Caregiver-directed home-based intensive bimanual training in young children with unilateral spastic cerebral palsy: a randomized trial

Roles Caregivers Take on in Pediatric Rehabilitation Telehealth Services: A Scoping Review

BACKGROUND

Caregivers and children continue to use pediatric rehabilitation telehealth services (PRTS) post-pandemic. Understanding how caregivers support children during PRTS can help us fully integrate caregivers for positive outcomes. This scoping review describes the roles caregivers take on during PRTS.

METHODS

We searched MEDLINE, CINAHL, PsycINFO, and ERIC for research published January 2005 to July 2023. We included English articles on the effect of PRTS. We excluded qualitative and non-peer-reviewed literature.

RESULTS

Thirty-four articles met inclusion criteria. Caregivers were gatekeepers, technicians, implementers, trainees, collaborators, telehealth consumers, and supervisors in PRTS. Caregivers took on roles throughout PRTS, and roles varied by type of PRTS delivered.

CONCLUSIONS

Caregivers take on multiple roles to support children during PRTS. Our results can inform clinical decisions about how to integrate and support caregivers in PRTS. Future research should explore strategies that support caregiver role taking to maximize caregiver involvement and outcomes in PRTS.

Programa domiciliar individualizado via telessaúde para crianças com paralisia cerebral durante a pandemia de COVID-19

Objetivo

Analisar os efeitos de um programa domiciliar individualizado via telessaúde no desempenho de objetivos funcionais de crianças e adolescentes com paralisia cerebral (PC) durante a pandemia de COVID‐19.

Método

Um estudo de intervenção prospectivo de único grupo com crianças/adolescentes com PC (n = 144; idade mediana = 92 meses [Q1 = 44.0, Q3 = 148.8]; 74 meninos, 70 meninas), representando todos os níveis do Sistema de Classificação da Função Motora Grossa (GMFCS), participaram de um programa domiciliar de 4 meses no Brasil. Equipes interdisciplinares encorajaram famílias a escolher um objetivo funcional a ser treinado. A Medida Canadense de Desempenho Ocupacional (COPM) foi usada no período pré‐intervenção (T1), pós‐intervenção (T2) e 3 meses de follow‐up (T3). As diferenças nos escores da COPM em T1, T2 e T3 foram avaliadas usando o teste de Friedman. O tamanho de efeito foi calculado usando o teste d de Cohen. Análise univariada foi incluída.

Resultado

Melhoras significativas foram observadas após a intervenção, com manutenção dos escores após 3 meses (p < 0.001; ddesempenho = 1.33; dsatisfação = 1.31). Nenhuma das variáveis testadas (habilidades das crianças, idade, nível educacional do cuidador, percepção de centrado na família e tipo de objetivo) foram significativamente relacionados às mudanças nos escores.

Interpretação

O programa domiciliar individualizado via telessaúde pode ser uma intervenção potencial, especialmente para crianças classificadas nos níveis IV e V do GMFCS. Além disso, essa intervenção forneceu uma possível solução para ajudar crianças e suas famílias no desempenho de objetivos funcionais prioritários durante o período de pandemia.

Feasibility of At-Home Hand Arm Bimanual Intensive Training in Virtual Reality: Case Study

This single-participant case study examines the feasibility of using custom virtual reality (VR) gaming software in the home environment for low-dose Hand Arm Bimanual Intensive Training (HABIT). A 10-year-old with right unilateral cerebral palsy participated in this trial. Fine and gross motor skills as well as personal goals for motor outcomes were assessed before and after the intervention using the Box and Blocks Test, Nine-Hole Peg Test, and Canadian Occupational Performance Measure. Movement intensities collected via the VR hardware accelerometers, VR game scores, and task accuracy were recorded via the HABIT-VR software as indices of motor performance. The child and family were instructed to use the HABIT-VR games twice daily for 30 minutes over a 14-day period and asked to record when they used the system. The child used the system and completed the 14-hour, low-dose HABIT-VR intervention across 22 days. There was no change in Box and Blocks Test and Nine-Hole Peg Test scores before and after the intervention. Canadian Occupational Performance Measure scores increased but did not reach the clinically relevant threshold, due to high scores at baseline. Changes in motor task intensities during the use of VR and mastery of the VR bimanual tasks suggested improved motor efficiency. This case study provides preliminary evidence that HABIT-VR is useful for promoting adherence to HABIT activities and for the maintenance of upper extremity motor skills in the home setting.

Individualized telehealth home programme for children with cerebral palsy during the COVID-19 pandemic

AIM

To analyse the effects of an individualized telehealth home programme on the performance of functional goals of children and adolescents with cerebral palsy (CP) during the COVID-19 pandemic.

METHOD

A prospective single-group intervention study with children/adolescents with CP (n = 144; median age = 92 months [Q1 = 44.0, Q3 = 148.8]; 74 males, 70 females), representing all Gross Motor Function Classification System (GMFCS) levels participated in a 4-month home programme in Brazil. An interdisciplinary team encouraged families to choose a functional goal to be trained. The Canadian Occupational Performance Measure (COPM) was used at pre-intervention (T1), post-intervention (T2), and 3-month follow-up (T3). The differences in COPM scores at T1, T2, and T3 were evaluated using Friedman's test. The effect size was calculated using Cohen's d. Univariate analysis was included.

RESULTS

Significant improvements were observed after the intervention, with maintenance of scores after 3 months (p < 0.001, dperformance = 1.33; dsatisfaction = 1.31). None of the tested variables (child's abilities, age, caregiver's educational level, perception of family-centredness, and type of goal) were significantly related to the change scores.

INTERPRETATION

The individualized remote telehealth home programme can be a potential intervention, especially for children with CP classified in GMFCS levels IV and V. Also, this intervention provided a possible solution to help some children and their families in performing prioritized functional goals during the pandemic period.

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

OBJECTIVE

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

DATA SOURCES

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

STUDY SELECTION

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

DATA EXTRACTION

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

DATA SYNTHESIS

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

CONCLUSIONS

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

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.

Exploring engagement in telepractice early intervention for young children with developmental disability and their families: a qualitative systematic review

PURPOSE

This review aimed to (1) describe the nature of engagement in telepractice early intervention (EI) for families of young children with developmental disabilities; and (2) identify major barriers and facilitators for developing and maintaining engagement via telepractice.

METHODS

A qualitative systematic review was conducted, searching systematically across six databases (i.e., PUBMED, CINAHL, PsycINFO, Web of Science, EMBASE, and Scopus). The search identified 14 studies which met the inclusion criteria of peer-reviewed studies exploring EI professionals', families', managers', or service's views of engagement in telepractice EI using qualitative methodologies. The studies were appraised using the Critical Appraisal Skills Programme and data were analysed using thematic synthesis.

RESULTS

The synthesised data were grouped into four main themes reflecting the nuances of engagement in telepractice EI: (1) children and family engagement is facilitated and enhanced during telepractice interaction; (2) engagement may enhance therapy outcomes through telepractice multidisciplinary collaboration and communication; (3) there are challenges to engagement in the telepractice environment; and (4) preparation in telepractice can improve the development of engagement.

CONCLUSION

This review provides a comprehensive characterisation of engagement and describes a set of conceptual recommendations for establishing and maintaining engagement when using telepractice in EI.IMPLICATIONS FOR REHABILITATIONBuilding and maintaining engagement with families of young children with developmental disability/delay through telepractice is feasible.Despite some similarities between in-person and telepractice engagement, there are certain unique features of telepractice engagement that professionals and families may need to consider while providing/receiving early intervention services remotely.Preparation and training on how to engage in telepractice is recommended for professionals and families of young children with developmental disability/delay.Understanding how professionals and families engage with one another during telepractice interactions may improve targeted child and family intervention outcomes.

Pediatric powered mobility training: powered wheelchair versus simulator-based practice

METHOD

Participants included 30 children and adolescents (23 males, 13 females) with cerebral palsy and other neuromuscular diseases, aged 6-18. Data were collected and compared at baseline and after 12 weeks of home-based practice via a powered wheelchair or a simulator. Powered mobility ability was determined by the Powered Mobility Program (PMP), the Israel Ministry of Health's Powered Mobility Proficiency Test (PM-PT) and the Assessment of Learning Powered Mobility (ALP).

RESULTS

All participants practiced for the required amount of time and both groups reported a similar user experience. Both groups achieved significant improvement following the practice period as assessed by the PMP and PM-PT assessments, with no significant differences between them. A significant improvement was found in the ALP assessment outcomes for the powered wheelchair group only.

CONCLUSIONS

This is the first study, to our knowledge, that compares two different wheelchair training methods. Simulator-based practice is an effective training option for powered mobility for children with physical disabilities aged 6-18 years old, demonstrating that it is possible to provide driving skill practice opportunities safe, controlled environments.

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

IMPORTANCE

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

OBJECTIVE

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

DESIGN

Randomized trial.

SETTING

Community.

PARTICIPANTS

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

INTERVENTION

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

OUTCOMES AND MEASURES

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

RESULTS

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

CONCLUSIONS AND RELEVANCE

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

Feasibility of a Home-Based Mirror Therapy Program in Children with Unilateral Spastic Cerebral Palsy

Children with Unilateral Spastic Cerebral Palsy (US CP) have motor and somatosensory impairments that affect one side of their body, impacting upper limb functioning. These impairments contribute negatively to children's bimanual performance and quality of life. Intensive home-based therapies have been developed and have demonstrated their feasibility for children with US CP and their parents, especially when therapies are designed with the proper coaching of families. Mirror Therapy (MT) is being studied to become an approachable intensive and home-based therapy suitable for children with US CP. The aim of this study is to analyze the feasibility of a five-week home-based program of MT for children with US CP that includes coaching by the therapist. Six children aged 8-12 years old performed the therapy for five days per week, 30 min per day. A minimum of 80% of compliance was required. The feasibility included compliance evaluations, total dosage, perceived difficulty of the exercises, and losses of follow-ups. All children completed the therapy and were included in the analysis. The total accomplishment was 86.47 ± 7.67. The perceived difficulty of the exercises ranged from 2.37 to 4.51 out of 10. In conclusion, a home-based program of Mirror Therapy is a safe, cost-efficient, and feasible therapy for children with US CP when the therapist is involved as a coach during the entire program.

Upper limb manual training for children with cerebral palsy: A systematic review and network meta-analysis of randomized controlled trials

OBJECTIVE

There are different upper limb manual training protocols, namely constraint-induced movement therapy, modified constraint-induced movement therapy, hand-arm bimanual intensive training, hand-arm bimanual intensive training including lower extremity, action observation training, and mirror therapy, available for improving functional outcomes in children with cerebral palsy. However, the effect and priority of these strategies remain unclear.

DATA SOURCES

We searched the PubMed, Cochrane Library, and Embase databases for relevant articles from inception to October 12, 2022.

REVIEW METHODS

To assess the effect and priority of different strategies of upper limb manual training protocols through a systematic review and network meta-analysis of randomized controlled trials.

RESULTS

We included 22 randomized controlled trials in this network meta-analysis. The ranking probability and standard mean differences with 95% credible intervals of the comparison between placebo and other forms of upper limb manual training were as follows: mirror therapy = 2.83 (1.78, 3.88), hand-arm bimanual intensive training including the lower extremity = 0.53 (0.09, 0.96), constraint-induced movement therapy = 0.44 (0.18, 0.71), hand-arm bimanual intensive training = 0.41 (0.15, 0.67), modified constraint-induced movement therapy = 0.39 (0.03, 0.74), and action observation training = 0.18 ( - 0.29, 0.65). No significant inconsistency was noted between the results of direct and indirect comparisons.

CONCLUSION

We suggest that mirror therapy could be the upper limb manual training protocol of choice for improving functional outcomes in patients with cerebral palsy.

Telerehabilitation for Children and Youth with Developmental Disabilities and Their Families: A Systematic Review

AIM

To determine the level of evidence for the effectiveness of telerehabilitation against comparison interventions in improving child- and parent-related outcomes in children and youth with developmental disabilities.

METHOD

A systematic approach, comprised of a comprehensive search; transparent study selection, data extraction, quality assessment by independent reviewers; and synthesis of sufficiently similar data (per diagnostic group, health profession, and overall level of evidence for each outcome) was undertaken.

RESULTS

Fifty-five studies (29 randomized trials) were included across six diagnostic groups and ten health professions. Common telerehabilitation targets varied across diagnostic groups and included motor function, behavior, language, and parental self-efficacy. Telerehabilitation was found to be either more effective or as effective versus comparison intervention in improving 46.9% or 53.1% of outcomes, respectively. It was never found to be detrimental or less effective. Strong to moderate, limited, and insufficient levels of evidence were found for 36.5%, 24.5%, and 38.6% of the outcomes, respectively.

CONCLUSION

There is sufficient evidence suggesting that telerehabilitation is a promising alternative when face-to-face care is limited. It is comparable to usual care and is more effective than no treatment. Blending in-person and telerehabilitation approaches could be beneficial for the post-pandemic future of rehabilitation in pediatric care.

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.

Instructions for Administering the Canadian Occupational Performance Measure with Children Themselves

AIMS

The Canadian Occupational Performance Measure (COPM) can be used to support children to clarify their needs themselves. However, for pediatric occupational therapists it is not sufficiently clear how to effectively use the COPM with children from 8 years of age.This study aimed to formulate specific instructions for using the COPM with children themselves, based on the experience of children, parents, and occupational therapists. In addition, professional consensus on the instructions was reached.

METHODS

A multi-stage approach was used to develop the instructions. Triangulation of methods was used to gather knowledge of how the COPM with children themselves is performed in daily practice: interviews with 23 children, questionnaires completed by 30 parents, interviews with 13 therapists, and 10 video recordings of COPM administration. Specific instructions were derived from this knowledge and consensus for these instructions was reached by Delphi method.

RESULTS

The data were analyzed and resulted in 40 specific instructions. Consensus of at least 80% amongst 10 occupational therapists, who regularly use the COPM with children, was achieved on each instruction.

CONCLUSION

There is consensus on 40 specific instructions for administering the COPM with children. Following these instructions might help children to formulate their own goals for intervention.

Wrist-Worn devices to encourage affected upper limb movement in unilateral cerebral palsy: Participatory design workshops

Background

Unilateral (Hemiplegic) cerebral palsy (UCP) causes weakness and stiffness affecting one sided of the body, often impacting activities of daily living. Upper limb therapy at effective intensity is not accessible to most.

Aim

To determine stakeholder views on design of an approach using wrist-worn devices and a smartphone application to encourage use of the affected upper limb for children with hemiplegia.

Method

Four participatory design workshops and one young people's advisory group workshop incorporating views of five young people with hemiplegia, 13 typically developing peers aged 8-18 years, four parents, three occupational therapists, one teacher and two paediatricians. Two special educational needs co-ordinators were consulted separately. Peers were included to explore a study design whereby each child with hemiplegia would have a participating "buddy". Topics included views on an acceptable wrist-worn device and smartphone application, participant age range, involvement of a buddy, and barriers to using the technology in a school setting. Ethical/welfare considerations included data security, and potential risks around providing smartphones to young children.

Results

Children wanted a comfortable, conventional-appearing wristband incorporating a watch face and a secure, well-fitting strap. They were prepared to wear a band on each wrist. They wanted support with explaining the study to schoolteachers. Most schools restricted smartphone use during the school day: the study design accommodated this. Children agreed with a game as reward but had different views on an acceptable game; direct access to feedback data was preferred by some. Parents commented on the lack of access to upper limb therapy for children with UCP; therapists concurred. The proposed participant age range was widened based on feedback. Typically developing children were prepared to be buddies to help a friend with CP. Stakeholders were reassured by data security explanations and plans to provide internet safety information to participants.

Conclusion

The participatory design process informed plans for the proof-of-concept stage of the study, hopefully leading to an approach that will be fun, easy to integrate into everyday life, and have the capacity to increase use of the affected arm and hand.

Providing a Primary Care Medical Home for Children and Youth With Cerebral Palsy

Cerebral palsy (CP) is the most common motor disorder of childhood, with prevalence estimates ranging from 1.5 to 4 in 1000 live births. This clinical report seeks to provide primary care physicians with guidance to detect children with CP; collaborate with specialists in treating the patient; manage associated medical, developmental, and behavioral problems; and provide general medical care to their patients with CP.

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.

Telehealth Interventions Within the Scope of Occupational Therapy Practice: A Systematic Review

Importance: With the increasing use of telehealth, it is imperative to synthesize the existing evidence to examine the effectiveness of telehealth interventions and inform practitioners and reimbursement entities.

Objective: To examine the effectiveness of telehealth occupational therapy interventions across the lifespan, delivered either independently or as part of an interdisciplinary team.

Data Sources: MEDLINE, CINAHL, SAGE, PsycInfo, Cochrane Database of Systematic Reviews, OTseeker, and OT Search and hand searches of systematic reviews, relevant journals, and known occupational therapy telehealth research.

Study Selection and Data Collection: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we screened and appraised articles that included an occupational therapy intervention delivered via telehealth and that were peer reviewed, written in English, published between 2009 and 2019, and Levels 1b to 3b evidence.

Findings: Twenty full-text articles (8 Level 1b, 9 Level 2b, and 3 Level 3b) met the inclusion criteria. Strong strength of evidence supports the use of telehealth approaches for occupational therapy interventions for people with neurological and pain conditions. Moderate strength of evidence supports the use of telehealth interventions to support education outcomes. Low strength of evidence was found for other outcomes for children with developmental disorders and additional conditions.

Conclusions and Relevance: There is evidence to support that occupational therapy interventions delivered via telehealth are similarly effective as those delivered face-to-face, especially for neurological and pain conditions.

What This Article Adds: The findings include an updated synthesis of telehealth occupational therapy interventions provided separately and with interdisciplinary health care teams. They expand occupational therapy’s scope of practice to include interventions provided across the lifespan for rehabilitation and habilitation needs and include effectiveness by conditions.

Pediatric Assessments for Preschool Children in Digital Physical Therapy Practice: Results From a Scoping Review

PURPOSE

To examine and map the extent and scope of pediatric physical therapy assessments previously used in the digital context.

METHODS

A 6-step evidence-based scoping methodological framework was used. Articles containing assessments conducted by a physical therapist using technology to assess a child aged 0 to 5 years were included and synthesized using descriptive statistics and thematic analysis.

RESULTS

Eighteen studies identifying 25 assessments were eligible. Asynchronous observational developmental instruments administered in the child's natural environment to those at risk or presenting with neurodevelopmental conditions were the most common. There is a need for detailed procedures and training for caregivers and clinicians.

CONCLUSION

Limited research exists on the use of pediatric physical therapy assessments for young children with musculoskeletal and cardiorespiratory conditions in a digital context. The development of new instruments or modifications of existing ones should be considered and be accompanied by detailed administration protocols and user guides.

Treatment of upper extremity palsies, gunshot wounds and scaphoid nonunion: my preferred approaches

The article reviews key considerations and our preferred methods in treating upper extremity palsies, gunshot wounds and scaphoid nonunion. For these three difficult conditions, I highlight the importance of a team approach when treating upper extremity neuromuscular disease, flexibility and creativity when treating gunshot wounds, and my personal protocol for dealing with scaphoid fracture nonunions.Level of evidence: V.

From Hemispheric Asymmetry through Sensorimotor Experiences to Cognitive Outcomes in Children with Cerebral Palsy

Recent neuroimaging studies allowed us to explore abnormal brain structures and interhemispheric connectivity in children with cerebral palsy (CP). Behavioral researchers have long reported that children with CP exhibit suboptimal performance in different cognitive domains (e.g., receptive and expressive language skills, reading, mental imagery, spatial processing, subitizing, math, and executive functions). However, there has been very limited cross-domain research involving these two areas of scientific inquiry. To stimulate such research, this perspective paper proposes some possible neurological mechanisms involved in the cognitive delays and impairments in children with CP. Additionally, the paper examines the ways motor and sensorimotor experience during the development of these neural substrates could enable more optimal development for children with CP. Understanding these developmental mechanisms could guide more effective interventions to promote the development of both sensorimotor and cognitive skills in children with CP.

Professional Care in Home for Children and Teenagers with Special Health Needs: An Integrative Review

Objective: Analyzing the results of scientific publications on professional home care for children and teenagers with special health needs. Materials and method: An integrative review with articles published between 2009 and 2020 conducted in the BDEnf, Lilacs, Medline/PubMed databases and in the SciELO electronic library. The data were analyzed in four stages: data reduction; display of the data; comparison of data; drawing and verification of completion. Results: There were identified 5,641 articles; after the application of the inclusion and exclusion criteria and disposal of duplicates, 637 articles were chosen for the reading of titles and abstracts, of which 61 were selected for full reading and of these, 28 composed the final sample. The offer of remote support actions and concern in training caregivers regarding the technical-scientific aspects of home care was identified, in addition to promoting the improvement of the quality of life of children/teenagers and their families. A gap was evidenced regarding the identification and management of pain by home service professionals. Conclusions: The performance of home services to this specific population focuses on the demands of care with health technologies and on promoting symptom relief, reducing the workload of caregivers and assisting in dehospitalization.

Tele-care intervention performed by parents involving specific task- environment- participation (STEP protocol) for infants at risk for developmental delay: protocol of randomized controlled clinical trial

BACKGROUND

With the implementation of social distancing due to the Covid-19 pandemic, many at-risk infants are without therapy. An alternative mode of therapy in this situation is tele-care, a therapy in which assessments and interventions are carried out online, in the home environment. We describe a tele-care protocol involving parent delivered task and context specific movement training, participation and environmental adaptation for infants at risk for developmental delay.

METHODS

Randomized controlled trial. Infants at risk, with 3 to 9 months corrected age, will be included, and randomized into two groups: control group (conventional guidelines) and experimental group (task, environment and participation in context-specific home program). Infants will be assessed for motor capacity (Infant Motor Profile and Alberta Infant Motor Scale); participation (Young Children's Participation and Environment Measure) and environment factors (Parent-Child Early Relational Assessment; Affordances in the Home Environment for Motor Development). The intervention period will be 10 weeks, and evaluations will be carried out before and after that period. All the assessment and intervention procedures will be carried out online, with instructions to parents for home therapy. The statistical analysis will be guided according to the distribution of the data, and a significance level of 5% will be adopted. All ethical approvals were obtained by the Ethics Committee of the University of São Carlos (Case number 31256620.5.0000.5504). The protocol will follow the SPIRIT statement. Findings will be disseminated in peer-reviewed publications and presented at national and international conferences.

DISCUSSION

The results of this study will describe the effectiveness of a home intervention, focusing on specific activities, participation and environmental changes. These results will support the implementation of a remote protocol, with lower financial costs and focused on the particularities of the family. This type of care model can possibly help public policies to ensure equal access to evidence-based quality healthcare.

TRIAL REGISTRATION

Brazilian Clinical Trials Registry: RBR8xrzjs , registered September 1, 2020.

Hand function development of children with hemiplegic cerebral palsy: A scoping review

PURPOSE

Hemiplegic cerebral palsy (hCP) typically impacts sensorimotor control of the hand, but comprehensive assessments of the hands of children with hCP are relatively rare. This scoping review summarizes the development of hand function for children with hCP.

METHODS

This scoping review focused on the development of hand function in children with hCP. Electronic databases (PubMed, PEDro, Web of Science, CINAHL, and SpringerLink) were searched to identify studies assessing hand function in children with hCP. The search was performed using keywords (e.g., "hemiplegia"). An iterative approach verified by two authors was used to select the studies. Articles which reported quantitative data for children with hCP on any items of a specified set of hand evaluations were included. Measures were sorted into three categories: quantitative neuromechanics, clinical assessments, and clinical functional evaluations.

RESULTS

Initial searches returned 1536 articles, 131 of which were included in the final review. Trends between assessment scores and age were examined for both hands.

CONCLUSION

While several studies have evaluated hand function in children with hCP, the majority relied on clinical scales, assessments, or qualitative descriptions. Further assessments of kinematics, kinetics, and muscle activation patterns are needed to identify the underlying impairment mechanisms that should be targeted for treatment.

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.

Measurement properties of the box and block test in children with unilateral cerebral palsy

This study aimed to examine the reliabilities (test-retest reliability and measurement error), construct validity, and the interpretability (minimal clinically important difference) of the Box and Block Test (BBT) to interpret test scores precisely for children with UCP. A total of 100 children with UCP were recruited and 50 children from the whole sample assessed the BBT twice within 2-week interval. The BBT, the Melbourne Assessment 2, the Bruininks-Oseretsky Test of Motor Proficiency, 2nd Edition, and the Pediatric Motor Activity Log Revised were measured before and immediately after a 36-h intensive neurorehabilitation intervention. Measurement properties of the BBT were performed according to the COnsensus-based Standards for the selection of health Measurement INstruments checklist. The test-retest reliability of the BBT was high (intraclass correlation coefficient = 0.98). The measurement error estimated by the MDC₉₅ value was 5.95. Construct validity was considered good that 4 of 4 (100%) hypotheses were confirmed. The interpretability estimated by the MCID ranged from 5.29 to 6.46. The BBT is a reliable and valid tool for children with UCP. For research and clinical applications, an improvement of seven blocks on the BBT is recommended as an indicator of statistically significant and clinically important change.

Caregivers' Feeding Experiences and Support of Their Child with Cerebral Palsy

Feeding difficulties are often reported in children with cerebral palsy (CP) and are associated with caregiver stress. This study explored the feeding experiences and support of caregivers with children who have CP. A qualitative approach was used where semi-structured telephone interviews were conducted and audio recorded. Thematic analysis was used to code and analyse the transcribed interview data from the eleven mothers that participated. Four major themes were identified from the data: Child-centred world, Making decisions, Knowing their child, and Seeking and receiving support. Caregivers knew their child's unique needs and made daily decisions around feeding based upon the child's feedback and changing condition. Family support was viewed as important, although the caregivers still reported feeling stressed. Health professional support varied from "amazing" to "frustrating", which contributed to the caregivers' stress. However, no single support strategy was appropriate as their needs or preferences varied. It is recommended that health professionals take an individualised partnership approach with caregivers and their child, with particular attention to those caregivers who lack a friend or family support and those who are physically isolated.

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]

Telehealth in paediatric occupational therapy: a scoping review

Background/Aims

This study reviewed the use of telehealth in paediatric occupational therapy practice and its clinical outcomes over the past 20 years.

Methods

A scoping review following Arksey and O'Malley's five stages was undertaken using six databases and Google Scholar. The scoping review covered articles from January 2000 to April 2020.

Results

A total of 22 articles were reviewed. Most studies indicated positive outcomes of using telehealth in paediatric occupational therapy practice. Although there is insufficient evidence, the results indicated that telehealth can be more effective than face-to-face interventions when there are mobility or travel challenges for children.

Conclusions

The use of telehealth in paediatric occupational therapy is an alternative service delivery model, facilitating access for children and their families to the rehabilitation services. Further research is needed to address the difficulties and potential solutions to expand the use of telehealth services to help children with disadvantages alongside their families.

Effect of Home-based Bimanual Training in Children with Unilateral Cerebral Palsy (The COAD-study): A Case Series

Purpose: To explore the child- and parent-related effects of home-based bimanual training in children with unilateral cerebral palsy.Methods: Case series of 14 children (2-7 years) who completed goal-oriented task-specific training for 3.5 hours/week for 12 weeks by a program adopting implicit (n = 5) or explicit (n = 9) motor learning. A therapist and remedial educationalist coached parents. Progression on bimanual goals (Canadian Occupational Performance Measure (COPM)) and therapy-related parental stress (interviews) were of primary interest. Data were collected at baseline (T0), halfway through and at the end of training (T1 and T2), and after 12 weeks (T3).Results: On the COPM performance scale a clinically relevant change was seen in 50% (7/14), 86% (12/14), and 85% (11/13) of the children, at T1, T2, and T3, respectively. Some parents indicated that they had experienced stress because of the training intensity.Conclusion: The child- and parent-related effects of the home-based bimanual training programs are encouraging.

The Canadian Occupational Performance Measure: a Feasible Multidisciplinary Outcome Measure for Pediatric Telerehabilitation

This study describes the feasibility of using the Canadian Occupational Performance Measure (COPM) as a multidisciplinary outcome measure for pediatric telerehabilitation (TR). The COPM was administered at monthly time points over four months. A follow-up survey was conducted with the therapists to assess clinical utility of the COPM. Seventy-three percent of the children seen in TR > one month had at least two administrations of the COPM. Eighty percent of therapists agreed or strongly agreed that the COPM was easy to use in a reasonable amount of time, helped identify functional goals, could be used with various children with varied diagnoses, and measured functional change. In 37 children, the median clinical change in performance and satisfaction was two points or greater on the COPM over the episode of TR. The COPM is a feasible measure perceived positively by pediatric therapists for TR use.

Efficacy of the use of unaffected hand containment in unimanual intensive therapy to increase visuomotor coordination in children with hemiplegia: a randomized controlled pilot study

Background:

The capacity of children with hemiplegia to be engaged in anticipatory action planning is affected. There is no balance among spatial, proprioceptive and visual information, thus altering the affected upper limb visuomotor coordination. The objective of the present study was to assess the improvement in visuomotor coordination after the application of a unimanual intensive therapy program, with the use of unaffected hand containment compared with not using unaffected hand containment.

Methods:

A simple blind randomized clinical trial was realized. A total of 16 subjects with congenital infantile hemiplegia participated in the study with an age mean of 5.54 years old (SD:1.55). Two intensive protocols for 5 weeks of modified constraint-induced movement therapy (mCIMT) or unimanual therapy without containment (UTWC) were executed 5 days per week (2 h/day). Affected upper limb visuomotor coordination (reaction time, task total time, active range, dynamic grasp) was measured before–after intensive therapy using a specific circuit with different slopes (10°/15°).

Results:

Statistically significant inter-group differences were found after the intervention, with clinically relevant results for the mCIMT group not seen in UTWC, in the following variables: reaction time 10°slope (p = 0.003, d = 2.44), reaction time 15°slope (p = 0.002, d = 2.15) as well as for the task total time 10°slope (p = 0.002, d = 2.25), active reach 10°slope (p = 0.002, d = 2.7), active reach 15°slope (p = 0.003, d = 2.29) and dynamic grasp 10°/15°slopes (p = <0.001, d = 2.69). There were not statistically significant inter-group differences in the total task time with 15°slope (p = 0.074, d = 1.27).

Conclusions:

The use of unaffected hand containment in mCIMT would allow improvements in the affected upper limb’s visuomotor coordination. Thus, it would favor clinical practice to make decisions on therapeutic approaches to increase the affected upper limb functionality and action planning in children diagnosed with infantile hemiplegia (4–8 years old).

How children and their parents value using the Canadian Occupational Performance Measure (COPM) with children themselves

PURPOSE

Although the Canadian Occupational Performance Measure (COPM) is used with children, it is unclear how they and their parents experience this. This study aims to investigate the opinions of children and their parents about the COPM when it is used with children.

METHODS

Semi-structured interviews were performed with 23 children varying in age between 8 and 18 years. The transcripts of the interviews were analysed using MAXQDA software to discover overarching themes. Parents' responses to an eight-item multiple-choice questionnaire were analysed using SPSS software.

RESULTS

Five themes extracted from the interviews with the children show: My way of doing the COPM; The COPM shows my own problems and wishes for change; The COPM is important for identifying the support I need; The influence of my parents and my therapist; and The COPM is suitable for me. The children experienced the COPM as a valuable tool for determining and measuring the impact of an intervention. The parents experienced the COPM as suitable for their child and judged that the child's scores were useful for showing the outcome of an intervention.

CONCLUSION

Both the children and their parents valued the COPM as an outcome measure for intervention.

Hand-arm bimanual intensive therapy and daily functioning of children with bilateral cerebral palsy: a randomized controlled trial

AIM

To examine the efficacy of Hand-Arm Bimanual Intensive Therapy (HABIT) on daily functioning, unimanual dexterity, and bimanual performance of children with bilateral cerebral palsy (CP) compared with customary care.

METHOD

Forty-one children with bilateral CP, aged 4 to 16 years, classified in levels I to III of the Manual Ability Classification System, were randomly assigned to HABIT (90h) (n=21) or to customary care (4.5h) (n=20). Participants' daily functioning (Pediatric Evaluation of Disability Inventory [PEDI], Canadian Occupational Performance Measure [COPM]), unimanual dexterity (Jebsen-Taylor Test of Hand Function, Box and Blocks Test [BBT]), and bimanual performance (Both Hands Assessment) were assessed pre-, post-, and 6 months after the intervention. Linear mixed-effects models were used for inferential analysis.

RESULTS

Children participating in HABIT showed greater improvements in daily functioning (COPM_performance : χ 1 2 =9.50, p<0.01; COPM_satisfaction : χ 1 2 =5.07, p<0.05; PEDI_{functional skills} : χ 1 2 =6.81, p<0.01; PEDI_{caregiver assistance} : χ 1 2 =6.23, p<0.05) and in the dexterity of the dominant hand (BBT: χ 1 2 =3.99, p<0.05) compared with children maintaining customary care. Group or time effects did not explain any variance in bimanual performance or in the dexterity of the non-dominant hand.

INTERPRETATION

HABIT may be beneficial for children with bilateral CP, with benefits evidenced for daily functioning outcomes.

WHAT THIS PAPER ADDS

Hand-Arm Bimanual Intensive Therapy (HABIT) improved daily functioning of children with bilateral cerebral palsy (CP). Bimanual performance, measured by the Both Hands Assessment, did not change after HABIT in children with bilateral CP. Children with asymmetric and symmetric hand use exhibited similar improvements after HABIT.

Feasibility and effectiveness of home-based therapy programmes for children with cerebral palsy: a systematic review

OBJECTIVE

To assess the feasibility and effectiveness of home-based occupational therapy and physiotherapy programmes in children with cerebral palsy (CP), focusing on the upper extremity and reporting on child-related and/or parent-related outcomes.

DESIGN

Systematic review.

DATA SOURCES

Electronic searches were performed in MEDLINE, EMBASE, CINAHL, PsycINFO, OTseeker and PEDro, and in ICTRP and CENTRAL trial registers, from inception to 6 June 2019.

ELIGIBLE CRITERIA

The review included all types of original studies concerning feasibility or effectiveness of home-based therapy in children aged <18 years with any type of CP. No language, publication status or publication date restrictions were applied.

DATA EXTRACTION AND SYNTHESIS

Study and intervention characteristics and the demographics of participating children and their parents were extracted. Feasibility was assessed by outcomes related to acceptability, demand, implementation, practicality, adaptation, expansion or integration. Regarding effectiveness, child-related outcome measures related to any level of the International Classification of Functioning, Disability and Health, or parent-related outcomes were investigated. Two authors independently extracted the data. Risk of bias was assessed using the Downs and Black checklist and the Joanna Briggs Institute Critical Appraisal Checklist.

RESULTS

The search resulted in a total of 92 records: 61 studies and 31 conference abstracts. Feasibility studies reported mainly on acceptability and implementation. Overall compliance to home-based training programmes (implementation) was moderate to high, ranging from 56% to 99%. In the effectiveness studies, >40 different child-related outcome measures were found. Overall, an improvement in arm-hand performance within group across time was shown. Only two studies reported on a parent-related outcome measure. No increase in parental stress was found during the intervention.

CONCLUSIONS

Based on the results of the included studies, home-based training programmes seem to be feasible. However, conclusions about the effectiveness of home programmes cannot be made due to the large variability in the study, patient and intervention characteristics, comparators, and outcome measures used in the included studies.

PROSPERO REGISTRATION NUMBER

CRD42016043743.

Conventional and Virtual Reality Mirror Therapies in Upper Obstetric Brachial Palsy: A Randomized Pilot Study

The abilities of children diagnosed with Obstetric Brachial Palsy (OBP) are limited by brachial plexus injuries. Thus, their participation in the community is hindered, which involves a lower quality of life due to worse performance in activities of daily living as a consequence of the functional limitations of the affected upper limb. Conventional Mirror Therapy (Conventional MT) and Virtual Therapy improve the affected upper limb functionality. Therefore, the aim of this study was to compare the effects of Conventional MT and Virtual Reality MT on the spontaneous use of the affected upper limb and quality of life of children with upper Obstetric Brachial Palsy between 6 and 12 years of age. A randomized pilot study was performed. Twelve children were randomly assigned to perform Conventional Mirror Therapy or Virtual Reality Mirror Therapy for four weeks. Ten children completed the treatment. Two assessments (pre/post-intervention) were carried out to assess the spontaneous use of the affected upper limb and the quality of life using the Children’s Hand-use Experience Questionnaire (CHEQ) and the Pediatric Quality of Life Inventory Generic Core Scales (PedsQL TM 4.0), respectively. There was a statistically significant increment in spontaneous use, observed in independent tasks (p = 0.02) and in the use of the affected hand with grasp (p = 0.04), measured with the CHEQ, for the Virtual Reality MT group. There were no statistically significant changes (p > 0.05) for the Conventional MT group in the spontaneous use of the affected upper limb. Regarding the quality of life, statistically significant changes were obtained in the Physical and Health activity categories of the parents’ questionnaire (p = 0.03) and in the total score of the children’s questionnaire (p = 0.04) in the Virtual Reality MT group, measured using the PedsQL TM 4.0. Statistically significant changes were not obtained for the quality of life in the Conventional MT group. This study suggests that, compared to Conventional MT, Virtual Reality MT would be a home-based therapeutic complement to increase independent bimanual tasks using grasp in the affected upper limb and improve the quality of life of children diagnosed with upper OBP in the age range of 6–12 years.

Stress in Caregivers and Children with a Developmental Disorder Who Receive Rehabilitation

This study aimed to evaluate the stress levels of caregivers and children with developmental disorders who were receiving rehabilitation treatment. The relationships between stress levels and factors such as early rehabilitation and home rehabilitation were quantified. Methods: This study was conducted in children with development disorders, aged from 1.5 years to 18 years, who were undergoing rehabilitation. The Korean version of the Child Behavior Checklist (K-CBCL) and the Adult Self-Report (K-ASR) were used to evaluate stress levels in children and caregivers, respectively. Results: Questionnaires were provided to 150 caregivers who agreed to participate. However, only 76 copies of the K-CBCL and 75 copies of the K-ASR were collected. The mean K-CBCL and K-ASR t scores were in the normal range. The K-CBCL score correlated positively with the K-ASR score (p value < 0.5). K-CBCL externalizing problems score correlated positively with the age at the start of rehabilitation, and the K-CBCL and K-ASR externalizing problems scores correlated negatively with home treatment delivered by caregivers. Conclusions: Stress levels of children and caregivers were closely related. Home rehabilitation provided by caregivers reduced stress in both caregivers and children. Early rehabilitation did not impart additional psychological burden on caregivers or children.

State of the Evidence Traffic Lights 2019: Systematic Review of Interventions for Preventing and Treating Children with Cerebral Palsy

PURPOSE OF REVIEW

Cerebral palsy is the most common physical disability of childhood, but the rate is falling, and severity is lessening. We conducted a systematic overview of best available evidence (2012-2019), appraising evidence using GRADE and the Evidence Alert Traffic Light System and then aggregated the new findings with our previous 2013 findings. This article summarizes the best available evidence interventions for preventing and managing cerebral palsy in 2019.

RECENT FINDINGS

Effective prevention strategies include antenatal corticosteroids, magnesium sulfate, caffeine, and neonatal hypothermia. Effective allied health interventions include acceptance and commitment therapy, action observations, bimanual training, casting, constraint-induced movement therapy, environmental enrichment, fitness training, goal-directed training, hippotherapy, home programs, literacy interventions, mobility training, oral sensorimotor, oral sensorimotor plus electrical stimulation, pressure care, stepping stones triple P, strength training, task-specific training, treadmill training, partial body weight support treadmill training, and weight-bearing. Effective medical and surgical interventions include anti-convulsants, bisphosphonates, botulinum toxin, botulinum toxin plus occupational therapy, botulinum toxin plus casting, diazepam, dentistry, hip surveillance, intrathecal baclofen, scoliosis correction, selective dorsal rhizotomy, and umbilical cord blood cell therapy. We have provided guidance about what works and what does not to inform decision-making, and highlighted areas for more research.

Defining Functional Therapy in Research Involving Children with Cerebral Palsy: A Systematic Review

Aim: To review definitions and elements of interventions in studies, which used the word "functional" to describe their intervention for children with cerebral palsy (CP), and to determine whether definitions and elements are similar to criteria of functional therapy described in the Dutch Guidelines.Methods: Systematic review of intervention studies, which used the word "functional" to describe interventions for children with CP. We described criteria of functional therapy that were used to describe the intervention, and whether criteria were described similarly to the descriptions used in the Dutch Guidelines.Results: Of the 27 included studies, criteria "based on the activities/participation level of the ICF-CY", "goal-directed" and "context-specific" were referred to the most (40-59.3%). Descriptions of these criteria were less comparable to the suggested definition (43.8-69.2%). The remaining three criteria ("active involvement", "task-specific", and "focused on functionality instead of normality") were referred to less frequently (18.5-33.3%). The descriptions reported for these criteria were, however, the most comparable with the suggested definitions (80-100%).Conclusions: The included studies, in general have not used criteria of functional therapy. Future studies have to describe the elements of interventions in detail. Moreover, it is important to reach consensus on the definition and elements of functional therapy.

Efficacy of a home-based platform for child-to-child interaction on hand motor function in unilateral cerebral palsy

AIM

To evaluate the feasibility and effectiveness of an action observation treatment (AOT) home-based platform promoting child-to-child interaction to improve hand motor function in unilateral cerebral palsy (CP).

METHOD

Twenty children (14 males, six females; mean age 6y 7mo, standard deviation 1y 7mo; range 5y 1mo-10y 6mo) with unilateral CP underwent 20 sessions where they had to observe and then imitate a wizard performing dexterity-demanding magic tricks; a child-to-child live video-session to practise the same exercise then took place. We assessed hand-motor skills with the Besta Scale, neurological motor impairment with Fugl-Meyer Assessment for upper extremity, as well as spasticity, muscle strength, visual analogue scale, and global impression of change 1-month before (T-1), at baseline (T0), and at the end of treatment (T1).

RESULTS

We observed a T0 to T1 improvement in global hand-motor and bimanual skills, and a significant correlation between motor improvement and difference in hand motor skills relative to the peer (r=-0.519).

INTERPRETATION

AOT associated with child-to-child interaction effectively improves hand motor function in unilateral CP. This improvement is linked to differences in hand motor ability among peers, suggesting that children should observe others with superior motor skills to their own. This study extends traditional AOT toward novel socially-enriched scenarios, where children might simultaneously be recipients and leaders within a motor learning process.

WHAT THIS PAPER ADDS

Home-based action observation treatment (AOT) based on child-to-child interaction improves hand motor function in children with unilateral cerebral palsy. Interaction with a more capable peer increases the chances of positive outcome in child-to-child AOT.

Effectiveness of Lower-Extremity Functional Training (LIFT) in Young Children With Unilateral Spastic Cerebral Palsy: A Randomized Controlled Trial

Background. Children with unilateral spastic cerebral palsy (USCP) have strength, coordination, and balance deficits affecting gross motor skills, such as walking, running, and jumping. However, there is a paucity of evidence for effective treatments for lower-extremity (LE) function in children with USCP. Objective. To determine the effectiveness of LE intensive functional training (LIFT) compared with an attention control group receiving upper-extremity bimanual training (Hand-Arm Bimanual Intensive Therapy [H-HABIT]). Methods. A total of 24 children with USCP were randomized to receive 90 hours of LIFT (5.8 [2.3] years) or an equivalent dosage of H-HABIT (5.1 [2.6] years) delivered 2 h/d, 5 d/wk for 9 weeks. Caregivers were trained to administer the intervention in the home setting. Progress and skill progression were monitored, and supervision was provided via weekly telerehabilitation. The primary outcome was the 1-minute walk test (1MWT). Secondary outcomes included self-selected and fast walking speeds, ABILOCO-kids, 30-s chair rise test, and single-leg stance. Results. LIFT showed greater improvement for the 1MWT ( P = .017) and ABILOCO-kids ( P = .008) compared with controls. The other secondary outcomes were not different between groups. Conclusions. The administration of LE intensive interventions in the home setting by caregivers was shown to be an effective and novel mode of delivery for improving gait capacity and performance. LIFT delivered in the home setting using telerehabilitation for monitoring resulted in improvements in ambulation distance and overall walking ability as compared to an intervention of equal intensity and duration that also controlled for the increased social interaction and attention between caregiver and child.

Therapy-related stress in parents of children with a physical disability: a specific concept within the construct of parental stress

PURPOSE

The aim of this article is to conceptualise the phenomenon of therapy-related parental stress in parents of children with a physical disability.

METHODS

Three models related to parental stress were reviewed, i.e., general parental stress, burden of caregiving in parents of children with physical disabilities, and experiences of these parents with their child's therapy.

RESULTS

The proposed definition of therapy-related parental stress is "the subjective stress and subsequent changes of functioning and health experienced by a parent of a child with a physical disability in response to paramedical therapies (i.e., physical, occupational, and/or speech and language therapy)". A theoretical model is proposed to describe the process of therapy-related parental stress. Available questionnaires will most likely not be valid and responsive to capture the (changes in) stress parents experience related to therapy their child receives.

CONCLUSIONS

This article provides a first definition of therapy-related parental stress and a theoretical model to visualise the processes with regard to this topic. Empirical testing of the presented components and their coherence is needed to confirm or improve the model. A questionnaire that specifically measures the concept of therapy-related parental stress is needed, along with evaluating therapy-related parental stress in clinical practice and research.Indications for rehabilitationIt is imperative to recognise paramedical therapies (i.e., physical, occupational, and speech and language therapy) as a potential stressor for parents of children with a physical disability, both in paediatric rehabilitation practice and research.A definition and theoretical model of therapy-related parental stress is proposed and the need for measures to evaluate this phenomenon is argued.The authors provide a starting point for the evidence base of the concept of therapy-related parental stress.

Early Intervention Therapy Services for Infants With or at Risk for Cerebral Palsy

OBJECTIVE

The purpose of this study was to explore the practices physical therapists and occupational therapists use in early intervention (EI) for infants with or at risk for cerebral palsy (CP).

METHODS

A survey was disseminated nationally to EI providers using an online anonymous link.

RESULTS

Two hundred sixty-nine therapists completed at least 50% of the survey. Four percent of therapists use the General Movement Assessment to predict CP, 57% reported infants at risk for CP receive therapy once a week, 89% identified parents' goals as the most important factor in customizing the EI program, and 75% provide parents with home programs. However, 73% never or rarely use outcome measures to prioritize parents' goals; 31% provide parents with individualized home program and more than 60% never assess environmental enrichment.

CONCLUSION

Therapists do not incorporate sufficient strategies for goal-oriented interventions, comprehensive parent education, and optimum environmental enrichment.

Effects of telerehabilitation in occupational therapy practice: A systematic review

Objective/background

This study aimed to review the current evidence on the application of telerehabilitation in occupational therapy practice and its clinical outcomes over the last 10 years.

Methods

A systematic review was performed on studies published in English in the decade 2008 to 2017, retrieved from seven electronic databases (MEDLINE, Cochrane Library, CINAHL, Web of Science, SAGE, Science Direct and EMBASE). Only articles evaluating the use of telerehabilitation to provide occupational therapy services from a distance were included, with no restrictions on pathology, impairment, age, or the nature of occupational therapy intervention.

Results

Fifteen articles (three randomised controlled trials, eight quasi-experimental studies, one trial with single-group post-intervention and three case studies) were reviewed. Despite various study designs and outcome measures, most studies indicated positive therapeutic effects of using telerehabilitation in occupational therapy practice. There is insufficient evidence, however, to confirm that telerehabilitation is more effective than the face-to-face model. Little evidence was shown on the long-term effect and cost efficacy. Only two studies used smartphones in their applications.

Conclusion

Telerehabilitation offers an alternative service delivery model for occupational therapy, not only bridging distance but also offering user-friendly treatment for patients at home. Further research, particularly on the use of the most cutting-edge mobile technology, is needed to determine effectiveness in occupational therapy practice treating various diseases, conditions and impairments and the characteristics of patients, interventions and therapists that lead to the best fit with this alternative and emerging form of service delivery.

Feasibility of a randomised controlled trial to evaluate home-based virtual reality therapy in children with cerebral palsy

PURPOSE

Evidence is increasing for effective virtual reality therapy for motor rehabilitation for children with Cerebral Palsy. We assessed the feasibility of a virtual reality therapy mode of intervention, appropriateness of measures, and potential cost-effectiveness.

METHODS

A 12-week, 2-group, parallel-feasibility trial (ISRCT 17624388) using Nintendo Wii Fit^TM at home. Children aged 5-16, with ambulatory Cerebral Palsy, who were able to follow simple instructions were randomised to two groups; one supported by physiotherapists (individualised activity programme), the other unsupported with children having free choice (control). Children were assessed in clinic at baseline, week 6, and week 12 by blinded assessors. Feasibility of the intervention was assessed via recruitment, adherence, and usefulness of measurement tools.

RESULTS

Forty-four children were eligible (out of 48 approached): 31 consented, 30 were randomised, 21 completed the study; 10 in the supported group and 11 in the unsupported group. Nine children discontinued from tiredness, after-school activities, homework, surgery, technical difficulties or negative system feedback. The supported group completed 19 of 36 (IQR 5-35) possible sessions; the unsupported group 24 of 36 sessions (IQR 8-36). Gross Motor Function Measure scores varied by Cerebral Palsy severity after the intervention. There were no adverse events.

CONCLUSION

Virtual reality therapy offers potential as a therapeutic adjunct for children with Cerebral Palsy, warranting substantive confirmatory study. Gross Motor Function Measure, with modifications to improve sensitivity, appeared appropriate as a primary measure, with Timed up and Go test secondary. The intervention was inexpensive costing £20 per child. An explanatory trial to evaluate the clinical/cost-effectiveness of commercial system virtual reality therapy is feasible with minor methodological adaptation. Implications for rehabilitation Home-based interactive computer gaming was feasible, safe and cost effective as a therapy adjunct. Discontinue if additional pressures are present: imminent surgery, family resilience to technical difficulties, negative system feedback, after-school activities. Change in Gross Motor Function Measurement scores varied by severity of Cerebral Palsy.

Diversity of practices in telerehabilitation for children with disabilities and effective intervention characteristics: results from a systematic review

Purpose: To describe the characteristics and effectiveness of pediatric telerehabilitation interventions offered to children 0-12 years old or to their families.Methods: A systematic review was conducted on randomized control trials published between 2007 and 2018 involving at least one rehabilitation professional who provided services remotely. Information was extracted about key study, participants and intervention characteristics. The percentage of outcomes that improved were computed per study, and per intervention characteristic.Results: Out of 4472 screened articles, 23 were included. Most studies were published after 2016 and evaluated outcomes related to the child's behavior (n = 12, 52.2%) or to the parent (n = 10, 43.5%), such as parental skills or stress. Overall, 56.1% (SD: 38.5%) of evaluated outcomes improved following telerehabilitation. A great diversity of population and teleintervention characteristics was observed. Effective interventions tended to target parents, centered around an exercise program, used a coaching approach, focused on improving children's behavioral functioning, lasted >8 weeks and were offered at least once a week.Conclusions: Intervention characteristics that appear to yield better outcomes should inform the development of future telerehabilitation studies, especially in populations for whom telerehabilitation is currently understudied (e.g., children's with physical functioning difficulties). Future trials should compare telerehabilitation interventions to well-described evidence-based face-to-face interventions, and document their cost-effectiveness.Implications for RehabilitationDespite a great variety in practices, telerehabilitation might be as effective as face-to-face interventions, across disciplines, for a variety of clinical outcomes.Telerehabilitation might be more effective when coaching approaches are used, especially to achieve outcomes related to children's behavior or parental skills.Further research is required to better understand the characteristics of effective telerehabilitation interventions, and to determine how these characteristics may differ for specific populations and outcomes.

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.