excellent reliability and low SEM for patients with subacute stroke. High convergent validity with the ARA test and UE-FMA and discriminative validity were supported.

Cognition and bimanual performance in children with unilateral cerebral palsy: protocol for a multicentre, cross-sectional study

Background

Motor outcomes of children with unilateral cerebral palsy are clearly documented and well understood, yet few studies describe the cognitive functioning in this population, and the associations between the two is poorly understood. Using two hands together in daily life involves complex motor and cognitive processes. Impairment in either domain may contribute to difficulties with bimanual performance. Research is yet to derive whether, and how, cognition affects a child’s ability to use their two hands to perform bimanual tasks.

Methods/Design

This study will use a prospective, cross-sectional multi-centre observational design. Children (aged 6–12 years) with unilateral cerebral palsy will be recruited from one of five Australian treatment centres. We will examine associations between cognition, bimanual performance and brain neuropathology (lesion type and severity) in a sample of 131 children. The primary outcomes are: Motor - the Assisting Hand Assessment; Cognitive - Executive Function; and Brain – lesion location on structural MRI. Secondary data collected will include: Motor - Box and Blocks, ABILHAND- Kids, Sword Test; Cognitive – standard neuropsychological measures of intelligence. We will use generalized linear modelling and structural equation modelling techniques to investigate relationships between bimanual performance, executive function and brain lesion location.

Discussion

This large multi-centre study will examine how cognition affects bimanual performance in children with unilateral cerebral palsy. First, it is anticipated that distinct relationships between bimanual performance and cognition (executive function) will be identified. Second, it is anticipated that interrelationships between bimanual performance and cognition will be associated with common underlying neuropathology. Findings have the potential to improve the specificity of existing upper limb interventions by providing more targeted treatments and influence the development of novel methods to improve both cognitive and motor outcomes in children with unilateral cerebral palsy.

Trial registration

ACTRN12614000631606; Date of retrospective registration 29/05/2014.

Genetic Variation in the Dopamine System Influences Intervention Outcome in Children with Cerebral Palsy

Background

There is large variation in treatment responses in children with cerebral palsy. Experimental and clinical results suggest that dopamine neurotransmission and brain-derived neurotrophic factor (BDNF) signalling are involved in motor learning and plasticity, which are key factors in modern habilitation success. We examined whether naturally occurring variations in dopamine and BDNF genes influenced the treatment outcomes.

Methods

Thirty-three children (18–60 months of age) with spastic unilateral cerebral palsy were enrolled in the study. Each child had participated in a training programme consisting of active training of the involved hand for 2 h every day during a 2-month training period. The training outcome was measured using Assisting Hand Assessment before and after the training period. Saliva was collected for genotyping of COMT, DAT, DRD1, DRD2, DRD3, and BDNF. Regression analyses were used to examine associations between genetic variation and training outcome.

Findings

There was a statistically significant association between variation in dopamine genes and treatment outcome. Children with a high polygenic dopamine gene score including polymorphisms of five dopamine genes (COMT, DAT, DRD1, DRD2, and DRD3), and reflecting higher endogenous dopaminergic neurotransmission, had the greatest functional outcome gains after intervention.

Interpretation

Naturally occurring genetic variation in the dopamine system can influence treatment outcomes in children with cerebral palsy. A polygenic dopamine score might be valid for treatment outcome prediction and for designing individually tailored interventions for children with cerebral palsy.

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Naturally occurring variation of dopamine genes is associated with treatment outcomes in children with cerebral palsy.

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Children with polymorphisms reflecting higher endogenous dopaminergic neurotransmission had the greatest functional gains.

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A polygenic dopamine score might be valid to predict treatment outcome.

New evidence-based therapies including active motor learning and training for children with cerebral palsy improve motor function at a group level, but there are also large inter-individual variations. Naturally occurring variations in dopamine and BDNF genes affect motor learning and cortical plasticity.

This study showed that naturally occurring genetic variation of five dopamine genes was associated with the outcome of a 2-month long active upper limb motor training intervention in children with unilateral cerebral palsy. The results suggest that a polygenic dopamine gene score can be used to predict the outcome of motor training programmes for children with cerebral palsy.

Development of the assisting hand assessment for adults following stroke: a Rasch-built bimanual performance measure

AIMS

To describe the development of a new test of bimanual performance for adults following Stroke, the Adult-Assisting Hand Assessment Stroke, and to report the evidence of internal and external validity.

METHODS

Scale development included: (i) establishing the test situation; (ii) constructing test items; (iii) evaluating internal construct validity by use of Rasch measurement analysis on 144 assessments of adults with hemiparesis, mean age 53 years (SD11.45); and (iv) investigating external validity by correlation to the Jebsen and Taylor Test of Hand Function and the ABILHAND Stroke.

RESULTS

The Adult-Assisting Hand Assessment Stroke scale, scored on 19 items using a four-point rating scale, provided a valid measure of bimanual performance. The rating scale structure, goodness of fit, and principal component analysis demonstrated evidence of a unidimensional construct. The strong reliability and high person separation ratio indicated high probability for the scale to be responsive to change. Correlation to outcomes of the Jebsen and Taylor Test of Hand Function and the ABILHAND Stroke indicated strong external validity.

CONCLUSION

Using two hands together is a critical aspect for performance of most daily life tasks. However, assessments of hand function commonly focus on measuring aspects of unimanual function. The Adult-Assisting Hand Assessment Stroke has the potential to contribute new and clinically important knowledge to stroke rehabilitation by providing an observation-based valid functional measure of bimanual performance. Implications for rehabilitation Hand function assessments commonly focus on unimanual aspects, although the use of two hands together is critical to perform most daily life tasks. The Adult-Assisting Hand Assessment Stroke measures how effectively a patient with a hemiparesis uses his/her affected hand together with the unaffected hand to perform bimanual tasks. The Adult-Assisting Hand Assessment Stroke contributes a new and clinically important aspect to stroke rehabilitation by providing a valid bimanual observation-based measure to guide intervention and measure change over time.

Development and psychometric properties of the Hand-Use-at-Home questionnaire to assess amount of affected hand-use in children with unilateral paresis

AIM

To describe the development of the parent-rated Hand-Use-at-Home questionnaire (HUH) assessing the amount of spontaneous use of the affected hand in children with unilateral paresis, and to test its internal structure, unidimensionality, and validity.

METHOD

Parents of children with unilateral cerebral palsy (CP) and professionals participated in the development of the HUH. To examine internal validity, data of 322 children (158 males, 164 females; mean age 6y 7mo, standard deviation [SD] 2y 1mo) with unilateral CP (n=131) or neonatal brachial plexus palsy (NBPP) (n=191) were collected. Rasch analysis was used to examine discriminative capacity of the 5-category rating scale as well as unidimensionality and hierarchy of the item set. Additionally, data of 55 children with typical development (24 males, 31 females; 6y 9mo, SD 2y 5mo) were used to examine construct validity.

RESULTS

The 5-category rating scale was disordered in all items and was collapsed to obtain the best discriminating sum score. Ten misfitting or redundant items were removed. Eighteen hierarchically ordered bimanual items fitted the unidimensional model within acceptable range. The HUH significantly discriminated between the three groups (children with typical development, NBPP, unilateral CP; H₍₂₎ =118.985, p<0.001), supporting its construct validity.

INTERPRETATION

The HUH is a valid instrument to assess the amount of spontaneous use of the affected hand in children with unilateral upper-limb paresis.

Reliability of the Assisting Hand Assessment in adolescents

AIM

To investigate the interrater and test-retest reliability of the Assisting Hand Assessment in adolescents (Ad-AHA) with cerebral palsy (CP) and to evaluate the alternate-form reliability of different test activities.

METHOD

Participants were 112 adolescents with unilateral CP (60 males, 52 females; mean age 14y 5mo [standard deviation {SD} 2y 8mo], Manual Ability Classification System levels I-III). Reliability was evaluated using intraclass correlation coefficients (ICC), smallest detectable change (SDC), and Bland-Altman plots.

RESULTS

ICCs for interrater (n=38) and test-retest reliability (n=31) were excellent: 0.97 (95% CI 0.94-0.98) and 0.99 (95% CI 0.98-0.99) respectively. The alternate-form reliability of different test activities was excellent for children (age 10-12y, n=30) performing the School-Kids AHA and Ad-AHA Board Game 0.99 (95% CI 0.98-0.99) and for adolescents (age 13-18y) performing the Ad-AHA Board Game compared to the Ad-AHA Present (n=28) 0.99 (95% CI 0.95-0.98), or the Ad-AHA Sandwich (n=29) 0.99 (95% CI 0.98-0.99) tasks. SDC for test-retest was 4.5 AHA-units.

INTERPRETATION

Ad-AHA scores are consistent across different raters and occasions. The good alternate-form reliability indicates that the different test activities can be used interchangeably in adolescents with unilateral CP. Differences greater than or equal to 5 AHA-units can be considered a change beyond measurement error. The use of logit based AHA-units makes change comparable for persons at different ability levels.

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.