Treatment of congenital hemiparesis with pediatric constraint-induced movement therapy

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A Review of Current Perspectives on Motoric Insufficiency Rehabilitation following Pediatric Stroke

Pediatric stroke (PS) is an injury caused by the occlusion or rupture of a blood vessel in the central nervous system (CNS) of children, before or after birth. Hemiparesis is the most common motoric deficit associated with PS in children. Therefore, it is important to emphasize that PS is a significant challenge for rehabilitation, especially since the consequences may also appear during the child's growth and development, reducing functional capacity. The plasticity of the child's CNS is an important predecessor of recovery, but disruption of the neural network, specific to an immature brain, can have harmful and potentially devastating consequences. In this review, we summarize the complexity of the consequences associated with PS and the possibilities and role of modern rehabilitation. An analysis of the current literature reveals that Constraint-Induced Movement Therapy, forced-use therapy, repetitive transcranial magnetic stimulation, functional electrical stimulation and robot-assisted therapy have demonstrated at least partial improvements in motor domains related to hemiparesis or hemiplegia caused by PS, but they are supported with different levels of evidence. Due to the lack of randomized controlled studies, the optimal rehabilitation treatment is still debatable, and therefore, most recommendations are primarily based on expert consensuses, opinions and an insufficient level of evidence.

Exploration of the relationship between functional motor and communication performance levels and amount of use of the more affected upper extremity based on the caregivers' perceptions in children with hemiplegic cerebral palsy: A cross-sectional study

OBJECTIVE

To investigate relationships between amount of use of the more affected upper extremity and functional motor and communication performance classification systems.

MATERIAL AND METHODS

The study comprised 95 children with congenital hemiplegic cerebral palsy (CP) aged 6-15 years (52 males, 43 females; mean age 9.53, SD 3.1) and their parents/caregivers. The amount of use of the more affected upper extremity was assessed using Pediatric Motor Activity Log-Revised-How Often subscale (PMAL-R HO). Functional levels of the enrolled children were defined by the parents/caregivers using Manual Ability Classification System (MACS), Gross Motor Function Classification System-Expanded and Revised (GMFCS-E&R), and Communication Function Classification System (CFCS).

RESULTS

A strong and negative correlation was found between PMAL-R HO subscale score and MACS (r=-0.819), suggesting that children with lower MACS levels are more likely to use their more affected upper extremity spontaneously. Additionally, negative and moderate associations between PMAL-R HO subscale score and GMFCS and CFCS were revealed (r1=-0.549 and r2=-0.567).

CONCLUSION

The amount of use of the more affected upper extremity is more sensitive to MACS than GMFCS-E&R and CFCS. Children with a given MACS level had a wide range of PMAL-R HO subscale score. In addition to MACS, a score on the PMAL-R HO subscale related to the more affected upper extremity should be included as an inclusion criterion in clinical trials to avoid misleading effects of intervention approaches aimed at improving the amount of use of the more affected upper extremity in children with congenital hemiplegic CP.

Advances in the Diagnosis and Treatment of Pediatric Arterial Ischemic Stroke

Though rare, stroke in infants and children is an important cause of mortality and chronic morbidity in the pediatric population. Neuroimaging advances and implementation of pediatric stroke care protocols have led to the ability to rapidly diagnose stroke and in many cases determine the stroke etiology. Though data on efficacy of hyperacute therapies, such as intravenous thrombolysis and mechanical thrombectomy, in pediatric stroke are limited, feasibility and safety data are mounting and support careful consideration of these treatments for childhood stroke. Recent therapeutic advances allow for targeted stroke prevention efforts in high-risk conditions, such as moyamoya, sickle cell disease, cardiac disease, and genetic disorders. Despite these exciting advances, important knowledge gaps persist, including optimal dosing and type of thrombolytic agents, inclusion criteria for mechanical thrombectomy, the role of immunomodulatory therapies for focal cerebral arteriopathy, optimal long-term antithrombotic strategies, the role of patent foramen ovale closure in pediatric stroke, and optimal rehabilitation strategies after stroke of the developing brain.

Locomotor learning in infants at high risk for cerebral palsy: A study protocol

Background

Physical disability in individuals with cerebral palsy (CP) creates lifelong mobility challenges and healthcare costs. Despite this, very little is known about how infants at high risk for CP learn to move and acquire early locomotor skills, which set the foundation for lifelong mobility. The objective of this project is to characterize the evolution of locomotor learning over the first 18 months of life in infants at high risk for CP. To characterize how locomotor skill is learned, we will use robotic and sensor technology to provide intervention and longitudinally study infant movement across three stages of the development of human motor control: early spontaneous movement, prone locomotion (crawling), and upright locomotion (walking).

Study design

This longitudinal observational/intervention cohort study (ClinicalTrials.gov Identifier: NCT04561232) will enroll sixty participants who are at risk for CP due to a brain injury by one month post-term age. Study participation will be completed by 18 months of age. Early spontaneous leg movements will be measured monthly from 1 to 4 months of age using inertial sensors worn on the ankles for two full days each month. Infants who remain at high risk for CP at 4 months of age, as determined from clinical assessments of motor function and movement quality, will continue through two locomotor training phases. Prone locomotor training will be delivered from 5 to 9 months of age using a robotic crawl training device that responds to infant behavior in real-time. Upright locomotor training will be delivered from 9 to 18 months of age using a dynamic weight support system to allow participants to practice skills beyond their current level of function. Repeated assessments of locomotor skill, training characteristics (such as movement error, variability, movement time and postural control), and variables that may mediate locomotor learning will be collected every two months during prone training and every three months during upright training.

Discussion

This study will develop predictive models of locomotor skill acquisition over time. We hypothesize that experiencing and correcting movement errors is critical to skill acquisition in infants at risk for CP and that locomotor learning is mediated by neurobehavioral factors outside of training.Project Number 1R01HD098364-01A1.ClinicalTrials.gov Identifier: NCT04561232.

Modified constraint induced movement therapy in children with obstetric brachial plexus palsy: a systematic review

INTRODUCTION

Obstetric brachial plexus palsy (OBPP) is a flaccid paralysis occurring in the upper limb during birth. The OBPP includes mild lesions with complete spontaneous recovery and severe injuries with no regain of arm function. Among the most promising rehabilitation treatments aimed at improving upper extremity motor activities in individuals with neurological dysfunctions, there is the modified constraint-induced movement therapy (mCIMT). The aim of this systematic review is to assess and synthesize the critical aspects of the use of mCIMT in children with OBPP.

EVIDENCE ACQUISITION

This systematic review has been carried out according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analysis). A comprehensive search of the literature was conducted using PubMed, MEDLINE and Evidence Based Medicine Reviews, databases. We enclosed experimental and original articles, case reports and book chapters. Four articles were finally included.

EVIDENCE SYNTHESIS

One case report tested the feasibility of mCIMT to encourage use of the affected arm in a child with Erb-Duchenne palsy and documented the clinical changes observed. A case series had the purpose to determine if mCIMT in combination with botulinum toxin (BTX-A) improved arm function in 2 children with OBPP. A cohort study compared the use of mCIMT in 19 OBPP and 18 unilateral Cerebral Palsy. A prospective single-blind RCT described mCIMT versus conventional therapy in a group of 39 children with OBPP.

CONCLUSIONS

This systematic review on the use of mCIMT in children with OBPP shows that there is unanimous agreement that a program should last 2 weeks at least. However, there is no scientific evidence supporting a single common mCIMT protocol in the management of OBPP because of a considerable heterogeneity. Further high methodological studies regarding the application of mCIMT for OBPP and based on larger patients' sample should have the potential to optimize the appropriateness of care provided to infants with OBPP and, therefore, their quality of life.

Contralesional plasticity following constraint-induced movement therapy benefits outcome: contributions of the intact hemisphere to functional recovery

Stroke is a leading cause of death and disability worldwide. A common, chronic deficit after stroke is upper limb impairment, which can be exacerbated by compensatory use of the nonparetic limb. Resulting in learned nonuse of the paretic limb, compensatory reliance on the nonparetic limb can be discouraged with constraint-induced movement therapy (CIMT). CIMT is a rehabilitative strategy that may promote functional recovery of the paretic limb in both acute and chronic stroke patients through intensive practice of the paretic limb combined with binding, or otherwise preventing activation of, the nonparetic limb during daily living exercises. The neural mechanisms that support CIMT have been described in the lesioned hemisphere, but there is a less thorough understanding of the contralesional changes that support improved functional outcome following CIMT. Using both human and non-human animal studies, the current review explores the role of the contralesional hemisphere in functional recovery of stroke as it relates to CIMT. Current findings point to a need for a better understanding of the functional significance of contralesional changes, which may be determined by lesion size, location, and severity as well stroke chronicity.

Modified constraint-induced movement therapy during hospitalization in children with perinatal brachial plexus palsy: A randomized controlled trial

STUDY DESIGN

Prospective single-blind, randomized controlled study.

INTRODUCTION

Children with perinatal brachial plexus palsy (PBPP) have motion limitations in the affected upper extremity. Modified constraint-induced movement therapy (mCIMT) is one of the treatment options used for the improvement of the function of the affected limb.

PURPOSE OF THE STUDY

The purpose of this study was to compare the effect of mCIMT and conventional therapy in improving active range of motion (ROM) and functional use of the affected upper extremity in children with PBPP with injuries to upper and middle trunks in the hospital environment.

MATERIALS

26 patients received conventional rehabilitation program (control group) and 13 patients participated in a mCIMT program (study group). Children had a mean age 56.3 months (range 4-10 years). The mCIMT included 1 hour therapy sessions emphasizing the affected arm use for 14 consecutive days during hospitalization. Their normal arm was also constrained for 6 hour per day. All the patients were assessed at the baseline, one day, one month, and three months after completion of therapy using active ROM, active movement scale, hand dynamometer, box and blocks test.

RESULTS

The mCIMT group improved more than the control group in shoulder internal rotation, forearm supination, elbow flexion active ROMs, hand grip strength, and in upper extremity function.

CONCLUSION

mCIMT has a potential to promote functional gains for children with PBPP; this approach should be widely applied within routine clinical practice.

Dual Task Effects on Speed and Accuracy During Cognitive and Upper Limb Motor Tasks in Adults With Stroke Hemiparesis

Background

Adults with stroke need to perform cognitive-motor dual tasks during their day-to-day activities. However, they face several challenges owing to their impaired motor and cognitive functions.

Objective

This case-controlled pilot study investigates the speed and accuracy tradeoffs in adults with stroke while performing cognitive-upper limb motor dual tasks.

Methods

Ten adults with stroke and seven similar-aged controls participated in this study. The participants used a robotic arm for the single motor task and participated in either the serial sevens (S7) or the controlled oral word association test (COWAT) for single-cognitive task. For the dual task, the participants performed the motor and cognitive components simultaneously. Their speed and accuracy were measured for the motor and cognitive tasks, respectively.

Results

Two-sample t-statistics indicated that the participants with stroke exhibited a lower motor accuracy in the cross task than in the circle task. The cognitive speed and motor accuracy registered by the subjects with stroke in the dual task significantly decreased. There was a negative linear correlation between motor speed and accuracy in the subjects with stroke when the COWAT task was performed in conjunction with the cross task (ρ = -0.6922, p = 0.0388).

Conclusions

This study proves the existence of cognitive-upper limb motor interference in adults with stroke while performing dual tasks, based on the observation that their performance during one or both dual tasks deteriorated compared to that during the single task. Both speed and accuracy were complementary parameters that may indicate clinical effectiveness in motor and cognitive outcomes in individuals with stroke.

Validity and reliability of the Turkish version of the pediatric motor activity log-revised (PMAL-R) for 2-17 year old children with hemiparetic cerebral palsy

PURPOSE

The Pediatric Upper-extremity Motor Activity Log-Revised (PMAL-R) is a structured interview that measures use of the more-affected arm in daily life in children with cerebral palsy (CP). This study investigated the concurrent validity and test-retest reliability of a Turkish version of the PMAL-R.

MATERIALS AND METHODS

The PMAL-R was translated and cross-culturally adapted to Turkish and administered to parents of eighty children with hemiplegic CP between 2-17 years. Its concurrent validity was examined by correlating scores on the PMAL-R How Well and How Often scales with ABILHAND-Kids scores. Fifty parents were re-interviewed after three weeks to establish test-retest reliability.

RESULTS

PMAL-R scores were strongly correlated with ABILHAND-Kids scores (How Well scale, r = 0.78, p < 0.001; How Often scale, r = 0.59, p < 0.001). PMAL-R test-retest reliability (Intraclass correlation; How Often = 0.98, How Well = 0.99) and internal consistency (Cronbach's α; How Often = 0.96, How Well = 0.97) were high.

CONCLUSIONS

This translation of the PMAL-R has good reliability and validity for measuring everyday use of the more-affected arm in Turkish children with hemiparesis due to CP between 2-17 years. Implications for rehabilitationAn instrument that evaluates real-world arm use in Turkish children with CP.Reliability and concurrent validity of the Turkish PMAL-R is established in 2-17-year old with upper-extremity hemiparesis.Systematic replication of the clinimetric properties of the English PMAL-R is demonstrated in a wider age range than previously, 2-17 years vs. 2-8 years.Reliability and concurrent validity of the PMAL-R is shown in both children with right and left hemiparesis.

Intervention bimanual stimulates the abilities in infants with asymmetry

Abstract Introduction: The cerebral palsy and brachial plexus injury may cause asymmetry in the use of the upper limbs (UL). This condition requires early treatment to reduce the impact of the child's life; therefore, several proposed interventions aim to increase their functional independence. The Constraint-Induced Movement Therapy (CIMT) and Hand-Arm Bimanual Intensive Therapy (HABIT) have been widely considered effective interventions to improve hand function. Objective: Investigate the effects of an intervention protocol based on the CIMT and HABIT theoretical foundations in the stimulation of manual function in infants with the UL asymmetry. Methods: Five infants (6-24 months) participated in the study. To evaluate the motor function of infants we used Pediatric Motor Activity Log (PMAL-R) and Manual Function Evaluation (AMIGO), and to assess the caregiver's perception of the participation of the infant in daily tasks, we used the Pediatric Disability Assessment Inventory (PEDI). All evaluations occurred before, immediately after the intervention, and after four months for follow-up recording, and were analyzed descriptively by Jacobson- Truax method. Results: The results between evaluation and reevaluation demonstrated evolution in all aspects studied. In the PEDI self-care session, an average of 38.6 (±8.4) - 44.2 (±7.4); PEDI Mobility: 28.8 (±20.3) - 36.28 (±21.7); PEDI Social Function: 40.1 (±10.2) - 42.3 (±8.9). The PMAL-R quantity and quality results evidence a highly positive clinical significance in all infants. Conclusion: The application of the modified restriction intervention protocol resulted in reliable and clinically significant changes in all cases.

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.

Reliability and Validity of the Lower Extremity Motor Activity Log for Measuring Real-World Leg Use in Adults With Multiple Sclerosis

OBJECTIVES

To determine the test-retest reliability and validity of the Lower Extremity Motor Activity Log (LE-MAL) for assessing LE use in the community in adults with multiple sclerosis (MS).

DESIGN

Prospective analysis of measures conducted by trained examiners.

SETTING

Participants were evaluated by telephone on several measures of LE use.

PARTICIPANTS

Adults with MS (N=43).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The LE-MAL has 3 subscales (Assistance, Functional Performance, and Confidence). It was administered twice, at least 2 weeks apart. The Multiple Sclerosis Walking Scale (MSWS-12), Patient Determined Disease Steps (PDDS), and Mobility Scale were only administered during the first call.

RESULTS

The test-retest reliability of the composite and the 3 subscale LE-MAL scores were high (intraclass correlation, >0.94). The composite and subscale LE-MAL scores were strongly correlated with the MSWS-12, PDDS, and Mobility Scale scores (r=-0.56 to -0.77; P<.001).

CONCLUSION

This initial study suggests that the LE-MAL reliably and validly measures LE use in the community in adults with MS.

Unimanual Intensive Therapy with or without Unaffected Hand Containment in Children with Hemiplegia. A Randomized Controlled Pilot Study

Children with hemiplegia have lower spontaneous use and quality of movement in the affected upper limb. The modified constraint-induced movement therapy (mCIMT) is applied to improve the affected upper limb function. The objective of this study was to study the efficacy of unaffected hand containment to obtain changes in the function of the affected upper limb after applying two unimanual therapies. A randomized controlled pilot study was performed with 16 children diagnosed with congenital infantile hemiplegia, with eight children randomized in each group (average age: 5.54 years; SD: 1.55). mCIMT and unimanual therapy without containment (UTWC) were applied, with a total of 50 h distributed in five weeks (two h/per day). Two assessments were performed (pre- and post-treatment) to evaluate the affected upper limb spontaneous use, measured with the Shiners Hospital Upper Extremity Evaluation (SHUEE), and the quality of movement, measured with the Quality of Upper Extremity Skills Test (QUEST scale). The progression of the variables was different in both groups. The results are expressed in the median of the improvement percent and interquartile range (IQR). The spontaneous use analysis showed an improvement percent of 31.65 (IQR: 2.33, 110.42) in the mCIMT group with respect to 0.00 (IQR: 0.00, 0.00) in the UTWC group. The quality of movement increased in the mCIMT and UTWC groups, 24.21 (IQR: 13.44, 50.39), 1.34 (IQR: 0.00, 4.75), respectively and the greatest increase was obtained in the grasp variable for both groups. The use of unaffected hand containment in mCIMT would produce improvements in the affected upper limb functionality in children with hemiplegia (4-8 years old) compared to the same protocol without containment (UTWC).

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.

Occupational Therapy Practice Guidelines for Early Childhood: Birth-5 Years

IMPORTANCE

This Practice Guideline provides stakeholders with a condensed summary of a large number of effectiveness studies. It is a valuable tool for facilitating decision making related to occupational therapy interventions for children ages birth-5 yr.

OBJECTIVE

Early childhood (birth-5 yr) is a critical period in which the foundation of key life occupations is developed (e.g., eating, dressing, play, learning, social participation, rest and sleep, and chores). The development of cognitive, motor, social-emotional, and self-care skills is important to support these occupations. This Practice Guideline synthesizes recent systematic reviews (SRs) on these areas of development to promote decision making for and high-quality interventions with this population.

METHOD

Four SRs related to cognition, mental health, motor function, and ADLs analyzed studies published from 2010 to 2017 retrieved from six electronic databases (MEDLINE, PsycINFO, CINAHL, ERIC, OTseeker, and Cochrane).

RESULTS

A total of 196 articles were included in the SRs, which served as a guide to final clinical recommendations. Case studies describe translation and application to practice.

CONCLUSION

and Recommendations: A variety of interventions within the domain of occupational therapy were found to support the development of cognitive, social-emotional, motor, and self-care skills. Although some of these interventions are typically implemented by occupational therapy practitioners, others can be implemented by parents after training or by teams working in preschool settings. These findings should be used to inform evidence-based practice provided by occupational therapy practitioners working in various early childhood settings.

WHAT THIS ARTICLE ADDS

This Practice Guideline gives occupational therapy practitioners clear information about which interventions will be effective for specific outcomes. Better intervention choices mean better outcomes for young children and their families.

Constraint-Induced Movement Therapy for Lower Extremity Function: Describing the LE-CIMT Protocol

Constraint-induced movement therapy (CIMT) is comprised of a set of techniques shown to produce significant changes in upper extremity (UE) function following stroke and other disorders. The significant positive results obtained with the UE protocol have led to the development of LE-CIMT, an intervention to improve lower extremity (LE) function. However, some modifications of the UE protocol were needed, including omitting use of a restraint device, development of supervised motor training tasks to emphasize movement of the lower limb, and adaptation of the UE Motor Activity Log for the lower extremity. The LE-CIMT protocol includes: (1) intensive supervised training delivered for 3.5 h/d for 10 consecutive weekdays, (2) use of shaping as a strategy for motor training, (3) application of a transfer package, and (4) strongly encouraging use of the more-affected LE with improved coordination. The transfer package consists of several strategies to facilitate transfer of the improved motor skills developed during supervised treatment to everyday situations. Research to date has yielded positive results. However, the intervention protocol continues to evolve. The purpose of this article is to describe the components of the complete LE-CIMT protocol to promote further development and investigation of this approach.

Interventions Within the Scope of Occupational Therapy Practice to Improve Motor Performance for Children Ages 0–5 Years: A Systematic Review

Importance: Occupational therapy practitioners need updated information about which interventions may improve motor skills for young children.

Objective: To identify the effectiveness of occupational therapy interventions to promote motor development and prevent delay for children ages 0–5 yr.

Data Sources: Six databases (CINAHL, MEDLINE, PsycINFO, ERIC, Cochrane, and OTseeker) were searched for articles published from January 2010 to March 2017.

Study Selection and Data Collection: The search yielded 4,488 articles that were reviewed for inclusion. Fifty-six studies were entered into both evidence and risk-of-bias tables. Included studies used Level I–III designs, were within occupational therapy’s scope of practice, included participants with a mean age younger than 6 yr, and addressed motor skills.

Findings: Three intervention themes emerged: early intervention for children younger than age 3 yr, interventions for preschool children ages 3–5 yr, and interventions for children with or at risk for cerebral palsy.

Conclusions and Relevance: Occupational therapy practitioners should consider use of interventions with moderate or strong evidence as described in this review. Limitations include high risk of bias and limited evidence for several interventions.

What This Article Adds: This article provides occupational therapy practitioners with updated information on evidence-based practices for children age 5 and younger who have motor delays.

Pediatric Stroke: Unique Implications of the Immature Brain on Injury and Recovery

Pediatric stroke causes significant morbidity for children resulting in lifelong neurological disability. Although hyperacute recanalization therapies are available for pediatric patients, most patients are ineligible for these treatments. Therefore the mainstay for pediatric stroke treatment relies on rehabilitation to improve outcomes. Little is known about the ideal rehabilitation therapies for pediatric patients with stroke and the unique interplay between the developing brain and our models of stroke recovery. In this review, we first discuss the consequences of pediatric stroke. Second, we examine the scientific evidence that exists between the mechanisms of recovery and how they are different in the pediatric developing brain. Finally, we evaluate potential interventions that could improve outcomes.

Postintensive Care Syndrome in Pediatric Critical Care Survivors: Therapeutic Options to Improve Outcomes After Acquired Brain Injury

PURPOSE OF REVIEW

Children surviving the pediatric intensive care unit (PICU) with neurologic illness or injury have long-term morbidities in physical, cognitive, emotional, and social functioning termed postintensive care syndrome (PICS). In this article, we review acute and longitudinal management strategies available to combat PICS in children with acquired brain injury.

RECENT FINDINGS

Few intervention studies in this vulnerable population target PICS morbidities. Small studies show promise for both inpatient- and outpatient-initiated therapies, mainly focusing on a single domain of PICS and evaluating heterogeneous populations. While evaluating the effects of interventions on longitudinal PICS outcomes is in its infancy, longitudinal clinical programs targeting PICS are increasing. A multidisciplinary team with inpatient and outpatient presence is necessary to deliver the holistic integrated care required to address all domains of PICS in patients and families. While PICS is increasingly recognized as a chronic problem in PICU survivors with acquired brain injury, few interventions have targeted PICS morbidities. Research is needed to improve physical, cognitive, emotional, and social outcomes in survivors and their families.

Nonpharmacological rehabilitation interventions for motor and cognitive outcomes following pediatric stroke: a systematic review

The aim of this review was to evaluate the evidence for nonpharmacological rehabilitation interventions for motor and cognitive impairment following pediatric stroke. A literature search was conducted using multiple scientific databases. Studies were included if (1) the study population was > 50% pediatric (< 18 years) stroke, (2) a diagnosis of stroke was explicitly stated, (3) there were ≥ 3 pediatric stroke participants included in the study sample, and (4) motor or cognitive outcome measures were used to assess effect of treatment. Levels of evidence were assigned to each study to determine the strength of the evidence for each intervention. A total of 18 articles met inclusion criteria. Most studies (N = 14) examined rehabilitation of the upper limb, with constraint-induced movement therapy (CIMT) as the most common intervention. Overall, the evidence supports the use of CIMT, forced use therapy, repetitive transcranial magnetic stimulation, functional electrical stimulation, and robotics, but suggests no beneficial effect of transcranial direct current stimulation. Very few studies assessed interventions for the lower limb (N = 1) or cognitive impairment (N = 3).Conclusion: Effective rehabilitation approaches are important for optimizing outcomes in children who have had a stroke. Although the number of published clinical trials has increased in recent years, little evidence-based guidance exists for this clinical population. What is Known: • Pediatric stroke is a significant cause of disability in children that is often associated with long-term motor and cognitive sequelae. • There is a need to establish a knowledge base regarding available evidence-based rehabilitation therapies for this clinical population. What is New: • Most studies examining interventions for motor function focus on upper limb rehabilitation, whereas few studies have investigated interventions for improving lower limb or cognitive impairment. • An important gap exists regarding evidence-based rehabilitative treatment approaches for pediatric stroke.

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.

Phase II Randomized Controlled Trial of Constraint-Induced Movement Therapy in Multiple Sclerosis. Part 2: Effect on White Matter Integrity

BACKGROUND

Constraint-induced movement therapy (CIMT) is a method of physical rehabilitation that has demonstrated clinical efficacy in patients with chronic stroke, cerebral palsy, and multiple sclerosis (MS).

OBJECTIVE

This pilot randomized controlled trial tested whether CIMT can also induce increases in white matter integrity in patients with MS.

METHODS

Twenty adults with chronic hemiparetic MS were randomized to receive either CIMT or complementary and alternative medicine (CAM) treatment (reported in the first article of this pair). Structural white matter change was assessed by tract-based spatial statistics (TBSS); measures included fractional anisotropy (FA), mean diffusivity (MD), axial diffusivity (AD), and radial diffusivity (RD).

RESULTS

CIMT and CAM groups did not differ in pretreatment disability or expectancy to benefit. As noted in the companion paper, the motor activity log (MAL) improved more after CIMT than CAM ( P < .001); the within-group effect size for CIMT was 3.7 (large d' = 0.57), while for CAM it was just 0.7. Improvements in white matter integrity followed CIMT and were observed in the contralateral corpus callosum (FA, P < .05), ipsilateral superior occipital gyrus (AD, P < .05), ipsilateral superior temporal gyrus (FA, P < .05), and contralateral corticospinal tract (MD and RD, P < .05).

CONCLUSION

CIMT produced a very large improvement in real-world limb use and induced white matter changes in patients with hemiparetic MS when compared with CAM. The findings suggest in preliminary fashion that the adverse changes in white matter integrity induced by MS might be reversed by CIMT.

CLINICAL TRIAL REGISTRATION NUMBER

ClinicalTrials.gov (NCT01081275).

Children with Hemiparesis Arm and Movement Project (CHAMP): protocol for a multisite comparative efficacy trial of paediatric constraint-induced movement therapy (CIMT) testing effects of dosage and type of constraint for children with hemiparetic cerebral palsy

INTRODUCTION

The Children with Hemiparesis Arm and Movement Project (CHAMP) addresses two pressing issues concerning paediatric constraint-induced movement therapy (CIMT): effects of two dosages and two types of constraint on functional outcomes. Systematic reviews conclude that CIMT is one of the most efficacious treatments, but wide variations in treatment protocols, outcome measures and patient characteristics have prevented conclusions about potential effects of dosage levels and constraint methods.

METHODS AND ANALYSIS

CHAMP is a multisite comparative efficacy randomised controlled trial of 135 children (2-8 years) with hemiparetic cerebral palsy. The 2×2 factorial design tests two dosage levels-60 hours (3.0 hours/day, 5 days/week × 4 weeks) and 30 hours (2.5 hours/day, 3 days/week × 4 weeks) and two constraint conditions-full-arm, full-time cast and part-time splint, plus usual and customary (UCT) controls, yielding five groups: (1) 60 hours CIMT+full-time cast, (2) 60 hours CIMT+part-time splint, (3) 30 hours CIMT+full-time cast, (4) 30 hours CIMT+part-time splint and (5) UCT. Trained therapists deliver the standardised ACQUIREc protocol for CIMT. Blinded assessments at baseline, end of treatment, and 6 and 12 months post treatment include the Assisting Hand Assessment, and subscales from the Peabody Developmental Motor Scales-2 and modified Quality of Upper Extremity Skills Test. Parents complete the Pediatric Motor Activity Log and Pediatric Evaluation of Disability Inventory. A new Fidelity of Implementation Rehabilitation Measure monitors treatment delivery. Data analyses involve repeated-measures multivariate analysis of co-variance controlling for selected baseline variables.

ETHICS AND DISSEMINATION

Ethics boards at site universities approved the study protocol. To promote equipoise, parents of UCT controls are offered ACQUIREc after 6 months. A Data Safety and Monitoring Committee reviews results regularly, including measures of child and family stress. We will disseminate CHAMP results via peer-reviewed publications and presentations to professional and advocacy organisations.

TRIAL REGISTRATION NUMBER

NCT01895660; Pre-results.

Does Dosage Matter? A Pilot Study of Hand-Arm Bimanual Intensive Training (HABIT) Dose and Dosing Schedule in Children with Unilateral Cerebral Palsy

AIM

We compared the efficacy of hand-arm bimanual intensive training (HABIT) in two doses (90 vs. 45 hours) and two schedules of the same dose (90 vs. 2 × 45 hours) on hand and daily functioning.

METHOD

Eighteen children with unilateral cerebral palsy were randomized to receive 6 hours of daily training over 3 weeks, totaling 90 hours (Group 90, n = 9) or receive 6 hours of daily training over 1.5 weeks, totaling 45 hours (Group 2 × 45, n = 9). After 6 months, Group 2 × 45 received an additional 45 hours. Hand (Jebsen-Taylor Test of Hand Function, Assisting Hand Assessment) and daily functioning tests (Canadian Occupational Performance Measure, Pediatric Evaluation of Disability Inventory) were administered before, immediately after, and 6 months after interventions.

RESULTS

Both groups demonstrated significant improvements in hand and daily functioning after 90 hours (Group 90) or the first 45 hours (Group 2 × 45), without differences between groups. However, more children from Group 90 obtained smallest detectable differences in the Assisting Hand Assessment. The addition of the second bout of 45 hours (Group 2 × 45) did not lead to further improvements.

CONCLUSIONS

As this study was powered to test for large differences between groups, future investigations on larger samples will be needed to compare differences at the two dosage levels.

Upper extremity motor training of a subject with initially motor complete chronic high tetraplegia using constraint-induced biofeedback therapy

Introduction

The purpose of this case study was to determine if a subject with chronic high tetraplegia (C3 AIS A) could learn to use an initially paralyzed upper extremity on the basis of training procedures alone.

Case presentation

Initially, an AIS examination revealed no purposive movement below the neck other than minimal shoulder movement. Training was carried out weekly over 39 months. Training began based on electromyographic biofeedback; the electrical activity of a muscle (biceps or triceps) was displayed visually on a computer monitor and the subject was encouraged to progressively increase the magnitude of the response in small increments on a trial-by-trial basis (i.e., shaping). When small, overt movements began to appear; these were, in turn, shaped so that their excursion progressively increased. Training then progressed to enable lifting the arm with the aid of the counterweight of a Swedish Help Arm. Mean movement excursions in the best session were: internal rotation 52.5 cm; external rotation 26.9 cm; shoulder extension 22.1 cm; shoulder flexion 15.2 cm; pronation/supination 120°; extension of index finger (D2) 2.5 cm. Movements were initially saltatory, becoming smoother over time. With the Swedish Help Arm, the subject was able to lift her hand an average of 24.3 cm in the best session with 0.7 kg counterweight acting at the wrist (1.9 J of work).

Discussion

Results suggest in preliminary fashion the effectiveness of this approach for improving upper extremity function after motor complete high tetraplegia. Thus, future studies are warranted. Possible mechanisms are discussed.

The Effects of Constraint-Induced Movement Therapy on Functions of Cerebral Palsy Children

OBJECTIVES

Constraint-Induced Movement Therapy (CIMT) is an intervention method that can enhance cerebral palsy (CP) children's hand function. CP is a pervasive and common disorder which affects many aspects of a child life. Hemiplegic CP affects one side of a child's hand and has great effect on child's independence. We investigated the CIMT's studies conducted in Iran, and indicated the effectiveness of CIMT on duration and children age?

MATERIALS & METHODS

This systematic review was conducted using the electronic databases such as Medline PubMed, CINAHL, etc. performed from 1990 to 2016. Iranian and foreigner famous journals in the fields of pediatrics such as Iranian Journal of Pediatrics (IJP), Iranian Rehabilitation Journal (IRJ) and Google scholar with some specific keywords such as CP, CIMT, and occupational therapy were searched.

RESULTS

Overall, 43 articles were found, from which, 28 articles were removed because of lack of relevancy. Ten article were omitted because of duplication and exclusion criteria, so finally 15 articles were included.

CONCLUSION

CIMT is effective compared to no intervention but there are some inconsistencies regarding some parts of CIMT effectiveness such as its effectiveness on muscle tone and protective extension.

At-home and in-group delivery of constraint-induced movement therapy in children with hemiparesis: A systematic review

BACKGROUND

Constraint-induced movement therapy (CIMT) is increasingly recognized as an effective therapy for children with hemiparesis. However, the effectiveness of CIMT outside the standard rehabilitation protocol in clinical settings is less known. The aim of this systematic review was to investigate the effectiveness of CIMT conducted at home or in a group.

METHODS

We searched CINAHL, PubMed and ScienceDirect in August 2017 to select articles of studies investigating the impact of CIMT performed at home and in a group on affected upper-limb ability, occupational performance, and quality of life of children. Quality was evaluated with the PEDro scale.

RESULTS

Among 374 reports of studies, 30 met the criteria; 15 examined CIMT at home and 15 in a group. CIMT with the 2 delivery models, at home or in a group, had a positive effect on the affected upper-limb ability and occupational performance. The quality of evidence was high for both these outcomes. However, the evidence was weaker and the results too limited to conclude on the impact on quality of life. The data also suggested that the glove may not be the best type of constraint.

CONCLUSIONS

CIMT performed at home or in a group may be a promising intervention for rehabilitation for children with hemiparesis, but more studies on the impact on quality of life are warranted.

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

AIM

To examine the efficacy of caregiver-directed, home-based intensive bimanual training in children with unilateral spastic cerebral palsy (USCP) using a randomized control trial.

METHOD

Twenty-four children (ages 2y 6mo-10y 1mo; 10 males, 14 females) performed home-based activities directed by a caregiver for 2 hours per day, 5 days per week, for 9 weeks (total=90h). Cohorts of children were age-matched into groups and randomized to receive home-based hand-arm bimanual intensive therapy (H-HABIT; n=12) or lower-limb functional intensive training (LIFT-control; n=12). Caregivers were trained before the intervention and supervised remotely via telerehabilitation. Dexterity and bimanual hand function were assessed using the Box and Blocks test (BBT) and the Assisting Hand Assessment (AHA) respectively. Caregiver perception of functional goals was measured using the Canadian Occupational Performance Measure (COPM).

RESULTS

H-HABIT showed greater improvement on the BBT compared to LIFT-control and no improvement on the AHA. H-HABIT demonstrated significant improvement in COPM-Performance compared to LIFT-control and both groups showed equal improvement in COPM-Satisfaction.

INTERPRETATION

H-HABIT improved dexterity and performance of functional goals, but not bimanual performance, in children with USCP compared to a control group receiving intervention of equal intensity/duration that also controlled for increased caregiver attention. Home-based models provide a valuable, family-centered approach to achieve increased treatment intensity.

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.

A natural user interface to integrate citizen science and physical exercise

Citizen science enables volunteers to contribute to scientific projects, where massive data collection and analysis are often required. Volunteers participate in citizen science activities online from their homes or in the field and are motivated by both intrinsic and extrinsic factors. Here, we investigated the possibility of integrating citizen science tasks within physical exercises envisaged as part of a potential rehabilitation therapy session. The citizen science activity entailed environmental mapping of a polluted body of water using a miniature instrumented boat, which was remotely controlled by the participants through their physical gesture tracked by a low-cost markerless motion capture system. Our findings demonstrate that the natural user interface offers an engaging and effective means for performing environmental monitoring tasks. At the same time, the citizen science activity increases the commitment of the participants, leading to a better motion performance, quantified through an array of objective indices. The study constitutes a first and necessary step toward rehabilitative treatments of the upper limb through citizen science and low-cost markerless optical systems.

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.

Unimanual versus bimanual therapy in children with unilateral cerebral palsy: Same, same, but different

BACKGROUND

There is high-level evidence supporting constraint-induced movement therapy (CIMT) and bimanual therapy for children with unilateral cerebral palsy. Evidence-based intervention includes time-limited, goal-directed, skills-based, intensive blocks of practice based on motor learning theory.

AIM AND METHODS

Using supporting literature and clinical insight, we provide a theoretical rationale to highlight previously unreported differences between CIMT and bimanual therapy.

DISCUSSION

The current emphasis on total dosage of practice for achieving positive outcomes fails to recognise the influence of other critical concepts within motor learning. Limitations exist in the application of motor learning principles using CIMT due to its unimanual nature. CIMT is effective for development of unimanual actions brought about by implicit learning, however it is difficult to target explicit learning that is required for learning how to use two hands together. Using bimanual therapy, object properties can be adapted to trigger goal-related perceptual and cognitive processes required for children to learn to recognise when two hands are required for task completion.

CONCLUSION

CIMT and bimanual should be viewed as complementary. CIMT could be used to target unimanual actions. Once these actions are established, bimanual therapy could be used for children to learn how to use these actions for bimanual skill development.

Speech production gains following constraint-induced movement therapy in children with hemiparesis

PURPOSE

The purpose of this study was to investigate changes in speech skills of children who have hemiparesis and speech impairment after participation in a constraint-induced movement therapy (CIMT) program. While case studies have reported collateral speech gains following CIMT, the effect of CIMT on speech production has not previously been directly investigated to the knowledge of these investigators.

METHODS

Eighteen children with hemiparesis and co-occurring speech impairment participated in a 21-day clinical CIMT program. The Goldman-Fristoe Test of Articulation-2 (GFTA-2) was used to assess children's articulation of speech sounds before and after the intervention. Changes in percent of consonants correct (PCC) on the GFTA-2 were used as a measure of change in speech production.

RESULTS

Children made significant gains in PCC following CIMT. Gains were similar in children with left and right-sided hemiparesis, and across age groups.

CONCLUSION

This study reports significant collateral gains in speech production following CIMT and suggests benefits of CIMT may also spread to speech motor domains.

Do we really know what they were testing? Incomplete reporting of interventions in randomised trials of upper limb therapies in unilateral cerebral palsy

BACKGROUND

Incomplete reporting of components of interventions limits uptake of evidence into clinical practice.

AIMS

To evaluate the completeness of reporting of research and control interventions in randomised trials of upper limb therapies for children with unilateral cerebral palsy.

METHODS AND PROCEDURES

Sixty randomized trials were included, encompassing 60 research and 68 control interventions. Using the 12-item Template for Intervention Description and Replication (TIDieR) checklist, two reviewers independently rated intervention and control descriptions.

OUTCOMES AND RESULTS

When using 50% of studies as the benchmark, five of the 12 TIDieR items for the research intervention, eight of the 12 items for the control intervention and 11 of 12 items for "usual care" interventions were inadequately reported. Procedures used to deliver the research intervention were adequately reported for 63% of studies. Materials were used in 94% of research interventions, yet only 27% provided details to access/replicate materials. Training materials for interventionists were used in 38% of trials, 10 (17%) had procedure manuals, yet only 3 reported details to access materials. The location where the research intervention was provided was detailed in 65% of studies. Reporting of all items was poorer for the control intervention.

CONCLUSIONS

No study adequately reported all elements on the TIDieR checklist. Details crucial for replication of interventions and interpretation of results were missing. Authors, reviewers, and editors all have a responsibility to improve the quality of intervention reporting in published trials. The TIDieR guide is a potential solution, helping to structure accounts of interventions.

Joint-Specific Play Controller for Upper Extremity Therapy: Feasibility Study in Children With Wrist Impairment

BACKGROUND

Challenges with any therapeutic program for children include the level of the child's engagement or adherence. Capitalizing on one of the primary learning avenues of children, play, the approach described in this article is to develop therapeutic toy and game controllers that require specific and repetitive joint movements to trigger toy/game activation.

OBJECTIVE

The goal of this study was to evaluate a specially designed wrist flexion and extension play controller in a cohort of children with upper extremity motor impairments (UEMIs). The aim was to understand the relationship among controller play activity, measures of wrist and forearm range of motion (ROM) and spasticity, and ratings of fun and difficulty.

DESIGN

This was a cross-sectional study of 21 children (12 male, 9 female; 4-12 years of age) with UEMIs.

METHODS

All children participated in a structured in-clinic play session during which measurements of spasticity and ROM were collected. The children were fitted with the controller and played with 2 toys and 2 computer games for 5 minutes each. Wrist flexion and extension motion during play was recorded and analyzed. In addition, children rated the fun and difficulty of play.

RESULTS

Flexion and extension goal movements were repeatedly achieved by children during the play session at an average frequency of 0.27 Hz. At this frequency, 15 minutes of play per day would result in approximately 1,700 targeted joint motions per week. Play activity was associated with ROM measures, specifically supination, but toy perception ratings of enjoyment and difficulty were not correlated with clinical measures.

LIMITATIONS

The reported results may not be representative of children with more severe UEMIs.

CONCLUSIONS

These outcomes indicate that the therapeutic controllers elicited repetitive goal movements and were adaptable, enjoyable, and challenging for children of varying ages and UEMIs.

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].

Home-based movement therapy in neonatal brachial plexus palsy: A case study

STUDY DESIGN

Case report.

INTRODUCTION

The value of movement-based therapy in peripheral nerve injury conditions such as neonatal brachial plexus palsy (NBPP) is unclear.

PURPOSE OF THE STUDY

To determine the effectiveness of a home-based movement therapy program in a 17 year old female patient with a right NBPP pan-plexopathy.

METHODS

Home training consisted of arm reaching and object manipulation tasks using devices which recorded performance. Training occurred for 1 h/day, 5 days/week for 6 weeks with periodic webcam supervision. Pre- and post clinical, functional and kinematic assessments were performed in a laboratory setting.

RESULTS

Following training, shoulder flexion and elbow extension active range of motion increased by 13° and 9°, respectively, and functional ability also improved. Reach movement duration decreased significantly with a concomitant improvement in movement coordination.

CONCLUSIONS

These results demonstrate that movement therapy has the potential to improve motor function in NBPP years after the initial insult.

LEVEL OF EVIDENCE

4.

Younger Children with Cerebral Palsy Respond Better Than Older Ones to Therapist-Based Constraint-Induced Therapy at Home on Functional Outcomes and Motor Control

AIMS

To examine the differences in efficacy of home-based constraint-induced therapy (CIT) on functional outcomes and motor control in two age groups of children with cerebral palsy (CP).

METHODS

Twenty-three children with spastic unilateral CP receiving 4-week home-based CIT by a therapist were divided into younger (6-8 years; n = 11) and older (9-12 years; n = 12) groups. The home-based CIT involved intensive functional training of the more affected upper-limb while restraining the less affected upper-limb. The outcome measures were Peabody Developmental Motor Scale-2nd edition (PDMS-2) that was being used in a modified way, Functional Independence Measure for Children (WeeFIM), and reach-to-grasp kinematic parameters, including reaction time (RT), normalized movement time (MT), normalized movement units (MUs), peak velocity (PV), and maximum grip aperture (MGA). The outcome measures were assessed at baseline, 4-weeks (post-treatment), 3- and 6-months (follow-up).

RESULTS

The younger group showed greater changes in visual motor integration skills and RT at all post-tests after intervention than the older group. Groups had comparable changes on any other measures.

CONCLUSIONS

Younger children with CP responded better to home-based CIT on some areas of upper-limb functions and reach-to-grasp motor control strategies than older children.

Early childhood constraint therapy for sensory/motor impairment in cerebral palsy: a randomised clinical trial protocol

INTRODUCTION

Cerebral palsy (CP) is the most common physical disability in childhood. It is a disorder resulting from sensory and motor impairments due to perinatal brain injury, with lifetime consequences that range from poor adaptive and social function to communication and emotional disturbances. Infants with CP have a fundamental disadvantage in recovering motor function: they do not receive accurate sensory feedback from their movements, leading to developmental disregard. Constraint-induced movement therapy (CIMT) is one of the few effective neurorehabilitative strategies shown to improve upper extremity motor function in adults and older children with CP, potentially overcoming developmental disregard.

METHODS AND ANALYSIS

This study is a randomised controlled trial of children 12-24 months corrected age studying the effectiveness of CIMT combined with motor and sensory-motor interventions. The study population will comprise 72 children with CP and 144 typically developing children for a total of N=216 children. All children with CP, regardless of group allocation will continue with their standard of care occupational and physical therapy throughout the study. The research material collected will be in the form of data from high-density array event-related potential scan, standardised assessment scores and motion analysis scores.

ETHICS AND DISSEMINATION

The study protocol was approved by the Institutional Review Board. The findings of the trial will be disseminated through peer-reviewed journals and scientific conferences.

TRIAL REGISTRATION NUMBER

NCT02567630.

Intensive training of motor function and functional skills among young children with cerebral palsy: a systematic review and meta-analysis

BACKGROUND

Young children with cerebral palsy (CP) receive a variety of interventions to prevent and/or reduce activity limitations and participation restrictions. Some of these interventions are intensive, and it is a challenge to identify the optimal intensity. Therefore, the objective of this systematic review was to describe and categorise intensive motor function and functional skills training among young children with CP, to summarise the effects of these interventions, and to examine characteristics that may contribute to explain the variations in these effects.

METHODS

Ten databases were searched for controlled studies that included young children (mean age less than seven years old) with CP and assessments of the effects of intensive motor function and functional skills training. The studies were critically assessed by the Risk of bias tool (RoB) and categorised for intensity and contexts of interventions. Standardised mean difference were computed for outcomes, and summarised descriptively or in meta-analyses.

RESULTS

Thirty-eight studies were included. Studies that targeted gross motor function were fewer, older and with lower frequency of training sessions over longer training periods than studies that targeted hand function. Home training was most common in studies on hand function and functional skills, and often increased the amount of training. The effects of constraint induced movement therapy (CIMT) on hand function and functional skills were summarised in six meta-analyses, which supported the existing evidence of CIMT. In a majority of the included studies, equal improvements were identified between intensive intervention and conventional therapy or between two different intensive interventions.

CONCLUSIONS

Different types of training, different intensities and different contexts between studies that targeted gross and fine motor function might explain some of the observed effect variations. Home training may increase the amount of training, but are less controllable. These factors may have contributed to the observed variations in the effectiveness of CIMT. Rigorous research on intensive gross motor training is needed.

SYSTEMATIC REVIEW REGISTRATION NUMBER

CRD42013004023.

Implications of CI therapy for visual deficit training

We address here the question of whether the techniques of Constraint Induced (CI) therapy, a family of treatments that has been employed in the rehabilitation of movement and language after brain damage might apply to the rehabilitation of such visual deficits as unilateral spatial neglect and visual field deficits. CI therapy has been used successfully for the upper and lower extremities after chronic stroke, cerebral palsy (CP), multiple sclerosis (MS), other central nervous system (CNS) degenerative conditions, resection of motor areas of the brain, focal hand dystonia, and aphasia. Treatments making use of similar methods have proven efficacious for amblyopia. The CI therapy approach consists of four major components: intensive training, training by shaping, a "transfer package" to facilitate the transfer of gains from the treatment setting to everyday activities, and strong discouragement of compensatory strategies. CI therapy is said to be effective because it overcomes learned nonuse, a learned inhibition of movement that follows injury to the CNS. In addition, CI therapy produces substantial increases in the gray matter of motor areas on both sides of the brain. We propose here that these mechanisms are examples of more general processes: learned nonuse being considered parallel to sensory nonuse following damage to sensory areas of the brain, with both having in common diminished neural connections (DNCs) in the nervous system as an underlying mechanism. CI therapy would achieve its therapeutic effect by strengthening the DNCs. Use-dependent cortical reorganization is considered to be an example of the more general neuroplastic mechanism of brain structure repurposing. If the mechanisms involved in these broader categories are involved in each of the deficits being considered, then it may be the principles underlying efficacious treatment in each case may be similar. The lessons learned during CI therapy research might then prove useful for the treatment of visual deficits.

Upper limb function in everyday life of children with cerebral palsy: description and review of parent report measures

PURPOSE

To determine the role, in clinical practice and measurement of outcomes of upper limb interventions, of cerebral palsy-specific self- or parent-report measures of upper limb performance in everyday activities.

METHOD

Search of databases and handsearching for information on test development procedures, psychometric properties or relevant studies to inform study objectives.

RESULTS

Children's Hand-use Experience Questionnaire holds most promise for guiding treatment planning but requires more psychometric evidence. ABILHAND-Kids has the strongest evidence for reliability, validity and sensitivity to change; evaluates impact of intervention on bimanual performance and can be used for children with unilateral or bilateral cerebral palsy. The original and revised versions of the Pediatric Motor Activity Log (PMAL) evaluate unilateral rather than bimanual upper limb performance. Neither ABILHAND-Kids nor PMAL offer information to assist treatment planning. PMAL-R is the only measure for the 2-5-year age group. No measure was adequate for children younger than 2 years to ascertain parents' perception of upper limb function in everyday activities.

CONCLUSIONS

Understanding upper limb performance in everyday life, as perceived by children with cerebral palsy and their families, informs a comprehensive assessment and acknowledges the importance of the perspectives of child and family. Implications for Rehabilitation Cerebral palsy-specific self- or parent-report measures of upper limb performance in everyday life complement observational assessments in understanding upper limb performance CHEQ provides clinical information, ABILHAND-Kids is validated for children with unilateral and bilateral cerebral palsy and possesses the most robust psychometric properties, Revised PMAL measures unilateral upper limb use. No adequate measure for children under 2 years exists.

Effectiveness of constraint-induced movement therapy on upper-extremity function in children with cerebral palsy: a systematic review and meta-analysis of randomized controlled trials

Objective:

To systematically examine the research literature on the effectiveness of constraint-induced movement therapy on improving arm function in children with cerebral palsy, and to assess the association between the study effect size and the characteristics of the patients and intervention protocol.

Data sources:

A systematic literature search was conducted in PubMed, PsycINFO, Cochrane, CINAHL, Web of Science, and TRIP Database up to May 2014.

Review methods:

Studies employing randomized controlled trial design, children with cerebral palsy, comparing constraint-induced movement therapy with another intervention with a focus on arm function, and upper-extremity measures were included in this review. Methodological quality was evaluated using the Physiotherapy Evidence-based Database (PEDro) scale.

Results:

The literature search resulted in 27 randomized controlled trial studies with good methodological quality that compared constraint-induced movement therapy with other intervention therapy. Overall, constraint-induced movement therapy provided a medium beneficial effect ( d = 0.546; p < 0.001) when compared with conventional therapy. For the subgroup analyses, presence of a dose-equivalent comparison group, intervention location, and time of follow-up were significant factors. Studies examining constraint-induced movement therapy effect without a dose-equivalent comparison group showed a large effect in children with cerebral palsy, but studies with a dose-equivalent group only showed a small effect. Children who received home-based constraint-induced movement therapy had a better improvement in arm function than those who received constraint-induced movement therapy elsewhere.

Conclusion:

The research literature supports constraint-induced movement therapy as an effective intervention to improve arm function in children with cerebral palsy.

The state of the evidence for intensive upper limb therapy approaches for children with unilateral cerebral palsy

Children with unilateral cerebral palsy experience difficulties with unimanual and bimanual upper limb function, impacting independence in daily life. Targeted upper limb therapies such as constraint-induced movement therapy, bimanual training, and combined approaches have emerged in the last decade. This article reviews the scientific rationale underpinning these treatments and current evidence to improve upper limb outcomes and goal attainment. Intensive models of therapy achieved modest to strong effects to improve upper limb function compared to usual care. Dose-matched comparisons of bimanual and unimanual training demonstrated similar gains in upper limb outcomes. The optimum timing, dose and impact of repeat episodes of intensive upper limb therapies require further investigation. Characteristics of children who achieve clinically meaningful outcomes remain unclear. Key components of intervention include collaborative goal setting with families and intensive repetitive, incrementally challenging, task practice. Choice of treatment approach should be governed by child/family goals and preferences, individual, and contextual factors.

Efficacy and acceptability of reduced intensity constraint-induced movement therapy for children aged 9-11 years with hemiplegic cerebral palsy: a pilot study

OBJECTIVE

Assess efficacy and acceptability of reduced intensity constraint-induced movement therapy (CIMT) in children with cerebral palsy (CP).

METHODS

Single-subject research design and semi-structured interviews. Children (9-11y) with hemiplegia underwent five baseline assessments followed by two weeks CIMT. Six further assessments were performed during treatment and follow-up phases. The primary outcome was the Melbourne Assessment of Unilateral Upper Limb Function (MUUL). Quantitative data were analysed using standard single-subject methods and qualitative data by thematic analysis.

RESULTS

Four of the seven participants demonstrated statistically significant improvements in MUUL (3-11%, p < .05). Two participants achieved significant improvements in active range of motion but strength and tone remained largely unchanged. Qualitative interviews highlighted limitations of the restraint, importance of family involvement, and coordination of treatment with education.

CONCLUSIONS

Reduced intensity CIMT may be effective for some children in this population; however it is not suitable for all children with hemiplegia.

The functional significance of cortical reorganization and the parallel development of CI therapy

For the nineteenth and the better part of the twentieth centuries two correlative beliefs were strongly held by almost all neuroscientists and practitioners in the field of neurorehabilitation. The first was that after maturity the adult CNS was hardwired and fixed, and second that in the chronic phase after CNS injury no substantial recovery of function could take place no matter what intervention was employed. However, in the last part of the twentieth century evidence began to accumulate that neither belief was correct. First, in the 1960s and 1970s, in research with primates given a surgical abolition of somatic sensation from a single forelimb, which rendered the extremity useless, it was found that behavioral techniques could convert the limb into an extremity that could be used extensively. Beginning in the late 1980s, the techniques employed with deafferented monkeys were translated into a rehabilitation treatment, termed Constraint Induced Movement therapy or CI therapy, for substantially improving the motor deficit in humans of the upper and lower extremities in the chronic phase after stroke. CI therapy has been applied successfully to other types of damage to the CNS such as traumatic brain injury, cerebral palsy, multiple sclerosis, and spinal cord injury, and it has also been used to improve function in focal hand dystonia and for aphasia after stroke. As this work was proceeding, it was being shown during the 1980s and 1990s that sustained modulation of afferent input could alter the structure of the CNS and that this topographic reorganization could have relevance to the function of the individual. The alteration in these once fundamental beliefs has given rise to important recent developments in neuroscience and neurorehabilitation and holds promise for further increasing our understanding of CNS function and extending the boundaries of what is possible in neurorehabilitation.