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.

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.

Development and Feasibility of a Kinect-Based Constraint-Induced Therapy Program in the Home Setting for Children With Unilateral Cerebral Palsy

Introduction: Cerebral palsy (CP) is the leading cause of childhood-onset physical disability. Children with CP often have impaired upper limb (UL) function. Constraint-induced therapy (CIT) is one of the most effective UL interventions for children with unilateral CP. However, concerns about CIT for children have been repeatedly raised due to frustration caused by restraint of the child’s less-affected UL and lack of motivation for the intensive protocol. Virtual reality (VR), which can mitigate the disadvantages of CIT, potentially can be used as an alternative mediator for implementing CIT. Therefore, we developed a VR-based CIT program for children with CP using the Kinect system.

Aims: The feasibility of the Kinect-based CIT program was evaluated for children with unilateral CP using a two-phase study design.

Materials and Methods: In phase 1, ten children with unilateral CP were recruited. To confirm the achievement of the motor training goals, maximal UL joint angles were evaluated during gameplay. To evaluate children’s perceptions of the game, a questionnaire was used. In phase 2, eight children with unilateral CP were recruited and received an 8 weeks Kinect-based CIT intervention. Performance scores of the game and outcomes of the box and block test (BBT) were recorded weekly.

Results: In phase 1, results supported that the design of the program was CIT-specific and was motivational for children with unilateral CP. In phase 2, game performance and the BBT scores began showing stable improvements in the fifth week of intervention.

Conclusion: It suggested the Kinect-based CIT program was beneficial to the motor function of the affected UL for children with unilateral CP. According to the results of this feasibility study, larger and controlled effectiveness studies of the Kinect-based CIT program can be conducted to further improve its clinical utility.

Clinical Trial Registration: ClinicalTrials.gov, NCT02808195; Comparative effectiveness of a Kinect-based unilateral arm training system vs. CIT for children with CP

Constraint Induced Movement Therapy in Infants and Toddlers with Hemiplegic Cerebral Palsy: A Scoping Review

Cerebral Palsy (CP) is the leading cause of motor disability in childhood. Recent studies have investigated the effectiveness of constraint induced movement therapy (CIMT) as an early intervention for infants and toddlers with hemiplegic CP. This scoping review aims to identify current evidence for CIMT protocols for children 3 months to 5 years 11 months as well as clinical applications for practice and gaps in research. Selected databases and additional studies were searched and reviewed with 10 studies were selected for review. Results show CIMT for infants and toddlers is a feasible and effective treatment consisting of caregiver coaching, treatment in the child's typical environment, and just right activities. Future research is needed to determine the effects of different dosages in early CIMT, and the long term developmental effects throughout childhood.

Constraint-induced movement therapy for children with neonatal brachial plexus palsy: a randomized crossover trial

AIM

To determine if constraint-induced movement therapy (CIMT) is more effective than standard care in improving upper-limb activity outcomes in children with neonatal brachial plexus palsy (NBPP).

METHOD

Twenty-one children with NBPP (mean age 25mo, SD=10.3, range=17-48mo; 11 males, 10 females) were enrolled in a crossover trial and randomly allocated to first receive CIMT or standard care, each for 8 weeks. The intervention arm consisted of 3 weeks of casting the unaffected limb followed by 5 weeks of transference activities. The Assisting Hand Assessment (AHA) was used to measure bimanual activity performance at baseline, 8 weeks, and 16 weeks, scored by blinded raters. The Pediatric Motor Activity Log-Revised (PMAL-R) was used as a caregiver-reported secondary outcome measure.

RESULTS

After concealed random allocation (n=21), there were no significant differences on demographics or baseline measures. CIMT was superior compared to control in terms of bimanual activity performance with a mean difference in AHA change score of 4.8 (SD=10.5, p=0.04, Cohen's δ=0.46). There were no significant differences between treatment conditions on the PMAL-R.

INTERPRETATION

CIMT is favored over standard care for bimanual activity performance. Future research should investigate a longer follow-up period, additional comparator interventions, and analyse differences by participant characteristics.

WHAT THIS PAPER ADDS

Gains in bimanual activity performance were greater after constraint-induced movement therapy (CIMT) compared to no CIMT. Frequency and quality of movement were not significantly different between treatment groups.

Preschool HABIT-ILE: study protocol for a randomised controlled trial to determine efficacy of intensive rehabilitation compared with usual care to improve motor skills of children, aged 2-5 years, with bilateral cerebral palsy

INTRODUCTION

Young children with bilateral cerebral palsy (BCP) often experience difficulties with gross motor function, manual ability and posture, impacting developing independence in daily life activities, participation and quality of life. Hand Arm Bimanual Intensive Training Including Lower Extremity (HABIT-ILE) is a novel intensive motor intervention integrating upper and lower extremity training that has been developed and tested in older school-aged children with unilateral and BCP. This study aims to compare an adapted preschool version of HABIT-ILE to usual care in a randomised controlled trial.

METHODS AND ANALYSIS

60 children with BCP aged 2-5 years, Gross Motor Function Classification System (GMFCS) II-IV will be recruited. Children will be stratified by GMFCS and randomised using concealed allocation to either receive Preschool HABIT-ILE or usual care. Preschool HABIT-ILE will be delivered in groups of four to six children, for 3 hours/day for 10 days (total 30 hours). Children receiving Preschool HABIT-ILE be provided a written home programme with the aim of achieving an additional 10 hours of home practice (total dose 40 hours). Outcomes will be assessed at baseline, immediately following intervention and then retention of effects will be tested at 26 weeks. The primary outcome will be the Peabody Developmental Motors Scales-Second Edition to evaluate gross and fine motor skills. Secondary outcomes will be gross motor function (Gross Motor Function Measure-66), bimanual hand performance (Both Hands Assessment), self-care and mobility (Pediatric Evaluation of Disability Inventory-Computer Adapted Test), goal attainment (Canadian Occupational Performance Measure), global performance of daily activities (ACTIVLIM-CP), cognition and adaptive function (Behavior Rating Inventory of Executive Function-Preschool Version), habitual physical activity (ActiGraph GT3X+) and quality of life (Infant Toddler Quality of Life Questionnaire and Child Health Utility Index-9). Analyses will follow standard principles for RCTs using two-group comparisons on all participants on an intention-to-treat basis. Comparisons between groups for primary and secondary outcomes will be conducted using regression models.

ETHICS AND DISSEMINATION

Ethics approval has been granted by the Medical Research Ethics Committee Children's Health Queensland Hospital and Health Service Human Research Ethics Committee (HREC/19/QCHQ/59444) and The University of Queensland (2020000336/HREC/19/QCHQ/59444).

TRIAL REGISTRATION NUMBER

ACTRN126200000719.

A Systematic Review of Training Methods That May Improve Selective Voluntary Motor Control in Children With Spastic Cerebral Palsy

Background: Impaired selective voluntary motor control is defined as “the reduced ability to isolate the activation of muscles in response to demands of a voluntary posture or movement.” It is a negative motor sign of an upper motor neuron lesion.

Objective: This paper reviews interventions that may improve selective motor control in children and youths with spastic cerebral palsy. The aim was to systematically evaluate the methodological quality and formulate the level of evidence from controlled studies.

Methods: Six databases (Scopus, Web of Science, PubMed, Embase, MEDLINE, and CINAHL) were searched with predefined search terms for population, interventions, and outcomes. Two reviewers independently completed study selection and ratings of methodological quality and risk of bias. Evidence was summarized in a best evidence synthesis.

Results: Twenty-three studies from initially 2,634 papers were included. The interventions showed a wide variety of approaches, such as constraint-induced movement therapy (CIMT), electrical stimulation, robot-assisted therapy, and functional training. The evidence synthesis revealed conflicting evidence for CIMT, robot-assisted rehabilitation and mirror therapy for the upper extremities in children with cerebral palsy.

Conclusions: Final recommendations are difficult due to heterogeneity of the reviewed studies. Studies that include both an intervention and an outcome that specifically focus on selective voluntary motor control are needed to determine the most effective therapy.

Mechanically assisted walking training for walking, participation, and quality of life in children with cerebral palsy

BACKGROUND

Cerebral palsy is the most common physical disability in childhood. Mechanically assisted walking training can be provided with or without body weight support to enable children with cerebral palsy to perform repetitive practice of complex gait cycles. It is important to examine the effects of mechanically assisted walking training to identify evidence-based treatments to improve walking performance.

OBJECTIVES

To assess the effects of mechanically assisted walking training compared to control for walking, participation, and quality of life in children with cerebral palsy 3 to 18 years of age.

SEARCH METHODS

In January 2020, we searched CENTRAL, MEDLINE, Embase, six other databases, and two trials registers. We handsearched conference abstracts and checked reference lists of included studies.

SELECTION CRITERIA

Randomized controlled trials (RCTs) or quasi-RCTs, including cross-over trials, comparing any type of mechanically assisted walking training (with or without body weight support) with no walking training or the same dose of overground walking training in children with cerebral palsy (classified as Gross Motor Function Classification System [GMFCS] Levels I to IV) 3 to 18 years of age.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

This review includes 17 studies with 451 participants (GMFCS Levels I to IV; mean age range 4 to 14 years) from outpatient settings. The duration of the intervention period (4 to 12 weeks) ranged widely, as did intensity of training in terms of both length (15 minutes to 40 minutes) and frequency (two to five times a week) of sessions. Six studies were funded by grants, three had no funding support, and eight did not report information on funding. Due to the nature of the intervention, all studies were at high risk of performance bias. Mechanically assisted walking training without body weight support versus no walking training Four studies (100 participants) assessed this comparison. Compared to no walking, mechanically assisted walking training without body weight support increased walking speed (mean difference [MD] 0.05 meter per second [m/s] [change scores], 95% confidence interval [CI] 0.03 to 0.07; 1 study, 10 participants; moderate-quality evidence) as measured by the Biodex Gait Trainer 2™ (Biodex, Shirley, NY, USA) and improved gross motor function (standardized MD [SMD] 1.30 [postintervention scores], 95% CI 0.49 to 2.11; 2 studies, 60 participants; low-quality evidence) postintervention. One study (30 participants) reported no adverse events (low-quality evidence). No study measured participation or quality of life. Mechanically assisted walking training without body weight support versus the same dose of overground walking training Two studies (55 participants) assessed this comparison. Compared to the same dose of overground walking, mechanically assisted walking training without body weight support increased walking speed (MD 0.25 m/s [change or postintervention scores], 95% CI 0.13 to 0.37; 2 studies, 55 participants; moderate-quality evidence) as assessed by the 6-minute walk test or Vicon gait analysis. It also improved gross motor function (MD 11.90% [change scores], 95% CI 2.98 to 20.82; 1 study, 35 participants; moderate-quality evidence) as assessed by the Gross Motor Function Measure (GMFM) and participation (MD 8.20 [change scores], 95% CI 5.69 to 10.71; 1 study, 35 participants; moderate-quality evidence) as assessed by the Pediatric Evaluation of Disability Inventory (scored from 0 to 59), compared to the same dose of overground walking training. No study measured adverse events or quality of life. Mechanically assisted walking training with body weight support versus no walking training Eight studies (210 participants) assessed this comparison. Compared to no walking training, mechanically assisted walking training with body weight support increased walking speed (MD 0.07 m/s [change and postintervention scores], 95% CI 0.06 to 0.08; 7 studies, 161 participants; moderate-quality evidence) as assessed by the 10-meter or 8-meter walk test. There were no differences between groups in gross motor function (MD 1.09% [change and postintervention scores], 95% CI -0.57 to 2.75; 3 studies, 58 participants; low-quality evidence) as assessed by the GMFM; participation (SMD 0.33 [change scores], 95% CI -0.27 to 0.93; 2 studies, 44 participants; low-quality evidence); and quality of life (MD 9.50% [change scores], 95% CI -4.03 to 23.03; 1 study, 26 participants; low-quality evidence) as assessed by the Pediatric Quality of Life Cerebral Palsy Module (scored 0 [bad] to 100 [good]). Three studies (56 participants) reported no adverse events (low-quality evidence). Mechanically assisted walking training with body weight support versus the same dose of overground walking training Three studies (86 participants) assessed this comparison. There were no differences between groups in walking speed (MD -0.02 m/s [change and postintervention scores], 95% CI -0.08 to 0.04; 3 studies, 78 participants; low-quality evidence) as assessed by the 10-meter or 5-minute walk test; gross motor function (MD -0.73% [postintervention scores], 95% CI -14.38 to 12.92; 2 studies, 52 participants; low-quality evidence) as assessed by the GMFM; and participation (MD -4.74 [change scores], 95% CI -11.89 to 2.41; 1 study, 26 participants; moderate-quality evidence) as assessed by the School Function Assessment (scored from 19 to 76). No study measured adverse events or quality of life.

AUTHORS' CONCLUSIONS

Compared with no walking, mechanically assisted walking training probably results in small increases in walking speed (with or without body weight support) and may improve gross motor function (with body weight support). Compared with the same dose of overground walking, mechanically assisted walking training with body weight support may result in little to no difference in walking speed and gross motor function, although two studies found that mechanically assisted walking training without body weight support is probably more effective than the same dose of overground walking training for walking speed and gross motor function. Not many studies reported adverse events, although those that did appeared to show no differences between groups. The results are largely not clinically significant, sample sizes are small, and risk of bias and intensity of intervention vary across studies, making it hard to draw robust conclusions. Mechanically assisted walking training is a means to undertake high-intensity, repetitive, task-specific training and may be useful for children with poor concentration.

Application of Low-Intensity Modified Constraint-Induced Movement Therapy to Improve the Affected Upper Limb Functionality in Infantile Hemiplegia with Moderate Manual Ability: Case Series

OBJECTIVE

To assess the functionality of the affected upper limb in children diagnosed with hemiplegia aged between 4 and 8 years after applying low-intensity modified Constraint-Induced Movement Therapy (mCIMT).

METHODS

Prospective case series study. A mCIMT protocol was applied for five weeks, with two hours of containment per day. The study variables were quality of movement of the upper limb, spontaneous use, participation of the affected upper limb in activities of daily living, dynamic joint position, grasp-release action, grasp strength, supination and extension elbow movements. Four measurements were performed, using the quality of upper extremity test (QUEST) scale, the Shriners Hospital for Children Upper Extremity Evaluation (SHUEE) Evaluation, a hand dynamometer and a goniometer.

RESULTS

The sample was composed of eight children with moderate manual ability. Statistically significant differences were detected in all the studied variables (p < 0.05) between the pre-treatment and post-treatment results (Week 0-Week 5), except for upper limb dressing, putting on splints and buttoning up. In the first week, the changes were statistically significant, except for protective extension, grasp strength, grasp-release and all functional variables (level of functionality and participation of the patient's upper limbs) in the SHUEE Evaluation (p > 0.05). The greatest increase occurred in spontaneous use from Assessment 1 to Assessment 4 (p = 0.01), reaching 88.87% active participation in bimanual tasks. The quality of movement of the upper limb exhibited a significant value due to the increase in dissociated movements and grasp (p = 0.01).

CONCLUSION

A low dose (50 h) of mCIMT increased the functionality of children diagnosed with congenital hemiplegia between 4 and 8 years of age with moderate manual ability.

Methodological Considerations to Investigate Dosage Parameters of Intensive Upper Limb Rehabilitation in Children with Unilateral Spastic Cerebral Palsy: A Scoping Review of RCTs

PURPOSES

To identify and synthesize RCTs on the isolated effect of dosage parameters of upper limb Intensive Motor Rehabilitation Treatments (IMRT) of children with Unilateral Spastic Cerebral Palsy (USCP); to identify the most frequent methodological weaknesses.

METHODS

Searches were conducted until September 2018 in gray and published literature databases and supplemented by exploring the identified studies' references. Inclusion criteria applied: RCT; children aged 1.5 to 19 years with USCP; upper limb IMRT differing only from ≥1/4 dosage parameters between groups. Literature analyses conducted: qualitative and descriptive.

RESULTS

We identified 461 studies. Seventeen were included: three presented a rehabilitation dosage distinction between groups in Frequency-Time, four in Intensity-Progressivity, three in Intensity-Restraint, two in Intensity-Environment and five presented ≥3 distinctions above.

CONCLUSIONS

Inconsistencies were noted between USCP lifelong issues, and the short follow-ups and lack of participation assessments. Confounding factors and misstatements in Intent To Treat (ITT) analyses were identified. A meta-analysis was considered irrelevant.

ABBREVIATIONS

USCP, CP: Unilateral Spastic Cerebral Palsy, Cerebral Palsy; RCT: Randomized Controlled Trial; IMRT: Intensive Motor Rehabilitation Treatment.

Effectiveness of hand-arm bimanual intensive training on upper extremity function in children with cerebral palsy: A systematic review

OBJECTIVE

To systematically review the effectiveness of Hand-Arm Bimanual Intensive Training (HABIT) on upper limb function in children with cerebral palsy.

METHODS

Six databases (MEDLINE, CINAHL, PubMed, Embase, Cochrane Library, and PsycINFO) were searched for HABIT-related studies published in English between 2007 and 2017. The methodological quality of the included studies was classified based on the Levels of Evidence of the American Occupational Therapy Association guidelines. If the included studies were randomized controlled trials (RCTs), the methodological quality was evaluated using the Revised Cochrane risk of bias tool. Cohen's d effect sizes were computed and synthesized to assess the effectiveness.

RESULTS

Among 646 studies, 15 fulfilled the inclusion criteria. Eleven studies were RCTs, 64% of which were rated as having a high risk of bias; one was a quasi-RCT, one was a retrospective study, and two were longitudinal studies. Nearly half of the included studies used HABIT for 6 h a day for three consecutive weeks (totaling 90 h), and some studies used different doses/schedules or added training components to HABIT. Synthesis of the results demonstrated a significantly small effect size (d = 0.36, P = 0.017) for improving upper limb function immediately after the interventions, and the improvements were maintained at follow-up. Similarly, significantly moderate or large effect sizes were found for self-care function (d = 0.52, P = 0.003) and goal improvements (d = 1.78-2.28, P < 0.001).

CONCLUSION

This review supports the effectiveness of HABIT as an intervention for improving upper limb function in children with cerebral palsy.

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.

Randomized controlled trial combining constraint-induced movement therapy and action-observation training in unilateral cerebral palsy: clinical effects and influencing factors of treatment response

Introduction:

Constraint-induced movement therapy (CIMT) improves upper limb (UL) motor execution in unilateral cerebral palsy (uCP). As these children also show motor planning deficits, action-observation training (AOT) might be of additional value. Here, we investigated the combined effect of AOT to CIMT and identified factors influencing treatment response.

Methods:

A total of 44 children with uCP (mean 9 years 6 months, SD 1 year 10 months) participated in a 9-day camp wearing a splint for 6 h/day and were allocated to the CIMT + AOT (n = 22) and the CIMT + placebo group (n = 22). The CIMT + AOT group received 15 h of AOT (i.e. video-observation) and executed the observed tasks, whilst the CIMT + AOT group watched videos free of biological motion and executed the same tasks. The primary outcome measure was bimanual performance. Secondary outcomes included measures of body function and activity level assessed before (T1), after the intervention (T2), and at 6 months follow-up (T3). Influencing factors included behavioural and neurological characteristics.

Results:

Although no between-groups differences were found (p > 0.05; η² = 0–16), the addition of AOT led to higher gains in children with initially poorer bimanual performance (p = 0.02; η² = 0.14). Both groups improved in all outcome measures after the intervention and retained the gains at follow up (p < 0.01; η² = 0.02–0.71). Poor sensory function resulted in larger improvements in the total group (p = 0.03; η² = 0.25) and high amounts of mirror movements tended to result in a better response to the additional AOT training (p = 0.06; η² = 0.18). Improvements were similar irrespective of the type of brain lesion or corticospinal tract wiring pattern.

Conclusions:

Adding AOT to CIMT, resulted in a better outcome for children with poor motor function and high amounts of mirror movements. CIMT with or without AOT seems to be more beneficial for children with poor sensory function.

Trial registration:

Registered at ClinicalTrials.gov on 22nd August 2017 (ClinicalTrials.gov identifier: NCT03256357).

Why Do Clinical Practice Guidelines Get Stuck during Implementation and What Can Be Done: A Case Study in Pediatric Rehabilitation

Aims: The purpose of this study was to obtain the perspectives of occupational and physical therapists working in pediatric rehabilitation about the factors that influence implementation of clinical practice guidelines (CPG) using the case of constraint induced movement therapy (CIMT). We aimed to identify factors that hinder implementation of CPGs and strategies for overcoming barriers when widespread implementation is stalled.Methods: Qualitative case study methodology was bounded within the parameters of CIMT implementation in pediatric rehabilitation in one jurisdiction. Twenty-one occupational and physical therapists participated in one of three focus groups. Data were analyzed using an inductive qualitative approach.Results: Participants viewed CPGs as useful, and emphasized the importance of consistency between guidelines and relevance to practice context. Therapists considered the "art and science" in clinical decision-making. Barriers and facilitators to CPG implementation were identified at the client, clinician, intervention location and systemic level. Potential solutions to help "unstick" guideline implementation were consistent with theories of collective knowledge exchange and mindlines.Conclusion: The presence of CPGs does not ensure evidence uptake; understanding of local barriers is required. This case study highlights the value of a collective knowledge exchange approach and attention to the social structures of knowledge development and evidence use.

Protocol for a multisite randomised trial of Hand-Arm Bimanual Intensive Training Including Lower Extremity training for children with bilateral cerebral palsy: HABIT-ILE Australia

INTRODUCTION

Children with bilateral cerebral palsy often experience difficulties with posture, gross motor function and manual ability, impacting independence in daily life activities, participation and quality of life (QOL). Hand-Arm Bimanual Intensive Training Including Lower Extremity (HABIT-ILE) is a novel intensive motor intervention integrating upper and lower extremity training. This study aimed to compare HABIT-ILE to usual care in a large randomised controlled trial (RCT) in terms of gross motor function, manual ability, goal attainment, walking endurance, mobility, self-care and QOL. A within-trial cost-utility analysis will be conducted to synthesise costs and benefits of HABIT-ILE compared with usual care.

METHODS AND ANALYSIS

126 children with bilateral cerebral palsy aged 6-16 years will be recruited across three sites in Australia. Children will be stratified by site and Gross Motor Function Classification System and randomised using concealed allocation to either receiving HABIT-ILE immediately or being waitlisted for 26 weeks. HABIT-ILE will be delivered in groups of 8-12 children, for 6.5 hours per day for 10 days (total 65 hours, 2 weeks). Outcomes will be assessed at baseline, immediately following intervention, and then retention of effects will be tested at 26 weeks. Primary outcomes will be the Gross Motor Function Measure and ABILHAND-Kids. Secondary outcomes will be brain structural integrity, walking endurance, bimanual hand performance, self-care, mobility, performance and satisfaction with individualised goals, and QOL. Analyses will follow standard principles for RCTs using two-group comparisons on all participants on an intention-to-treat basis. Comparisons between groups for primary and secondary outcomes will be conducted using regression models.

ETHICS AND DISSEMINATION

Ethics approval has been granted by the Medical Research Ethics Committee of Children's Health Queensland Hospital and the Health Service Human Research Ethics Committee (HREC/17/QRCH/282) of The University of Queensland (2018000017/HREC/17/QRCH/2820), and The Cerebral Palsy Alliance Ethics Committee (2018_04_01/HREC/17/QRCH/282).

TRIAL REGISTRATION NUMBER

ACTRN12618000164291.

Treatment and re/habilitation of children with cerebral palsy in India: a scoping review

AIM

To describe the nature and extent of the literature addressing the medical and its re/habilitative management of cerebral palsy (CP) in India.

METHOD

Online worldwide scholarly databases, research hosting directories, Indian publishing houses, and grey literature were used to identify papers published between 2005 and 2016. We retrieved 144 English language papers that described the medical and rehabilitative management of Indian children with CP.

RESULTS

Quantitative, qualitative, and mixed research designs are published by a variety of health care professionals in India. Intervention (45%) and observational studies (30%) predominate. Outcomes were categorized using the World Health Organization's International Classification of Functioning, Disability and Health framework, with body structure and function most reported and activity/participation least reported; 57% described its re/habilitation interventions and 43% were medical interventions.

INTERPRETATION

There is a substantial body of CP research in India that focuses on interventions to reduce impairments, with minimal attention given to activities and participation, environmental, and personal factors. Twenty-six per cent of studies are published in what appear to be 'predatory journals'. This paper serves as an alert about the presence of 'predatory journals' in medicine that may introduce publication bias, which can distort results reported in those studies individually, or from conclusions drawn in reviews that contain those studies.

WHAT THIS PAPER ADDS

Cerebral palsy research in India focuses on interventions to reduce impairment. Activities, participation, and environmental factors are minimally addressed. Quantitative studies are more common than qualitative studies. Many Indian studies are published in journals that are not indexed in worldwide databases of scholarly journals.

Effects of Therapeutic Exercise Intensity on Cerebral Palsy Outcomes: A Systematic Review With Meta-Regression of Randomized Clinical Trials

Background and Objective: Intensive physical therapy or exercise has been associated with favorable cerebral palsy (CP) outcomes, but few studies have investigated the effects of exercise intensity on the improvement in CP outcomes. In this study, we assessed the effects of intensive exercise-based therapy on improvement in gross motor function in children with CP. Methods: We searched three databases for randomized clinical trials evaluating the effects of therapeutic exercise training by using Gross Motor Function Measurement (GMFM) 66 and 88 among children with CP. Studies that used interventions in addition to therapeutic exercise were excluded from the present meta-analysis. Exercise intensity was defined using the number of training hours per day and duration of intervention (in weeks). The effects of the number of daily training hours and program duration on GMFM improvement were evaluated using meta-regression. Results: The comprehensive search returned 270 references, and 13 of 270 references met our eligibility criteria. The 13 trials recruited 412 children with CP. These trials measured motor improvements by using GMFM-66 (n = 8) and GMFM-88 (n = 5). The GMFM scores in the children who received the therapeutic intervention did not show significantly greater improvement than those of the children who received standard care. Meta-regression analysis revealed that the improvement in GMFM scores was positively associated with the number of daily training hours (point estimate = 0.549; p = 0.031) and program duration (point estimate = 0.067; p = 0.075). Discussion and Conclusions: Intensive physical exercise improved CP outcomes in the intervention and standard therapy groups. The duration of therapeutic intervention improved CP outcomes among the children who received the therapeutic intervention, while an increase in the number of daily training hours improved in CP outcomes in the children who received standard therapy.

Effectiveness of paediatric occupational therapy for children with disabilities: A systematic review

INTRODUCTION

Paediatric occupational therapy seeks to improve children's engagement and participation in life roles. A wide variety of intervention approaches exist. Our aim was to summarise the best-available intervention evidence for children with disabilities, to assist families and therapists choose effective care.

METHODS

We conducted a systematic review (SR) using the Cochrane methodology, and reported findings according to PRISMA. CINAHL, Cochrane Library, MEDLINE, OTSeeker, PEDro, PsycINFO were searched. Two independent reviewers: (i) determined whether studies met inclusion: SR or randomised controlled trial (RCT); an occupational therapy intervention for children with a disability; (ii) categorised interventions based on name, core components and diagnostic population; (iii) rated quality of evidence and determined the strength of recommendation using GRADE criteria; and (iv) made recommendations using the Evidence Alert Traffic Light System.

RESULTS

129 articles met inclusion (n = 75 (58%) SRs; n = 54 (42%)) RCTs, measuring the effectiveness of 52 interventions, across 22 diagnoses, enabling analysis of 135 intervention indications. Thirty percent of the indications assessed (n = 40/135) were graded 'do it' (Green Go); 56% (75/135) 'probably do it' (Yellow Measure); 10% (n = 14/135) 'probably don't do it' (Yellow Measure); and 4% (n = 6/135) 'don't do it' (Red Stop). Green lights were: Behavioural Interventions; Bimanual; Coaching; Cognitive Cog-Fun & CAPS; CO-OP; CIMT; CIMT plus Bimanual; Context-Focused; Ditto; Early Intervention (ABA, Developmental Care); Family Centred Care; Feeding interventions; Goal Directed Training; Handwriting Task-Specific Practice; Home Programs; Joint Attention; Mental Health Interventions; occupational therapy after toxin; Kinesiotape; Pain Management; Parent Education; PECS; Positioning; Pressure Care; Social Skills Training; Treadmill Training and Weight Loss 'Mighty Moves'.

CONCLUSION

Evidence supports 40 intervention indications, with the greatest number at the activities-level of the International Classification of Function. Yellow light interventions should be accompanied by a sensitive outcome measure to monitor progress and red light interventions could be discontinued because effective alternatives existed.

Prescribing Physical, Occupational, and Speech Therapy Services for Children With Disabilities

Pediatric health care providers are frequently responsible for prescribing physical, occupational, and speech therapies and monitoring therapeutic progress for children with temporary or permanent disabilities in their practices. This clinical report will provide pediatricians and other pediatric health care providers with information about how best to manage the therapeutic needs of their patients in the medical home by reviewing the International Classification of Functioning, Disability and Health; describing the general goals of habilitative and rehabilitative therapies; delineating the types, locations, and benefits of therapy services; and detailing how to write a therapy prescription and include therapists in the medical home neighborhood.

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.

Preliminary Efficacy of a Friendly Constraint-Induced Therapy (Friendly-CIT) Program on Motor and Psychosocial Outcomes in Children with Cerebral Palsy

AIMS

Constraint-induced therapy (CIT) is effective, but concerns have been repeatedly raised regarding the generalizability, feasibility, and potentially intrusive nature of restraining a child's unimpaired upper limb. We examined the feasibility and efficacy of friendly-CIT, which uses home-based model, a caregiver-determined schedule, and gentle restraint, in children with cerebral palsy.

METHODS

In a one-group pre-post intervention trial, 15 children (median of age = 8 years, 4 months) participated in 8 weeks of friendly-CIT (36 hours). Motor and psychosocial outcomes were investigated.

RESULTS

Participants showed significant improvement on the manual dexterity subtest of the Bruininks-Oseretsky Test of Motor Proficiency (p = 0.004); the how often (p = 0.01) and how well (p = 0.02) scales of the Revised Pediatric Motor Activity Log; and the functional skills score on the Chinese version of the Pediatric Evaluation of Disability Inventory (p = 0.002). For psychosocial outcomes, children with CP consistently demonstrated high engagement and increased playfulness (p < 0.0001) during the 8-week intervention. Parents showed no change in stress status and high satisfaction with friendly-CIT.

CONCLUSION

Friendly-CIT is feasible and promising for improving a child's motor and psychosocial outcomes without increasing parental stress.

Evidence-based Approach to Physical Therapy in Cerebral Palsy

Physiotherapy plays a key role in the management of cerebral palsy (CP) and comprises of various therapeutic interventions in enhancing the various physiological and functional outcomes. Though physiotherapy is used widely and recommended by all members of the health-care team, the effectiveness of physiotherapy is inconsistent. The objective of this review was to summarize and evaluate the effectiveness of physiotherapy interventions in children with CP. PubMed and Cochrane database were searched from January 2006 to April 2017 using the Medical Subject Heading and general keywords. Only systematic reviews and meta-analysis on PT interventions in children diagnosed with CP were included. Two reviewers independently assessed the methodological quality and retrieved the results. Thirty-four systematic reviews were identified that distinguished 15 different interventions. Moderate evidence of effectiveness was found for constraint-induced movement therapy for upper limb recovery, goal-directed/functional training, and gait training to improve gait speed. Conflicting evidence was found for the role of exercises on strength training and cardiorespiratory training. Intervention such as neurodevelopmental therapy (NDT) was found ineffective. This review suffer from limitations such as including reviews that had small sample size and that had considered heterogeneity of treatment interventions. Hence, the effectiveness of most PT interventions is found to be limited. On the basis of the present evidence, functional goal-oriented approaches are found to be effective and future research is required to determine the best ways to improve functional outcomes in children with CP.

Brain Lesions as a Predictor of Therapeutic Outcomes of Hand Function in Infants With Unilateral Cerebral Palsy

AIM

The present study aimed to investigate whether the response variability of infants to modified constraint-induced movement therapy and bimanual therapy are associated with different types of brain lesions.

METHOD

Infants with unilateral cerebral palsy (N = 22) ages 8-15 months (mean = 10.95, standard deviation = 2.15 months) were grouped according to having either a periventricular brain lesion or a middle cerebral artery infarct lesion. Improvement in hand function was analyzed based on the mini-Assistive Hand Assessment results.

RESULTS

Infants with periventricular brain lesion displayed greater positive response to upper limb treatment compared to those with middle cerebral artery infarct ( P = .02). A significant difference in improvement according to type of treatment was found in the middle cerebral artery infarct group but not in the periventricular brain lesion.

CONCLUSION

The present study showed an association between the type of brain lesion and the efficacy of upper limb treatment in infants. Infants with periventricular brain lesions displayed greater positive responses than those with middle cerebral artery infarct.

Effectiveness of Modified Constraint-Induced Movement Therapy Compared With Bimanual Therapy Home Programs for Infants With Hemiplegia: A Randomized Controlled Trial

OBJECTIVE. We examined the effectiveness of modified constraint-induced movement therapy (mCIMT) in treating infants with hemiplegic cerebral palsy and compared therapy outcomes with a nonconstraining bimanual therapy (BIM) of equal intensity.

METHOD. In a single-blinded randomized controlled trial, 33 infants with hemiplegia (mean corrected age = 11.1 mo, standard deviation = 2.2) received either mCIMT (n = 17) or BIM (n = 16). Both interventions included home programs encouraging the use of the affected hand during daily 1-hr play sessions for 8 wk. Outcome measures were administered pre- and posttreatment and included the Mini-Assisting Hand Assessment for babies and the Functional Inventory. At baseline, parents also filled out the Dimensions of Mastery Questionnaire.

RESULTS. Both groups demonstrated a significantly large and equal improvement in hand and gross motor function posttreatment (p &lt; .001) and high treatment compliance.

CONCLUSION. mCIMT and BIM are equally effective methods for treating infants with hemiplegia.

Determinants of parent-delivered therapy interventions in children with cerebral palsy: A qualitative synthesis and checklist

INTRODUCTION

Parent-delivered therapy interventions for children with cerebral palsy can help achieve a sufficient therapy dose, improve parental mental well-being, and facilitate parent-child relationships creating a more relaxed familial environment. However, parent-delivered interventions may also lead to increased parental stress, guilt if the therapy is not delivered, and time constraints. The primary aim of this review was to gain a deeper understanding of the determinants of effective parent-delivered therapy interventions.

METHOD

Searches were conducted in the following databases: Medline, PubMed, Scopus, Embase, CINAHL, and Cochrane. Studies had to meet the following inclusion criteria: descriptions of parent/health care professional/child experiences of parent-delivered therapy interventions for children and young people age 0-18 years with cerebral palsy, published in the English language between January 1989 and May 2017, with qualitative or mixed methods research design. The articles were critically appraised, then synthesized using a meta-ethnographic approach.

RESULTS

A literature search identified 17 articles, which met the inclusion criteria. Three main themes were identified: (a) building trusting relationships, (b) enabling the parents to cope, and (c) for parents and health care professionals to see the intervention as a priority. Further synthesis presented three concepts identifying the important aspects of the interventions: empowerment, motivation, and relationships.

CONCLUSIONS

The themes and concepts emerging from this qualitative synthesis can be addressed by specific points of action to support parent-delivered therapy interventions. We have summarized these in a checklist for use by intervention developers, health care professionals, and parents.

Examination of psychometric properties of PROMIS®: Pediatric upper limb measures in youth with cerebral palsy

Introduction

This study examines the validity and distribution characteristics of the PROMIS® pediatric upper limb measures in a sample of young people with cerebral palsy.

Method

Data are a cross-sectional subset of a larger prospective study of the responsiveness to change of PROMIS® pediatric measures following surgery to improve functioning in young people with cerebral palsy. Ninety-three participants between the ages of eight and 21 years completed the PROMIS® pediatric mobility and upper limb computer adaptive tests and short forms in conjunction with a set of static “legacy” measures of physical functioning, including a parent-report of upper limb function.

Results

The PROMIS® Pediatric upper limb short form demonstrated acceptable internal consistency (Cronbach’s alpha = 0.85). PROMIS® pediatric upper limb computer adaptive tests and short form mean values (42.1(11) and 43(10.4), respectively) were nearly 1 SD below normal, which is appropriate when a generic measure is used in a sample of young persons with cerebral palsy. The PROMIS® pediatric upper limb computer adaptive tests had a higher frequency of ceiling effects (29.50%) compared to the short form (18.30%).

Conclusion

Results of this study suggest that the PROMIS® pediatric upper limb computer adaptive tests and the short form are valid indicators of upper limb function in young people with cerebral palsy. The item bank can be replenished to address ceiling effects.

Management of Pediatric Movement Disorders: Present and Future

Management of movement disorders in children is an evolving field. This article outlines the major categories of treatment options for pediatric movement disorders and general guidelines for their use. We review the evidence for existing therapies, which continue to lack large-scale controlled trials to guide treatment decisions. The field continues to rely on extrapolations from adult studies and lower quality evidence such as case reports and case series to guide treatment guidelines and consensus statements. Developments in new pharmaceuticals for rare diseases have begun to provide hope for those cases in which a genetic diagnosis can be made. Advances in surgical therapies such as deep brain stimulation as well as new modes of treatment such as gene therapy, epigenetic modulation, and stem cell therapy hold promise for improving outcomes in both primary and secondary causes of movement disorders. There is a critical need for larger, multicenter, controlled clinical trials to fully evaluate treatments for pediatric movement disorders.

The validity and reliability of the Test of Arm Selective Control for children with cerebral palsy: a prospective cross-sectional study

AIM

This study examined the reliability and validity of the Test of Arm Selective Control (TASC) to examine upper extremity selective voluntary motor control in children and adolescents with all types of spastic cerebral palsy (CP).

METHOD

Fifty-six participants with CP, ranging in age from 5 years 9 months to 18 years 11 months (average 11y 7mo, SD 3y 9mo; 25 males, 31 females), participated in this prospective cross-sectional study. They were evaluated using the TASC and several clinical measures.

RESULTS

TASC and Manual Ability Classification System (r=-0.529, p<0.001), TASC and ABILHAND-Kids (r=0.596, p<0.001), and TASC and affected extremities (r=-0.486, p=0.001) were moderately correlated. There was a weak correlation between the TASC and Gross Motor Function Classification System (r=-0.363, p=0.006) and no correlation between the TASC and age (p=0.366) or rater (p=0.713). Interrater reliability for upper extremity total score (intraclass correlation coefficient [ICC]=0.92-0.94) and upper extremity limb scores (ICC=0.92-0.96) was high for two independent rater groups (p≤0.001). Average time to administer was 16 minutes, 18 seconds.

INTERPRETATION

The TASC is a reliable and valid tool for objective assessment of selective voluntary motor control. Clinically this measure may guide the selection of medical, surgical, or therapy interventions and may improve outcome prognosis.

WHAT THIS PAPER ADDS

The Test of Arm Selective Control (TASC) demonstrates a high degree of reliability and multiple aspects of validity when assessing upper extremity selective control in those with cerebral palsy. The TASC is an upper limb companion to the Selective Control Assessment of the Lower Extremity.

The Feasibility of Functional Electrical Stimulation to Improve Upper Extremity Function in a Two-year-old Child with Perinatal Stroke: A Case Report

AIMS

To evaluate the effectiveness and feasibility (i.e. tolerability, adherence) of functional electrical stimulation (FES) for the upper extremity (UE) in a two-year-old child with perinatal stroke.

METHODS

Forty hours of FES over eight weeks was prescribed. FES to the hemiplegic triceps, extensor carpi radialis longus and brevis, extensor carpi ulnaris and extensor digitorum was timed with reaching during play. Assessments were performed before, during, and two months post-intervention. UE function (Melbourne Assessment 2 (MA2), Assisting Hand Assessment (AHA)) and spasticity (Modified Tardieu with electrogoniometry and electromyography) were measured. The mother completed a semi-structured interview post-intervention. Descriptive statistics were used for adherence and UE measures. A repeated-measures ANOVA compared Modified Tardieu parameters (e.g. catch angle) over time. Conventional content analysis was used for the interview data.

RESULTS

The child completed 39.2/40 hours. Immediately post-intervention, improvements were observed on MA2's Range of Motion subscale and catch angle (Modified Tardieu, p < 0.001). Two months post-intervention, improvements were observed on MA2's Accuracy and Fluency subscales. No change in AHA score occurred. Three themes emerged from the interview: (1) Ingredients for program success; (2) Information about the FES device; and (3) The child's response.

CONCLUSIONS

UE FES was feasible in a two-year-old child with hemiplegia.

Computerised Tracking Training for Coordination in Children with Hemiplegic Cerebral Palsy: A Case Series

Objective: To examine whether elbow coordination training can improve elbow coordination in cerebral palsy and whether any benefit carries over to upper limb activity.

Methods: A case series A–B–C multiple baseline study was carried out. Two weeks of no intervention (A) was followed by 2 weeks of computerised tracking (B), which was followed by 2 weeks of no intervention (C). Six children (age range 7–12 years) with hemiplegic cerebral palsy (Level I–III of the Manual Ability Classification System) participated. Coordination training consisted of 10 × 1-min trials of computerised tracking each session for 10 sessions over a 2-week period. Coordination was measured as tracking performance using a different target from the training target. Upper limb activity was measured using the 9-Hole Peg Test. Data were analysed using the 2-SD band method.

Results: None of the participants appeared to improve tracking performance or 9-Hole Peg Test (9HPT) scores (p > 0.05) after the 2 weeks of intervention. On withdrawal of the intervention, visual analysis showed that tracking performance and 9HPT scores remained at the same level as the intervention phase.

Conclusions: Ten minutes of computerised elbow tracking daily for 10 sessions did not improve coordination in six children with cerebral palsy.

Constraint-induced movement therapy of upper limb of children with cerebral palsy in clinical practice: systematic review of the literature

ABSTRACT The purpose of the present study was to perform a systematic review of the literature to investigate how and with what modifications or adaptations constraint-induced movement therapy has been employed in clinical practice for therapeutic interventions in children with cerebral palsy. Searches were conducted of the CAPES (Brazilian fostering agency) periodical portal, Pubmed, Bireme, Science Direct, Scielo and PEDro databases for relevant articles published between January 2010 and May 2016. The articles retrieved were evaluated, scored and qualified by two blinded reviewers using the Physical therapy Evidence Database Scale. The searches led to the retrieval of 102 articles, 12 of which were included in the present systematic review. A table was created containing information on the study groups, inclusion criteria, intervention, intervention frequency, difficulties encountered, evaluations and outcomes. Considerable variety was found in the therapeutic intervention models. The findings of the present review demonstrate that constraint-induced movement therapy in pediatric clinical practice is not employed in its original form. Although the studies analyzed did not have a common methodology regarding the use of this type of therapy, the method has been adapted with considerable flexibility, providing promising, positive results regarding the therapeutic intervention of the paretic upper limb in children with cerebral palsy.

The effects of dosage time and frequency on motor outcomes in children with cerebral palsy: A systematic review

PURPOSE

Provide an updated review regarding treatment dosage for children with cerebral palsy (CP) by examining the variables of type, time, frequency, and intensity.

METHODS

A systematic review was performed with 30 articles meeting the inclusion criteria. Two authors independently extracted data including information about risk of bias. Ten articles were included in the review.

RESULTS

Eight studies manipulated time, two studies manipulated frequency, and three studies manipulated both variables. No studies investigated intensity. Findings suggest that manipulating time and/or frequency may result in better motor function for higher total dosing; however, benefits were not consistent across studies and few showed clinically significant improvements.

CONCLUSION

This most current evidence regarding the effect of dosage on motor function for children with CP suggests that there is insufficient evidence to support implementing high-dosage therapy. Further research is needed to clarify the relationship between dosage variables on motor function for children with CP.

Early Intensive Leg Training to Enhance Walking in Children With Perinatal Stroke: Protocol for a Randomized Controlled Trial

BACKGROUND

Development of motor pathways is modulated by activity in these pathways, when they are maturing (ie, critical period). Perinatal stroke injures motor pathways, including the corticospinal tracts, reducing their activity and impairing motor function. Current intervention for the lower limb emphasizes passive approaches (stretching, braces, botulinum toxin injections). The study hypothesis was that intensive, early, child-initiated activity during the critical period will enhance connectivity of motor pathways to the legs and improve motor function.

OBJECTIVE

The study objective was to determine whether early intervention with intensive activity is better than standard care, intervention delivered during the proposed critical period is better than after, and the outcomes are different when the intervention is delivered by a physical therapist in an institution vs. a parent at home.

DESIGN

A prospective, delay-group, single-blind, randomized controlled trial (RCT) and a parallel, cohort study of children living beyond commuting distance and receiving an intervention delivered by their parent.

SETTING

The RCT intervention was provided in university laboratories, and parent training was provided in the childs home.

PARTICIPANTS

Children 8 months to 3 years old with MRI-confirmed perinatal ischemic stroke and early signs of hemiparesis.

INTERVENTION

Intensive, play-based leg activity with weights for the affected leg and foot, 1 hour/day, 4 days/week for 12 weeks.

MEASUREMENTS

The primary outcome was the Gross Motor Function Measure-66 score. Secondary outcomes were motion analysis of walking, full-day step counts, motor evoked potentials from transcranial magnetic stimulation, and patellar tendon reflexes.

LIMITATIONS

Inter-individual heterogeneity in the severity of the stroke and behavioral differences are substantial but measurable. Differences in intervention delivery and assessment scoring are minimized by standardization and training.

CONCLUSIONS

The intervention, contrary to current practice, could change physical therapy interventions for children with perinatal stroke.

Histological and functional assessment of the efficacy of constraint-induced movement therapy in rats following neonatal hypoxic-ischemic brain injury

Constraint-induced movement therapy (CIMT) is used in stroke rehabilitation to promote recovery of upper limb motor function. However, its efficacy in improving functional outcomes in children with hemiplegic cerebral palsy has not been clearly determined in clinical or experimental research. The aim of our study was to assess the efficacy of a new experimental model of CIMT, evaluated in terms of mortality, stress, motor and cognitive function in rats having undergone a neonatal hypoxic-ischemic (HI) brain injury. Neonatal HI injury was induced at post-natal day 7 through unilateral ligation of the common carotid artery followed by exposure to hypoxia for 2 h. CIMT was implemented at 3 weeks, post-HI injury, using a pouch to constrain the unimpaired forelimb and forcing use of the affected forelimb using a motorized treadmill. After HI injury, animals demonstrated motor and cognitive deficits, as well as volumetric decreases in the ipsilateral hemisphere to arterial occlusion. CIMT yielded a modest recovery of motor and cognitive function, with no effect in reducing the size of the HI lesion or post-HI volumetric decreases in brain tissue. Therefore, although animal models of stroke have identified benefits of CIMT, CIMT was not sufficient to enhance brain tissue development and functional outcomes in an animal model of hemiplegic cerebral palsy. Based on our outcomes, we suggest that CIMT can be used as an adjunct treatment to further enhance the efficacy of a program of rehabilitation in children with hemiplegic cerebral palsy.

Efficacy of constraint-induced movement therapy compared with bimanual intensive training in children with unilateral cerebral palsy: a systematic review

OBJECTIVE

To systematically review the evidence on the effect of constraint-induced movement therapy compared with bimanual intensive training in children with unilateral cerebral palsy.

DATA SOURCES

Seven electronic databases (Cinahl, Cochrane Library, EMBASE, Ovid MEDLINE, PEDro, PsycINFO, PubMed) were searched from database inception through December 2016.

METHODS

A systematic review was performed using the American Academy of Cerebral Palsy and Developmental Medicine and Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Standardised mean differences (effect sizes) were calculated for each study and outcome.

RESULTS

Nine studies met the eligibility criteria. All studies provided level II evidence. Methodological quality was high in two studies, moderate in four studies and low in three studies. The methodology, participant and intervention characteristics were heterogeneous. The participants' ages ranged from 1.5 to 16 years. Their initial hand function ranged from Manual Ability Classification System Level I to Level III. The total intervention dose ranged from 24 to 210 hours and duration from one week to ten weeks. The studies measured outcomes assessing unimanual and bimanual hand and arm function, participation and attainment of individualised goals. Overall, the effect sizes did not favour one of the interventions at short- or long-term follow-up. The 95% confidence intervals were broad, indicating inaccurate precision of the effect sizes. Pooling of the data for a meta-analysis was judged to be of little clinical value owing to heterogeneity.

CONCLUSION

It is not possible to conclude whether constraint-induced movement therapy or bimanual intensive training is more effective than the other in children with unilateral cerebral palsy.

Constraint-Induced Movement Therapy for Children With Brain Tumors

PURPOSE

The purpose of this pilot study was to investigate the feasibility of a 3-week constraint-induced movement therapy program in children with brain tumors and upper extremity hemiplegia and to describe resultant change in extremity use.

METHODS

Affected arm use, health-related quality of life, and parent-reported feasibility of program participation were measured before and after the intervention and at a 3-month follow-up visit.

RESULTS

All 9 participants completed the entire study. The quality and amount of affected arm use improved significantly; gains were maintained at the 3-month follow-up evaluation. Some parents (44%) reported that program participation was difficult; however, all reported satisfaction with the program. Participants did not experience negative changes in health-related quality of life during the intervention, indicating that they tolerated the program well.

CONCLUSIONS

Findings suggest that a child with hemiplegia as a result of a brain tumor can adhere to and benefit from a constraint-induced movement therapy program.

Transcranial direct current stimulation for children with perinatal stroke and hemiparesis

Objective:

To determine whether the addition of transcranial direct current stimulation (tDCS) to intensive therapy increases motor function in children with perinatal stroke and hemiparetic cerebral palsy.

Methods:

This was a randomized, controlled, double-blind clinical trial. Participants were recruited from a population-based cohort with MRI-classified unilateral perinatal stroke, age of 6 to 18 years, and disabling hemiparesis. All completed a goal-directed, peer-supported, 2-week after-school motor learning camp (32 hours of therapy). Participants were randomized 1:1 to 1 mA cathodal tDCS over the contralesional primary motor cortex (M1) for the initial 20 minutes of daily therapy or sham. Primary subjective (Canadian Occupational Performance Measure [COPM]), objective (Assisting Hand Assessment [AHA]), safety, and secondary outcomes were measured at 1 week and 2 months after intervention. Analysis was by intention to treat.

Results:

Twenty-four participants were randomized (median age 11.8 ± 2.7 years, range 6.7–17.8). COPM performance and satisfaction scores doubled at 1 week with sustained gains at 2 months (p < 0.001). COPM scores increased more with tDCS compared to sham control (p = 0.004). AHA scores demonstrated only mild increases at both time points with no tDCS effects. Procedures were safe and well tolerated with no decrease in either arm function or serious adverse events.

Conclusion:

tDCS trials appear feasible and safe in hemiparetic children. Lack of change in objective motor function may reflect underdosing of therapy. Marked gains in subjective function with tDCS warrant further study.

ClinicalTrials.gov identifier:

NCT02170285.

Classification of evidence:

This study provides Class II evidence that for children with perinatal stroke and hemiparetic cerebral palsy, the addition of tDCS to moderate-dose motor learning therapy does not significantly improve motor function as measured by the AHA.

Effect of parent-delivered action observation therapy on upper limb function in unilateral cerebral palsy: a randomized controlled trial

AIM

To determine whether home-based, parent-delivered therapy comprising action observation (AO) and repeated practice (RP) improves upper limb function more than RP alone in children with unilateral cerebral palsy (UCP).

DESIGN

single-blinded parallel-group randomized controlled trial with 1:1 allocation comparing AO+RP (intervention) with RP alone (control).

RANDOMIZATION

computer-generated, with allocation concealment by opaque sequentially-numbered envelopes.

SETTING

northern England, August 2011 to September 2013.

PARTICIPANTS

70 children with UCP; mean age 5.6 years (SD 2.1), 31 female.

INTERVENTION

home-based activities were provided, tailored to interests and abilities.

DURATION

15 minutes/day, 5 days/week for 3 months.

ASSESSMENTS

Assisting Hand Assessment (AHA; primary outcome measure), Melbourne Assessment 2 (MA2), and ABILHAND-Kids at baseline, 3 months, and 6 months.

RESULTS

Outcome data was available at 3 months for 28 children in the AO+RP group and 31 controls, and at 6 months for 26 and 28 children respectively. There were no between-group differences in AHA, MA2, or ABILHAND-Kids at 3 or 6 months versus baseline (all p>0.05). Combined-group improvements (p<0.001), observed in AHA and MA2 at 3 months, were maintained at 6 months. ABILHAND-Kids also showed improvement at 3 months (p=0.003), maintained at 6 months.

INTERPRETATION

Parent-delivered RP (with or without AO) improves upper limb function and could supplement therapist input.

Rehabilitation - a new approach. Part two: the underlying theories

This editorial considers how healthcare systems should approach the problems associated with ongoing, persistent symptoms and limitations on a person's ability to undertake activities. It starts from the premise, established in the first editorial, that the current reliance on the biomedical model of health and illness is no longer 'fit for purpose', and is one major cause of current difficulties within the health service. Among other problems, it may lead to the marginalisation of rehabilitation services, especially when resources are limited. This editorial describes and then highlights the implications of the holistic, biopsychosocial model of illness. It also outlines the rehabilitation process, demonstrating its similarity to the process used by medical services, with the primary difference being the centre of attention: disease for medical service, disability for rehabilitation services. The model of rehabilitation emphasises: the importance of being patient-centred and goal-directed in rehabilitation; the need for liaison by the team and learning by the patient; and that the patient needs to be encouraged and enabled to practice wanted activities.

Constraint-induced movement therapy improves upper limb activity and participation in hemiplegic cerebral palsy: a systematic review

QUESTIONS

Does constraint-induced movement therapy improve activity and participation in children with hemiplegic cerebral palsy? Does it improve activity and participation more than the same dose of upper limb therapy without restraint? Is the effect of constraint-induced movement therapy related to the duration of intervention or the age of the children?

DESIGN

Systematic review of randomised trials with meta-analysis.

PARTICIPANTS

Children with hemiplegic cerebral palsy with any level of motor disability.

INTERVENTION

The experimental group received constraint-induced movement therapy (defined as restraint of the less affected upper limb during supervised activity practice of the more affected upper limb). The control group received no intervention, sham intervention, or the same dose of upper limb therapy.

OUTCOME MEASURES

Measures of upper limb activity and participation were used in the analysis.

RESULTS

Constraint-induced movement therapy was more effective than no/sham intervention in terms of upper limb activity (SMD 0.63, 95% CI 0.20 to 1.06) and participation (SMD 1.21, 95% CI 0.41 to 2.02). However, constraint-induced movement therapy was no better than the same dose of upper limb therapy without restraint either in terms of upper limb activity (SMD 0.05, 95% CI -0.21 to 0.32) or participation (SMD -0.02, 95% CI -0.34 to 0.31). The effect of constraint-induced movement therapy was not related to the duration of intervention or the age of the children.

CONCLUSIONS

This review suggests that constraint-induced movement therapy is more effective than no intervention, but no more effective than the same dose of upper limb practice without restraint.

REGISTRATION

PROSPERO CRD42015024665. [Chiu H-C, Ada L (2016) Constraint-induced movement therapy improves upper limb activity and participation in hemiplegic cerebral palsy: a systematic review.Journal of Physiotherapy62: 130-137].

Brain stimulation and constraint for perinatal stroke hemiparesis: The PLASTIC CHAMPS Trial

OBJECTIVE

To determine whether the addition of repetitive transcranial magnetic stimulation (rTMS) and/or constraint-induced movement therapy (CIMT) to intensive therapy increases motor function in children with perinatal stroke and hemiparesis.

METHODS

A factorial-design, blinded, randomized controlled trial (clinicaltrials.gov/NCT01189058) assessed rTMS and CIMT effects in hemiparetic children (aged 6-19 years) with MRI-confirmed perinatal stroke. All completed a 2-week, goal-directed, peer-supported motor learning camp randomized to daily rTMS, CIMT, both, or neither. Primary outcomes were the Assisting Hand Assessment and the Canadian Occupational Performance Measure at baseline, and 1 week, 2 and 6 months postintervention. Outcome assessors were blinded to treatment. Interim safety analyses occurred after 12 and 24 participants. Intention-to-treat analysis examined treatment effects over time (linear mixed effects model).

RESULTS

All 45 participants completed the trial. Addition of rTMS, CIMT, or both doubled the chances of clinically significant improvement. Assisting Hand Assessment gains at 6 months were additive and largest with rTMS + CIMT (β coefficient = 5.54 [2.57-8.51], p = 0.0004). The camp alone produced large improvements in Canadian Occupational Performance Measure scores, maximal at 6 months (Cohen d = 1.6, p = 0.002). Quality-of-life scores improved. Interventions were well tolerated and safe with no decrease in function of either hand.

CONCLUSIONS

Hemiparetic children participating in intensive, psychosocial rehabilitation programs can achieve sustained functional gains. Addition of CIMT and rTMS increases the chances of improvement.

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence that combined rTMS and CIMT enhance therapy-induced functional motor gains in children with stroke-induced hemiparetic cerebral palsy.