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

The Screening Hand Assessment for Infants for detecting the risk of unilateral cerebral palsy: Item selection and development

AIM

To develop a screening tool (the screening Hand Assessment for Infants [s-HAI]) for infants aged from 3.5 months that can identify a high risk of developing unilateral cerebral palsy (CP) based on a selection of items from the HAI.

METHOD

Receiver operating characteristic curve analysis was performed on previously collected HAI assessments from 212 infants (104 females, 108 males) aged from 3.5 to 8.5 months, to select items suitable for screening. The area under the curve (AUC), sensitivity, specificity, and cut-off values were derived for the suggested item combination. The clinical outcome (unilateral CP yes or no) at 24 months or older served as the external criterion.

RESULTS

About half of the infants developed unilateral CP. The AUC across the items ranged from 0.63 to 0.80, and from 0.85 to 0.87 for different item combinations. Sensitivity for the selected 6-item set was 91% for 8 points or less and 88% for 7 points or less on the contralesional score of each hand, while specificity was 60% and 73% respectively.

INTERPRETATION

The s-HAI, designed from six HAI items, has the potential to be used to screen infants at risk of unilateral CP from 3.5 months of age. It is easy to administer, time-efficient, and can be used in different settings. Its measurement properties and feasibility need to be tested in a new data set.

Outcomes of a Parent-Delivered Baby-mCIMT Model for Infants at High Risk of Unilateral Cerebral Palsy Using Remote Coaching in Telerehabilitation

There is growing evidence of the positive effects of constraint-induced movement therapy (CIMT) for infants at high risk of unilateral cerebral palsy (UCP) when provided by parents with in-person coaching/supervision from occupational therapists during home visits. The aim of this study is to investigate whether Baby-mCIMT (modifiedCIMT) can be as effective if parents are coached/supervised remotely. In this case-control study, we recruited 20 infants and re-used 18 controls, 4-8-month-old infants in both groups at high risk of UCP. The same protocol regarding inclusion criteria, data collection, and training volume was used in both groups. The training was conducted for two 6-week periods, separated by a 6-week break, consisting of daily 30 min sessions conducted by parents, supported by therapist coaching once a week. The primary outcome was measured using the Hand Assessment for Infants (HAI). There was no difference in the change of HAI units (p = 0.803) or that of the affected-hand raw score (p = 0.942) between the two groups. The remote coaching method was well received by parents. In conclusion, this demonstrates that remote coaching/supervision is as effective as the in-person approach, requiring less time and effort for both families and healthcare providers.

Factors influencing caregiver buy-in to early intervention physical therapy

OBJECTIVE

The family-centered care framework of Early Intervention (EI) has shifted the focus toward caregiver engagement, but the underlying processes that build this are unknown. The aims of this study were 1) to describe the process of caregiver engagement in therapy and (2) to identify factors perceived to influence caregiver buy-in, confidence, and engagement in EI.

METHODS

This preliminary descriptive study utilized quantitative questionnaires and qualitative semi-structured interviews of EI participants (23 caregivers and four physical therapists). Interviews were transcribed and theme coded until saturation was achieved and a concept map was developed.

RESULTS

All caregivers believed that their children benefited from EI, that they were empowered and confident in caring for their children, and their quality of life improved based on the quantitative data. The qualitative data revealed that building a rapport and therapeutic relationship is the foundation to developing buy-in. Reciprocal communication is critical to the relationship and the buy-in. Caregiver knowledge and awareness of progress foster caregiver buy-in and confidence once the relationship is established.

CONCLUSION

Improved understanding of the factors influencing the development of buy-in will provide a framework for the clinician to enhance caregiver buy-in. Enhanced buy-in may promote parental engagement and improved outcomes for the child and family.

Early Intensive Bimanual Stimulation Program (BB-Bim) for Infants at Risk of Unilateral Cerebral Palsy: A Randomized, Multiple-Baseline, Single-Case Study

IMPORTANCE

Clinical practice guidelines for infants at high risk of cerebral palsy (CP) emphasize the importance of very early and intensive intervention.

OBJECTIVE

To determine the feasibility of a new, home-based, early intensive bimanual stimulation program (BB-Bim) and its impact on hand function in infants at risk of unilateral CP.

DESIGN

Single case experimental design, multiple baseline across subjects, lasting from 12 to 15 wk, including a 4- to 7-wk randomized baseline, followed by 8 wk of BB-Bim.

SETTING

Home.

PARTICIPANTS

Infants (ages 3-12 mo) with suspected unilateral CP, whose parents agreed to participate in the stimulation program.

INTERVENTION

Parent-provided bimanual stimulation 20 min/day, 6×/wk, with weekly occupational therapist coaching visits.

MEASURES

Weekly repeated measures were the Hand Assessment in Infants (HAI) and Goal Attainment Scaling (GAS). Feasibility and relevance were assessed with a logbook and a parental report, including 10 continuous 0-10 scaled questions.

RESULTS

Six infants were included (2 with left and 4 with right brain lesions). Parents provided a mean 3.4 to 6.2 stimulation sessions/wk. Feasibility and relevance were highly rated (Ms = 8.2-9.6, SDs = 0.2-1.3). Stimulation significantly improved HAI bimanual and total scores for all infants, with no impact on HAI unilateral scores. GAS scores improved with stimulation (significant for 3 infants).

CONCLUSIONS AND RELEVANCE

BB-Bim was feasible and tended to improve bimanual function in infants at risk of unilateral CP. What This Article Adds: Parent-provided daily bimanual stimulation at home is feasible when parents are coached weekly by an occupational therapist. Bimanual stimulation seems to improve functional interactions between the hands among infants at high risk of unilateral CP.

Interventions for Motor Disorders in High-Risk Neonates

Early childhood affords rapid brain development and advancement of the motor system. In High-Risk Infant Follow-Up programs, watchful waiting and monitoring of infants at high risk is shifting toward active surveillance and early diagnosis, followed by immediate targeted very early interventions. Infants with delayed motor skills benefit from developmental care, NIDCAP, and generic or specific motor training. Infants with cerebral palsy benefit from enrichment, targeted skills interventions, and task-specific motor training at high intensity. Infants with degenerative conditions benefit from enrichment but also require accommodations such as powered mobility.

Evaluation of the Training in Early Detection for Early Intervention (TEDEI) e-learning course using Kirkpatrick's method

BACKGROUND

Early intervention in cerebral palsy could improve motor outcome but is only possible following early identification of those affected. There is a need for training of healthcare professionals (HCPs) in early detection of atypical motor development. We developed a video-based e-learning course - Training in Early Detection for Early Intervention (TEDEI) - to address this need. We evaluated whether participation in the course improved knowledge and changed behaviour of HCPs.

METHODS

Participants were 332 HCPs (38% physiotherapists, 35.8% occupational therapists), predominantly UK-based (83.7%). Analysis of training effects used mixed methods and followed Kirkpatrick's model, first assessing "Reaction" through a feedback questionnaire involving Likert scale and free text responses (n = 141). "Learning" was assessed through multiple choice questions (MCQs): all 332 HCPs completed a pre-course quiz of 6 MCQs followed by the course, then a 16 item post-course quiz including the 6 pre-course questions. "Behaviour" was assessed through in-depth qualitative interviewing of 23 participants.

RESULTS

"Reaction": TEDEI was found to be effective, engaging and well structured. "Learning": Scores improved significantly between the pre-course and post-course quiz, median improvement 1/6 (z = 5.30, p < 0.001). HCPs also reported a perceived improvement in their knowledge, confidence and ability. "Behaviour": HCPs could see how TEDEI would improve their clinical practice through having an assessment framework, ways of working better with parents, and developing observational skills useful for tele-health assessments.

CONCLUSION

Our brief e-learning course on early detection for early intervention was viewed positively, improved knowledge and showed potential for positive changes in practice. Kirkpatrick's model provided a useful framework for undertaking this evaluation.

Neuromotor Rehabilitation Interventions After Pediatric Stroke: A Focused Review

Pediatric stroke is a condition that often results in life-long motor, cognitive, or sensory deficits for children. The purpose of this focused review is to compile the most recent literature on pediatric stroke neuromotor interventions and summarize evidence for use by rehabilitation providers and researchers. Terms including stroke, pediatric, and neuromotor were searched with appropriate MeSH terms. Information was collected regarding interventions conducted and outcome measures used for each article. Interventions and outcome measures were organized based on ICF components (Body Structure and Function, Activity, Participation, and Environmental Factors). 16 articles were included after full-text screens. From these 16 articles, a large majority of them included some form of neuromodulation as a part of intervention. Results identified a potentially problematic gap between domains addressed by interventions and measured by outcomes, with a need to include more expansive outcome measures in research studies. There are several areas of potential growth in pediatric stroke literature. Research studies should be precise when describing included samples. As interventions for pediatric stroke shift toward neuromodulation and other neurologic treatments, there is a need for well-defined populations, both clinically in the community as well as in research studies. There is also a need for US guidelines for rehabilitation after pediatric stroke. Overall, the trend in the literature seems to suggest that combining some form of neuromodulatory technique with existing recommended rehabilitation technique (ex: CIMT) may promote overall recovery for children after stroke, though further research is needed.

What Works to Improve Wellbeing? A Rapid Systematic Review of 223 Interventions Evaluated with the Warwick-Edinburgh Mental Well-Being Scales

INTRODUCTION

The Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS) is a commonly used scale of mental wellbeing focusing entirely on the positive aspect of mental health. It has been widely used in a broad range of clinical and research settings, including to evaluate if interventions, programmes or pilots improve wellbeing. We aimed to systematically review all interventions that used WEMWBS and evaluate which interventions are the most effective at improving wellbeing.

METHODS

Eligible populations included children and adults, with no health or age restrictions. Any intervention study was eligible if the wellbeing outcome was measured using the 7 or 14-item WEMWBS scale assessed both pre- and post-intervention. We identified eligible intervention studies using three approaches: a database search (Medline, EMBASE, CINAHL, PyschInfo and Web of Science from January 2007 to present), grey literature search, and by issuing a call for evidence. Narrative synthesis and random-effects meta-analysis of standardised mean differences in the intervention group were used to summarise intervention effects on WEMWBS score.

RESULTS

We identified 223 interventions across 209 studies, with a total of 53,834 participants across all studies. Five main themes of interventions were synthesised: psychological (n = 80); social (n = 54); arts, culture and environment (n = 29); physical health promotion (n = 18); and other (n = 28). Psychological interventions based on resilience, wellbeing or self-management techniques had the strongest effect on wellbeing. A broad range of other interventions were effective at improving mental wellbeing, including other psychological interventions such as cognitive behavioural therapy, psychoeducation and mindfulness. Medium to strong effects were also seen for person-centred support/advice (social), arts-based, parenting (social) and social prescribing interventions. However, a major limitation of the evidence was that only 75 (36%) of studies included a control group.

CONCLUSIONS

WEMWBS has been widely used to assess wellbeing across a diverse range of interventions, settings and samples. Despite substantial heterogeneity in individual intervention design, delivery and groups targeted, results indicate that a broad range of intervention types can successfully improve wellbeing. Methodological changes, such as greater use of control groups in intervention evaluation, can help future researchers and policy makers further understand what works for mental wellbeing.

Perinatal Stroke in Fetuses, Preterm and Term Infants

Perinatal stroke is a well-defined heterogenous group of disorders involving a focal disruption of cerebral blood flow between 20 weeks gestation and 28 days of postnatal life. The most focused lifetime risk for stroke occurs during the first week after birth. The morbidity of perinatal stroke is high, as it is the most common cause of hemiparetic cerebral palsy which results in lifelong disability that becomes more apparent throughout childhood. Perinatal strokes can be classified by the timing of diagnosis (acute or retrospective), vessel involved (arterial or venous), and underlying cause (hemorrhagic or ischemic). Perinatal stroke has primarily been reported as a disorder of term infants; however, the preterm brain possesses different vulnerabilities that predispose an infant to stroke injury both in utero and after birth. Accurate diagnosis of perinatal stroke syndromes has important implications for investigations, management, and prognosis. The classification of perinatal stroke by age at presentation (fetal, preterm neonatal, term neonatal, and infancy/childhood) is summarized in this review, and includes detailed descriptions of risk factors, diagnosis, treatment, outcomes, controversies, and resources for family support.

Grappling with uncertainty - Experiences of parents of infants following perinatal stroke

BACKGROUND

The term perinatal stroke describes focal damage to the developing brain due to cerebrovascular disease and occurring either before or shortly after birth. Aetiology, presentation and evolution differ from stroke in adults.

AIMS

We aimed to explore early parental experiences related to having a child with perinatal stroke, including how parental psychological wellbeing had been impacted, to consider how support for families could be improved.

METHODS AND PROCEDURES

We undertook a qualitative research study, using in-depth interviews of parents of infants with perinatal stroke when the infants were 5-6 months corrected gestational age. Sixteen parents (11 female, 5 male) of 11 infants with perinatal stroke took part. Thematic analysis was used in data interpretation.

OUTCOMES AND RESULTS

Parents described distress related to the lack of information regarding likely outcome following perinatal stroke, as well as confusion around the term 'stroke'. Guilt and self-blame were expressed, with increased emotional sensitivity. Seeking information about stroke to reduce uncertainty was a useful strategy for some, but overwhelming for others.

CONCLUSIONS AND IMPLICATIONS

The diagnosis of perinatal stroke led to psychological distress in parents. Uncertainty following diagnosis produced significant emotional difficulties. Recommendations for practice include providing timely, paced information and psychological support.

Parental engagement in early intervention for infants with cerebral palsy-A realist synthesis

BACKGROUND

Emphasis on parental engagement strategies within occupational therapy and physiotherapy early intervention (EI) programmes for infants at high risk of cerebral palsy (CP) has increased. This reflects consensus that increasing parent participation enhances treatment efficacy, potentially improving infant and parent outcomes. However, evaluation of parental engagement in EI is complex. Despite the growing application of parental engagement strategies, aligned with family-centred care practice, theoretical evaluation is currently lacking within the literature. This realist synthesis aimed to identify component theories underlying EI strategies to support parental engagement and to use empirical findings to evaluate how these work in practice.

METHODS

Realist synthesis: Databases Medline, Embase, Amed, CINAHL and PsychInfo were searched (from February 1985 - February 2020); further articles were sourced from reference lists. A data extraction form was used, and a Critical Appraisal Skills Programme tool was used to assess study rigour.

RESULTS

Twenty-six articles were included. Quality of relationships, parent education and intervention co-design were the key themes related to parental engagement strategies. Findings indicate that constructive parent reasoning mechanisms of trust, belief, sense of control, perceived feasibility of home programme delivery and ultimately motivation are linked to the underlying intervention resources afforded by specific strategies (e.g., coaching pedagogy). These responses are precursors to engagement outcomes that include increased parental self-efficacy and adherence. Importantly, parental self-efficacy can initiate a process of change leading to improved parental confidence and anxiety.

CONCLUSIONS

Sensitively designed programme strategies, centred on relational quality between parent, infant and therapist, are fundamental for effective parent connection, involvement and investment within EI for infants with CP.

Interrater and test-retest reliability of the Hand Assessment for Infants

AIM

To evaluate the interrater and test-retest reliability, standard error of measurement (SEM), and the smallest detectable difference (SDD) of the Hand Assessment for Infants (HAI).

METHOD

HAI assessments of 55 infants (26 females, 29 males), 25 with clinical signs of unilateral cerebral palsy (CP) and 30 typically developing (mean [SD] age 6.8mo [2.4], range 3-11mo), were scored individually by three therapists. Three clinically experienced occupational therapists (OT 1-OT 3) with extensive experience in using the HAI, independently scored the video recorded HAI play sessions. Analysis of the combined group of infants and just the infants with clinical signs of unilateral CP (12 females, 13 males; mean age 7.6mo [2.1]) were conducted. Intraclass correlation coefficients (ICC, 2.1), Bland-Altman plots, SEM, and SDD were calculated.

RESULTS

Interrater and test-retest reliability were excellent for the Both Hands Measure (BoHM) and the Each Hand Sum score (EaHS), with ICCs of 0.96 to 0.99. For individual items, the interrater and test-retest reliability was good to excellent (ICC 0.81-0.99). The SDD for the EaHS was 2 points, and for the BoHM the SDD it was 3 HAI units for infants with signs of unilateral CP.

INTERPRETATION

The HAI results showed good to excellent reliability. The SDDs were low, indicating that results beyond these levels exceed the measurement error and, thus, can be considered true changes. What this study adds The Hand Assessment for Infants (HAI) shows excellent reliability. A change of ≥3 HAI units is considered a true change. The HAI yields reliable measures for research and clinical practice.

Early interventions in infants with unilateral cerebral palsy: A systematic review and narrative synthesis

BACKGROUND

Recent systematic reviews have already provided an overview of the impact of early interventions on developmental outcomes in infants at risk for cerebral palsy. However, none has thus far focused specifically on how early interventions might improve motor outcome in infants diagnosed with unilateral cerebral palsy (uCP). Hence, the aim of this systematic review was to provide an overview of early intervention programs used in infants with uCP to improve motor outcome.

METHODS

A systematic literature search was performed in PubMed, Embase, Cochrane Central Register of Controlled trials, CINAHL and Web of Science following the PRISMA-statement guidelines. Risk of bias was assessed using the Cochrane risk-of-bias 2 tool.

RESULTS

Three single-blinded randomized controlled trials (RCTs) were identified, including 88 infants with uCP. These RCTs suggest that modified constraint-induced movement therapy (mCIMT) is effective and safe for improving upper limb function in infants with uCP. Bimanual training compared to mCIMT was found to be equally effective in one study. No clinical or neurological predictors of treatment response could be identified yet.

CONCLUSION

Although more high-quality RCTs are urgently needed, early interventions seem effective, safe and feasible to apply in infants with uCP for improving upper limb motor function. This underlines the importance of prompt referral to diagnostic-specific centres to start up such early interventions.

Early intervention evidence for infants with or at risk for cerebral palsy: an overview of systematic reviews

AIM

To perform an overview of systematic reviews and more recent randomized controlled trials (RCTs) on early motor interventions in infants aged 0 to 3 years with or at risk of cerebral palsy to inform current clinical and research efforts and provide a benchmark to assess future interventions ideally initiated within the first 6 months.

METHOD

Standardized searches of the PubMed, Embase, Scopus, and Web of Science databases were conducted for systematic reviews (2009-2020) and RCTs (2015-2020).

RESULTS

From 840 unique records, 31 full texts were reviewed, yielding three systematic reviews encompassing 46 studies, 16 with comparison groups, and six additional RCTs that met the criteria. Two enrichment- and activity-based approaches had medium effect sizes on motor development, only one with low risk of bias; two others had large task-specific effect sizes but some bias concerns; and three enriched environment studies with some bias concerns had medium effect sizes on cognitive development. Most had small or no effect sizes, bias concerns, and uncertain diagnostic determinations.

INTERPRETATION

Data synthesis revealed limited data quantity and quality, and suggest, although not yet confirmed, greater benefit from early versus later intervention. Research efforts with greater early diagnostic precision and earlier intervention are accelerating, which may transform future outcomes and practices. What this paper adds For over 50% of trials within the reviews, the intervention was compared to standard care with only two showing efficacy. Similar to results in older children, constraint-induced movement therapy (CIMT) emerged as efficacious with high effect sizes. CIMT was not superior to similarly intense bimanual training or occupational therapy. Goals-Activity-Motor Enrichment intervention initiated before 5 months of age was superior to equally intense standard care. Several other enriched environment strategies promoted cognitive and/or motor development.

Perinatal stroke: mapping and modulating developmental plasticity

Most cases of hemiparetic cerebral palsy are caused by perinatal stroke, resulting in lifelong disability for millions of people. However, our understanding of how the motor system develops following such early unilateral brain injury is increasing. Tools such as neuroimaging and brain stimulation are generating informed maps of the unique motor networks that emerge following perinatal stroke. As a focal injury of defined timing in an otherwise healthy brain, perinatal stroke represents an ideal human model of developmental plasticity. Here, we provide an introduction to perinatal stroke epidemiology and outcomes, before reviewing models of developmental plasticity after perinatal stroke. We then examine existing therapeutic approaches, including constraint, bimanual and other occupational therapies, and their potential synergy with non-invasive neurostimulation. We end by discussing the promise of exciting new therapies, including novel neurostimulation, brain-computer interfaces and robotics, all focused on improving outcomes after perinatal stroke.

How Does the Cause of Infantile Hemiparesis Influence Other Conditioning Factors? A Preliminary Study in a Spanish Population

Infantile hemiparesis may be associated with significant morbidity and may have a profound impact on a child’s physical and social development. Infantile hemiparesis is associated with motor dysfunction as well as additional neurologic impairments, including sensory loss, mental retardation, epilepsy, and vision, hearing, or speech impairments. The objective of this study was to analyze the association between the cause of infantile hemiparesis and birth (gestational age), age of diagnosis, and associated disorders present in children with infantile hemiparesis aged 0 to 3 years. An observational and cross-sectional study was performed. A simple and anonymous questionnaire was created ad hoc for parents of children diagnosed with infantile hemiparesis aged between 0 and 3 years about the situation regarding the diagnosis of hemiparesis, birth, cause of hemiparesis, and presence of other associated disorders. Perinatal stroke (60.1%) was the most common cause of hemiparesis, and the most typical associated disorder was epilepsy (34.2%), with the second largest percentage in this dimension corresponding to an absence of associated disorders (20.7%). The most frequent birth was “no premature” (74.1%). The mean age of diagnosis of infantile hemiparesis was registered at 8 months (IQR: 0–36). Knowing the possible association between different conditioning factors and the cause of infantile hemiparesis facilitates the prevention of severe sequelae in children and family, implementing an early comprehensive therapeutic approach in children with infantile hemiparesis.

Feasibility Trial of Thumb Taping by Parents in Infants with Cerebral Palsy: Brief Report

Aim: To determine the feasibility and acceptability of parent-delivered elastic taping to the thumb and wrist in infants with cerebral palsy (CP).Design: Randomized cross-over feasibility trial.Participants: 20 infants (11 male; mean age 22 months) with CP.Intervention: Groups A and B received taping for 4 and 2 weeks, respectively.Outcomes: Primary: Recruitment and retention rates; adherence to protocol; Parent Satisfaction Questionnaire. Secondary: House Thumb score; Zancolli classification; Assisting Hand Assessment (AHA)/mini AHA. Exploratory: Duration of hand regard, thumb in palm, and open hand contact with toys during AHA/mini AHA.Results: Recruitment was feasible (95.2% uptake). Completion rates were 80% and 60% in Groups A and B. Questionnaire feedback was generally positive. Some parents reported increased awareness of the taped hand. Objective improvements were rare though one participant showed consistent improvement in thumb position.Conclusion: Taping proved feasible and acceptable; individual case benefit suggests further research is required.Trial registration: ISRCTN41918400.

Perinatal arterial ischemic stroke

Perinatal arterial ischemic stroke is a relatively common and serious neurologic disorder that can affect the fetus, the preterm, and the term-born infant. It carries significant long-term disabilities. Herein we describe the current understanding of its etiology, pathophysiology and classification, different presentations, and optimal early management. We discuss the role of different brain imaging modalities in defining the extent of lesions and the impact this has on the prediction of outcomes. In recent years there has been progress in treatments, making early diagnosis and the understanding of likely morbidities imperative. An overview is given of the range of possible outcomes and optimal approaches to follow-up and support for the child and their family in the light of present knowledge.