Development of hand function and precision grip control in individuals with cerebral palsy: a 13-year follow-up study

Somatosensation and motor performance in the less-affected and more-affected hand of unilateral cerebral palsy children: a cross-sectional study

PURPOSE

This study aimed to examine motor performance and somatosensory processing of unilateral cerebral palsy (UCP) children in both the less-affected hand and the more-affected hand. This study is also aimed at analysing the somatosensory proccessing in the more-affected hand in relation to age and damaged hemisphere.

MATERIALS AND METHODS

Forty-seven children aged from 6 to 15 years (UCP = 23; TD = 24) were recruited. Grip strength, pinch strength, Box and Block Test and Jebsen Taylor Hand Function Test were used to analyse motor performance. A comprehensive somatosensory assessment battery was included: tactile registration, unilateral, bilateral and spatio-temporal perception, haptic recognition, texture perception, proprioception, pressure pain threshold and functional sensitivity.

RESULTS

UCP children exhibited lower performance in all aspects of motor performance measured in both the less-affected hand and the more-affected hand, except grip strength in the less-affected hand. Significant differences were found for all tests included in the somatosensory assessment in both the less-affected hand and the more-affected hand, except unilateral perception tests in the less-affected hand.

CONCLUSIONS

UCP children present difficulties in motor performance and somatosensory processing not only in the more-affected hand, but also in the less-affected hand. Somatosensation may be a critical driver of functional performance.Implications for rehabilitationThe less-affected hand of children with unilateral cerebral palsy should be included in both assessment and intervention programmes.Somatosensory processing should be assessed through a comprehensive battery, both in the less-affected hand and in the more-affected hand of unilateral cerebral palsy children.Somatosensory treatment must be taken into account if functional performance in the activities of daily living of unilateral cerebral palsy children is to be improved.

Fidelity of Delivery in a Multisite Randomized Clinical Trial of Intervention Efficacy for Infants With Unilateral Cerebral Palsy

PURPOSE

To investigate the reliability of a measure of fidelity of therapist delivery, quantify fidelity of delivery, and determine factors impacting fidelity in the Rehabilitation EArly for Congenital Hemiplegia (REACH) clinical trial.

METHODS

Ninety-five infants (aged 3-9 months) with unilateral cerebral palsy participated in the REACH clinical trial. The Therapist Fidelity Checklist (TFC) evaluated key intervention components. Video-recorded intervention sessions were scored using the TFC.

RESULTS

Inter- and intrarater reliability was percentage agreement 77% to 100%. Fidelity of delivery was high for 88.9% of sessions and moderate for 11.1% of sessions. Sessions with moderate scores included infants receiving infant-friendly bimanual therapy and occurred at the intervention midpoint or later. No significant relationships were found for TFC scores and infant age, manual ability, or parent engagement.

CONCLUSIONS

Fidelity of delivery was high for the REACH trial in most intervention sessions. Standardized therapist training with intervention manuals and monthly peer-to-peer support likely contributed to these results.

Developmental and acquired brain injury have opposite effects on finger coordination in children

The ability to coordinate finger forces to dexterously perform tasks develops in children as they grow older. Following brain injury, either developmental (as in cerebral palsy-CP) or acquired (as in traumatic brain injury-TBI), this developmental trajectory will likely be impaired. In this study, we compared finger coordination in a group of children aged 4-12 with CP and TBI to a group of typically developing children using an isometric pressing task. As expected, deficits were observed in functional tests (Jebsen Taylor test of hand function, Box and Block test) for both groups, and children in both groups performed the pressing task less well than the control group. However, differing results were observed between the CP and TBI groups when using the uncontrolled manifold hypothesis to look at the synergy index. This index measures the relative amount of "good" (does not affect the outcome measure) and "bad" (does affect the outcome measure) variability, where in this case the outcome measure is the total force produced by the fingers. While children with CP were more variable in their performance, their synergy index was not significantly different from typically developing children, suggesting the development of compensatory strategies. In contrast, the children following TBI showed performance that got worse as a function of age (i.e., the older children with TBI performed worse than the younger children with TBI). These differences between the groups may be a result of different areas of brain injury typically observed in CP and TBI, and the different amount of time that has passed since the injury.

Assessing IQ in adolescents with mild to moderate cerebral palsy using the WISC-V

Objective: To examine the influence of subtests that require fine motor responses on measures of intellectual ability, and compare three approaches to minimizing motor demands while assessing cognitive abilities in adolescents with cerebral palsy (CP) to the traditional method of the Wechsler Intelligence Scale for Children - Fifth edition (WISC-V). Method: Seventy adolescents with CP (M = 14 years 6 months, SD = 10 months) who were able to provide either a verbal or point response were assessed using the WISC-V administered via Q-interactive. The pencil-to-paper version of Coding was also administered. Performance on Block Design and pencil-to-paper Coding was compared to Visual Puzzles and Coding on Q-interactive, respectively. Full Scale IQ (FSIQ) scores derived according to the Traditional method of the WISC-V were compared to alternative estimates of FSIQ derived according to the Q-interactive, Nonmotor, and Motor-free methods, which minimized motor demands. Results: An additional 7-12% of participants were able to respond to Visual puzzles and Coding on Q-interactive compared to Block Design and pencil-to-paper Coding, respectively, and performance was marginally but significantly better. For 54 adolescents (Gross Motor Function Classification System (GMFCS) Level I-III) who were able to obtain FSIQ scores, the Traditional method underestimated FSIQ by 3-6 points compared to the alternative methods and the difference was most pronounced for those with more severe CP as measured by the GMFCS. Conclusion: Adolescents with CP are at an inherent disadvantage when cognitive ability is assessed using the Traditional method of the WISC-V. Findings suggest clinicians should employ the Nonmotor or Motor-free methods when assessing IQ in adolescents with CP.

Efficacy of fine motor and balance exercises on fine motor skills in children with sensorineural hearing loss

BACKGROUND

Childhood hearing impairment is a major disability associated with delayed motor development. The affected Fine motor performance in children with sensorineural hearing loss (SNHL) could be due to dynamic balance deficits and visual-motor incoordination.

OBJECTIVE

This study was designed to investigate the effects of fine motor exercises with or without balancing exercises on fine motor skills in children with SNHL.

METHODS

One hundred and eighty (180) children their age ranged from 8 to 18 years old diagnosed with SNHL were selected. They were divided into three groups, 60 children (control group) practiced only their ordinary activities of daily living, 60 children (fine motor exercises group) practiced fine motor exercises, and 60 children (fine motor and balance exercise) group practiced fine motor and balance exercises. The outcomes were assessed by the Bruininks Oseretsky Test of the motor proficiency second edition scale (BOT-2).

RESULTS

Generally, there was a statistically significant difference between control group and fine motor exercises group where (p <  0.05), besides, there was a statistically significant difference between control group and fine motor and balance exercises group where (p <  0.05). But, there was no statistically significant difference between fine motor exercises group and fine motor and balance exercises group where (p >  0.05).

CONCLUSIONS

The Fine Motor performance of children with SNHL has been improved by Fine motor with or without balancing exercises according to (BOT-2).

Upper Limb Motor Planning in Individuals with Cerebral Palsy Aged between 3 and 21 Years Old: A Systematic Review

Individuals with cerebral palsy have difficulties performing activities of daily living. Beyond motor execution impairments, they exhibit motor planning deficits contributing to their difficulties. The objective of this review is to synthesize the behavioral evidence of motor planning deficits during an upper limb motor task in children, adolescents and young adults with cerebral palsy aged between 3 and 21 years. Methods: The inclusion criteria were: (1) including individuals with cerebral palsy from 3 to 21 years old; (2) assessing upper limb motor planning. Six databases were screened. The quality assessment of the studies was performed. Results: Forty-six studies and 686 participants were included. Five articles have been identified as very high quality, 12 as high, 20 as moderate, six as low, three as very low. Force planning studies reported a deficit for the more affected hand but adequate performances for the less affected hand. Object-manipulation studies reported hand posture planning deficits irrespectively of the hand assessed. Conclusions: Motor planning deficits has been shown in the more affected hand for force scaling, while the results for other variables showed overall deficits. Hence, variables affected by motor planning deficits in both hands should be considered in children with cerebral palsy to optimize intervention.

Sensorineural hearing loss imprint on fine motor skills: A pediatric and adolescent innovative study

BACKGROUND

Sensorineural hearing loss is the most common type of permanent hearing impairment and results in balance and motor deficits in children which may affect and/or delay all developmental indicators.

OBJECTIVE

The purpose of this study was to investigate the consequences of sensorineural hearing loss regarding fine motor skills in children and adolescents.

METHODS

Two hundred children with an age range between 7 to 18 years and diagnosed with sensorineural hearing loss were selected from the Public School for the Deaf and Hard of Hearing in El-Minia district, Minia governorate, Egypt. The outcome was assessed by the use of Bruininks-Oseretsky Test of Motor Proficiency Second Edition scale (BOT-2) to measure fine motor skills.

RESULTS

There was a statistically significant difference between the scores of Fine Motor Precision and Fine Motor Integration subtests of each study subgroup and its counterpart subgroup in the control group (normative values according to the scale) which has the same age and gender characteristics where p value equals (0.0008 or less, 0.0009 or less) respectively, with a large effect size less than -0.83.

CONCLUSION

The findings of this study suggest that children with sensorineural hearing loss have a defect in their fine motor skills when compared to normal children of the same gender and age groups according to Bruininks-Oseretsky scale.

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

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

Arm Muscle Strength in Children with Bilateral Spastic CP

AIMS

To assess arm-muscle strength related to motor function in children with bilateral spastic cerebral palsy, 5-15 years old.

METHODS

Muscle strength was measured for shoulder abductors, elbow extensors and flexors, wrist extensors, and grip strength. The children were grouped according to the Manual Ability Classification Scale (MACS).

RESULTS

Forty-two children were included. The majority of the children at MACS levels I-II were within the normal range; shoulder abductors were weakest (mean 60-80% of predicted value), and variation was greatest for wrist extensors.Children at MACS level II showed lower values than children at level I, with significant differences for shoulder abductors (p=.028) and wrist extensors (p<.001). Differences between the dominant and non-dominant side was greater in children at MACS level II and statistically significant for wrist extensors (p=.024).Of 15 children tested for grip strength, nine were within the 2 SD range. The three children at MACS level II, all walking with a walker, had a higher mean value than those at MACS level I.

CONCLUSIONS

Muscle strength was lower and differences were greater between sides in children at MACS level II. Wrist extensors showed a decreasing trend with age as compared with normal development.

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.

Investigating fine motor deficits during maintenance therapy in children with acute lymphoblastic leukemia

OBJECTIVES

Children diagnosed with acute lymphoblastic leukemia (ALL) in their early childhood are more susceptible to neuromuscular and musculoskeletal impairments. This cross-sectional study was designed to address different types of fine motor impairments in Egyptian children diagnosed with ALL.

METHODS

Fifty-four children treated for ALL in maintenance phase aged from four to seven years were compared with an age- and sex-matched control group. Fine motor performance was assessed using the total fine motor form of the Bruininks-Oseretsky Test of Motor Proficiency-second edition (BOT-2). Sex- and age-specific norms of BOT-2 were used to calculate scale and standard scores in both groups.

RESULTS

Children with ALL had significantly impaired fine motor skills in all subtests and composites of BOT-2 compared with the typically developing group (P < 0.00001). Cumulative doses of vincristine, methotrexate, and dexamethasone revealed no significant correlation with any BOT-2 measure. Males performed significantly better than females in all BOT-2 scores except for the fine motor integration subtest and the total fine motor control composite as no significant differences were observed. The protocol risk stratum, duration of maintenance treatment, and the age at assessment did not significantly affect the BOT-2 measures.

CONCLUSION

About 67% of children with ALL on maintenance treatment experienced fine motor difficulties. Periodic evaluation along the course of chemotherapy could identify specific impaired fine motor domains providing the base for a successful rehabilitation program.

Danish translation, adaptation and validation of the ABILHAND-Kids questionnaire for children with cerebral palsy

Purpose: To translate and cross-culturally adapt the ABILHAND-Kids questionnaire into Danish and assess its psychometric properties in children with cerebral palsy (CP).Materials and methods: A Danish version of the parent-reported ABILHAND-Kids questionnaire was created through a standardized translation process. Dimensionality (confirmatory factor analysis), reliability, smallest detectable change, floor and ceiling effects, and Rasch analysis were carried out.Results: One-hundred-and-fifty children diagnosed with CP were included. No parent had difficulty completing the ABILHAND-Kids (DK). Psychometric testing demonstrated a unidimensional scale, excellent test-retest reliability (ICC2.1A = 0.97) and internal consistency (α = 0.96). A smallest detectable change of 5.15 points was considered acceptable. One item showed Differential Item Functioning, four pairs of items showed signs of local dependence and one item had disordered thresholds. Nevertheless, analyses did not lead to the removal of any items. Item thresholds covered most levels of person abilities. Lastly, 24.7% scored within measurement error at the ceiling of the scale, indicating that it was not possible to measure further improvement.Conclusion: ABILHAND-Kids (DK) seems to be a valid, reliable and comprehensive measurement scale to assess manual ability in children with CP. It can be used in goal setting and to inform future interventions and rehabilitation evaluation.IMPLICATIONS FOR REHABILITATIONImpaired hand function leads to limited participation in activities of everyday life in children with cerebral palsy.Adequate outcome measures of hand function are crucial for the planning and evaluation of interventions.The Danish version of ABILHAND-Kids is a valid and reliable measure of manual ability in children with cerebral palsy, and it can be used in clinical practice and for research purposes.

Upper limb impairments, process skills, and outcome in children with unilateral cerebral palsy

AIM

To examine the relationships between upper limb impairments and independence in self-care (ISC) in children with unilateral cerebral palsy (CP).

METHOD

One hundred and eight children with unilateral CP (46 females, 62 males; mean age 8y 7mo, SD 3y 9mo) recruited from a population register were assessed for upper limb muscle power, spasticity, sensation, motor control, and process skills, and for ISC as the functional outcome using structural equation modelling.

RESULTS

The model showed good fit indices and explained 90% of the variance in ISC. Direct effects were significant between manual ability and ISC (β=0.47), and process skills and ISC (β=0.63). Sensation had a significant positive indirect effect on ISC through manual ability (β=0.24) and a positive but marginally non-significant indirect effect through process skills (β=0.21, bootstrapped 95% confidence interval -0.05 to 0.55). Spasticity had a significant negative indirect effect on ISC through its effect on manual ability (β=-0.21). Age had a significant positive indirect effect on ISC, as did intellect, through their effect on process skills (β=0.34 and 0.21 respectively).

INTERPRETATION

ISC is affected by upper limb impairments and process skill. Sensation influences ISC through its effects on manual and process skill abilities. Both sensation and process skills require further evaluation to assist ISC in children with unilateral CP.

WHAT THIS PAPER ADDS

Process skills and manual ability most strongly positively influence independence in self-care (ISC) in children with unilateral cerebral palsy. Sensation influences ISC through manual ability and process skill.

Impaired Ability to Suppress Excitability of Antagonist Motoneurons at Onset of Dorsiflexion in Adults with Cerebral Palsy

We recently showed that impaired gait function in adults with cerebral palsy (CP) is associated with reduced rate of force development in ankle dorsiflexors. Here, we explore potential mechanisms. We investigated the suppression of antagonist excitability, calculated as the amount of soleus H-reflex depression at the onset of ankle dorsiflexion compared to rest, in 24 adults with CP (34.3 years, range 18–57; GMFCS 1.95, range 1–3) and 15 healthy, age-matched controls. Furthermore, the central common drive to dorsiflexor motoneurons during a static contraction in the two groups was examined by coherence analyses. The H-reflex was significantly reduced by 37% at the onset of dorsiflexion compared to rest in healthy adults (P < 0.001) but unchanged in adults with CP (P = 0.91). Also, the adults with CP had significantly less coherence. These findings suggest that the ability to suppress antagonist motoneuronal excitability at movement onset is impaired and that the central common drive during static contractions is reduced in adults with CP.

Development of bimanual performance in young children with cerebral palsy

AIM

To describe the development of bimanual performance among young children with unilateral or bilateral cerebral palsy (CP).

METHOD

A population-based sample of 102 children (53 males, 49 females), median age 28.5 months (interquartile range [IQR] 16mo) at first assessment and 47 months (IQR 18mo) at last assessment, was assessed half-yearly with the Assisting Hand Assessment (AHA) or the Both Hands Assessment (BoHA) for a total of 329 assessments. Developmental limits and rates were estimated by nonlinear mixed-effects models. Developmental trajectories were compared between levels of manual ability (Mini-Manual Ability Classification System [Mini-MACS] and MACS) and AHA or BoHA performance at 18 months of age (AHA-18/BoHA-18) for both CP subgroups, and additionally between children with bilateral CP with symmetric or asymmetric hand use.

RESULTS

For both CP subgroups, children classified in Mini-MACS/MACS level I, and those with high AHA-18 or BoHA-18 reached the highest limits of performance. For children with bilateral CP the developmental change was small, and children with symmetric hand use reached the highest limits.

INTERPRETATION

Mini-MACS/MACS levels and AHA-18 or BoHA-18 distinguished between various developmental trajectories both for children with unilateral and bilateral CP. Children with bilateral CP changed their performance to a smaller extent than children with unilateral CP.

WHAT THIS PAPER ADDS

Manual Ability Classification System levels and Assisting Hand Assessment/Both Hands Assessment performance at 18 months are important predictors of hand use development in cerebral palsy (CP). Children with bilateral CP improved less than those with unilateral CP. Children with bilateral CP and symmetric hand use reached higher limits than those with asymmetry.

Precision grip control while walking down a step in children with unilateral cerebral palsy

Aim

To compare grip force (GF) and load force (LF) coordination while walking down a step between children with unilateral cerebral palsy (UCP) and typically developing (TD) children.

Methods

Twenty-five children with UCP (age 9.3±1.7 y) and 25 TD controls (age 9.4±2.1 y) walked down a step while holding a grip-lift manipulandum. Dynamic and temporal variables were analyzed. The maximum voluntary contraction (MVC) was also assessed.

Results

The temporal course was perturbed mainly in the more affected hand of children with UCP when compared to TD children because the increases in GF and LF onset occurred in a reversed order. Compared with the TD controls, the children with UCP presented higher LF values on both hands and a higher GF on the less affected hand. In children with UCP, the GF to LF adaptation was adequate on the less affected hand but overestimated on the more affected hand. Furthermore, children with UCP presented a lower MVC in the more affected hand, leading to a higher percentage of MVC used during the task.

Interpretation

Our findings highlight an anticipatory control of precision grip during a stepping down task in children with UCP that is adequate for the less affected hand but altered for the more affected hand.

Hand Function in a Population-Based Sample of Young Children with Unilateral or Bilateral Cerebral Palsy

AIM

To describe aspects of hand function in a population-based sample of young children with clinical signs of unilateral or bilateral cerebral palsy (CP).

METHOD

A cross-sectional study with data from national CP registers in Norway. Manual ability was classified with the Manual Ability Classification System (MACS) or Mini-MACS. Hand use in bimanual activities was measured with the Assisting Hand Assessment (AHA) for unilateral CP or the newly developed Both Hands Assessment (BoHA) for bilateral CP.

RESULTS

From 202 children, 128 (57 females) were included (Mini-MACS/MACS levels I-V, mean age 30.4 months; SD = 12.1). Manual abilities were distributed across levels I-III in unilateral CP and levels I-V in bilateral CP. Variations in AHA and BoHA units were large. One-way ANOVA revealed associations between higher AHA or BoHA units and Mini-MACS/MACS levels of higher ability (p < 0.01) and higher age (p < 0.04).

CONCLUSIONS

Compared with young children with unilateral CP, children with bilateral CP showed greater variation in Mini-MACS/MACS levels, and both sub-groups showed large variations in AHA or BoHA units. The classifications and assessments used in this study are useful to differentiate young children's ability levels. Such information is important to tailor upper limb interventions to the specific needs of children with CP.

Including a Lower-Extremity Component during Hand-Arm Bimanual Intensive Training does not Attenuate Improvements of the Upper Extremities: A Retrospective Study of Randomized Trials

Hand-Arm Bimanual Intensive Therapy (HABIT) promotes hand function using intensive practice of bimanual functional and play tasks. This intervention has shown to be efficacious to improve upper-extremity (UE) function in children with unilateral spastic cerebral palsy (USCP). In addition to UE function deficits, lower-extremity (LE) function and UE-LE coordination are also impaired in children with USCP. Recently, a new intervention has been introduced in which the LE is simultaneously engaged during HABIT (Hand-Arm Bimanual Intensive Therapy Including Lower Extremities; HABIT-ILE). Positive effects of this therapy have been demonstrated for both the UE and LE function in children with USCP. However, it is unknown whether the addition of this constant LE component during a bimanual intensive therapy attenuates UE improvements observed in children with USCP. This retrospective study, based on multiple randomized protocols, aims to compare the UE function improvements in children with USCP after HABIT or HABIT-ILE. This study included 86 children with USCP who received 90 h of either HABIT (n = 42) or HABIT-ILE (n = 44) as participants in previous studies. Children were assessed before, after, and 4-6 months after intervention. Primary outcomes were the ABILHAND-Kids and the Assisting Hand Assessment. Secondary measures included the Jebsen-Taylor Test of Hand Function, the Pediatric Evaluation of Disability Inventory [(PEDI); only the self-care functional ability domain] and the Canadian Occupational Performance Measure (COPM). Data analysis was performed using two-way repeated-measures analysis of variance with repeated measures on test sessions. Both groups showed similar, significant improvements for all tests (test session effect p < 0.001; group × test session interaction p > 0.05) except the PEDI and COPM. Larger improvements on these tests were found for the HABIT-ILE group (test session effect p < 0.001; group × test session interaction p < 0.05). These larger improvements may be explained by the constant simultaneous UE-LE engagement observed during the HABIT-ILE intervention since many daily living activities included in the PEDI and the COPM goals involve the LE and, more specifically, UE-LE coordination. We conclude that UE improvements in children with USCP are not attenuated by simultaneous UE-LE engagement during intensive intervention. In addition, systematic LE engagement during bimanual intensive intervention (HABIT-ILE) leads to larger functional improvements in activities of daily living involving the LE.

Impaired Voluntary Movement Control and Its Rehabilitation in Cerebral Palsy

Cerebral palsy is caused by early damage to the developing brain, as the most common pediatric neurological disorder. Hemiplegia (unilateral spastic cerebral palsy) is the most common subtype, and the resulting impairments, lateralized to one body side, especially affect the upper extremity, limiting daily function. This chapter first describes the pathophysiology and mechanisms underlying impaired upper extremity control of cerebral palsy. It will be shown that the severity of impaired hand function closely relates to the integrity of the corticospinal tract innervating the affected hand. It will also shown that the developing corticospinal tract can reorganize its connectivity depending on the timing and location of CNS injury, which also has implications for the severity of hand impairments and rehabilitation. The mechanisms underlying impaired motor function will be highlighted, including deficits in movement execution and planning and sensorimotor integration. It will be shown that despite having unimanual hand impairments, bimanual movement control deficits and mirror movements also impact function. Evidence for motor learning-based therapies including Constraint-Induced Movement Therapy and Bimanual Training, and the possible pathophysiological predictors of treatment outcome and plasticity will be described. Finally, future directions for rehabilitations will be presented.

Structured skill practice during intensive bimanual training leads to better trunk and arm control than unstructured practice in children with unilateral spastic cerebral palsy

BACKGROUND

Recently, intensive practice showed good efficacy in improving upper extremity function for children with unilateral spastic cerebral palsy (USCP). However, little is known about the significance of skill progression frequently used during intensive practice.

AIMS

We evaluate the importance of skill progression during intensive bimanual practice on movement coordination.

METHODS AND PROCEDURES

Twenty children with USCP (average age: 8.5; MACS levels: I-III) participated in the study. Ten children were randomly allocated to a structured practice group (SPG) with skill progression, and the other 10 children randomized to an unstructured practice group (UPG) without skill progression. Both groups practiced bimanual activities 6h a day for 15days. Children were asked to perform a bimanual drawer-opening task before and after intensive practice using 3-D kinematic analyses.

OUTCOMES AND RESULTS

Both groups showed improved temporal bimanual coordination with increased normalized movement overlap of the two hands (p=0.005) and decreased goal synchronization time (p=0.002). However, only the SPG showed decreased trunk involvement (p=0.01) and increased elbow joint excursion (p=0.017) with decreased variability (p=0.015 and 0.048 respectively).

CONCLUSIONS AND IMPLICATIONS

The results highlighted the importance of skill progression for intensive practice to improve upper extremity and trunk movement control and consistency for children with USCP.

Longitudinal development of hand function in children with unilateral spastic cerebral palsy aged 18 months to 12 years

AIM

The aim of the study was to describe the development of hand function, particularly the use of the affected hand in bimanual tasks, among children with unilateral cerebral palsy aged 18 months to 12 years.

METHOD

A convenience sample of 96 children (53 males, 43 females) was assessed with the Assisting Hand Assessment (AHA) at regular intervals from the ages of 18 months to 12 years. The children ranged from 17 to 127 months (median age 24mo) at recruitment. Subgroups were created to identify differences in development using the child's AHA at 18 months and the Manual Ability Classification System (MACS). A nonlinear mixed effects model was used to analyze data according to a 'stable limit' development model.

RESULTS

The results were based on 702 AHA sessions. The children showed a rapid development at a young age and reached 90% of their stable limit between 30 months and 8 years. The subgroups, based on the 18-month AHA and the MACS levels respectively, had distinctly different patterns of development.

INTERPRETATION

The AHA at 18 months may be used to make a crude prediction of future development.

The Jebsen Taylor Test of Hand Function: A Pilot Test-Retest Reliability Study in Typically Developing Children

AIMS

The aim of this pilot study was to evaluate reproducibility of the Jebsen Taylor Test of Hand Function (JTTHF) in children.

METHODS

Eighty-seven typically developing children 5 to 10 years old were included from five Outside School Hours Care centers in the Greater Brisbane Region, Australia. Hand function was assessed on two occasions with a modified JTTHF, then reproducibility was assessed using Intraclass Correlation Coefficient (ICC [3,1]) and the Standard Error of Measurement (SEM).

RESULTS

Total scores for male and female children were not significantly different. Five-year-old children were significantly different to all other age groups and were excluded from further analysis. Results for 71 children, 6 to 10 years old were analyzed (mean age 8.31 years (SD 1.32); 33 males). Test-retest reliability for total scores on the dominant and nondominant hands were ICC 0.74 (95% CI 0.61, 0.83) and ICC 0.72 (95% CI 0.59, 0.82), respectively. 'Writing' and 'Simulated Feeding' subtests demonstrated poor reproducibility. The Smallest Real Difference was 5.09 seconds for total score on the dominant hand.

CONCLUSIONS

Findings indicate good test-retest reliability for the JTTHF total score to measure hand function in typically developing children aged 6 to 10 years.

Hand Sensorimotor Function in Older Children With Neonatal Brachial Plexus Palsy

BACKGROUND

Routine sensory assessments in neonatal brachial plexus palsy are infrequently performed because it is generally assumed that sensory recovery exceeds motor recovery. However, studies examining sensory function in neonatal brachial plexus palsy have produced equivocal findings. The purpose of this study was to examine hand sensorimotor function in older children with neonatal brachial plexus palsy using standard clinical and research-based measures of tactile sensibility.

METHODS

Seventeen children with neonatal brachial plexus palsy (mean age: 11.6 years) and 19 age-matched controls participated in the study. Functional assessments included grip force, monofilament testing, and hand dexterity (Nine-Hole Peg, Jebsen-Taylor Hand Function). Tactile spatial perception involving the discrimination of pin patterns and movement-enhanced object recognition (stereognosis) were also assessed.

RESULTS

In the neonatal brachial plexus palsy group, significant deficits in the affected hand motor function were observed compared with the unaffected hand. Median monofilament scores were considered normal for both hands. In contrast, tactile spatial perception was impaired in the neonatal brachial plexus palsy group. This impairment was seen as deficits in both pin pattern and object recognition accuracy as well as the amount of time required to identify patterns and objects. Tactile pattern discrimination time significantly correlated with performance on both functional assessment tests (P < 0.01).

DISCUSSION

This study provides evidence that tactile perception deficits may accompany motor deficits in neonatal brachial plexus palsy even when measures of tactile registration (i.e., monofilament testing) are normal. These results may reflect impaired processing of somatosensory feedback associated with reductions in goal-directed upper limb use and illustrate the importance of including a broader range of sensory assessments in neonatal brachial plexus palsy.

Establishing Australian Norms for the Jebsen Taylor Test of Hand Function in Typically Developing Children Aged Five to 10 Years: A Pilot Study

AIMS

The aim of this study was to present preliminary normative data for the Jebsen Taylor Test of Hand Function test (JTTHF) in Australian children. Normative data provide reference values for comparison of upper limb capacity when evaluating and planning treatment.

METHODS

The JTTHF administration procedures and materials were standardized. One hundred and two typically developing children aged 5 to 10 years in Brisbane, Australia, were then assessed using the JTTHF.

RESULTS

Five-year-old children were significantly different to all other groups (one year age bands), and 6-year-old children were significantly different from 9-year-old children in the dominant hand. Regression modeling showed improvements of 0.9 and 0.89 s in JTTHF total time for the dominant and nondominant hands, respectively, for every 12 months of maturation in 6- to 10-year-old children.

CONCLUSIONS

This paper presents preliminary JTTHF norms for Australian typically developing children 5 years, 6 to 7 years, 8 to 9 years, and 10 years of age.

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.

Muscle Recruitment and Coordination following Constraint-Induced Movement Therapy with Electrical Stimulation on Children with Hemiplegic Cerebral Palsy: A Randomized Controlled Trial

Objective

To investigate changes of muscle recruitment and coordination following constraint-induced movement therapy, constraint-induced movement therapy plus electrical stimulation, and traditional occupational therapy in treating hand dysfunction.

Methods

In a randomized, single-blind, controlled trial, children with hemiplegic cerebral palsy were randomly assigned to receive constraint-induced movement therapy (n = 22), constraint-induced movement therapy plus electrical stimulation (n = 23), or traditional occupational therapy (n = 23). Three groups received a 2-week hospital-based intervention and a 6-month home-based exercise program following hospital-based intervention. Constraint-induced movement therapy involved intensive functional training of the involved hand during which the uninvolved hand was constrained. Electrical stimulation was applied on wrist extensors of the involved hand. Traditional occupational therapy involved functional unimanual and bimanual training. All children underwent clinical assessments and surface electromyography (EMG) at baseline, 2 weeks, 3 and 6 months after treatment. Surface myoelectric signals were integrated EMG, root mean square and cocontraction ratio. Clinical measures were grip strength and upper extremity functional test.

Results

Constraint-induced movement therapy plus electrical stimulation group showed both a greater rate of improvement in integrated EMG of the involved wrist extensors and cocontraction ratio compared to the other two groups at 3 and 6 months, as well as improving in root mean square of the involved wrist extensors than traditional occupational therapy group (p<0.05). Positive correlations were found between both upper extremity functional test scores and integrated EMG of the involved wrist as well as grip strength and integrated EMG of the involved wrist extensors (p<0.05).

Conclusions

Constraint-induced movement therapy plus electrical stimulation is likely to produce the best outcome in improving muscle recruitment and coordination in children with hemiplegic cerebral palsy compared to constraint-induced movement therapy alone or traditional occupational therapy.

Trial registration

chictr.org ChiCTR-TRC-13004041

Spontaneous improvement in oculomotor function of children with cerebral palsy

Eye movements are essential to get a clear vision of moving objects. In the present study, we assessed quantitatively the oculomotor deficits of children with cerebral palsy (CP). We recorded eye movements of 51 children with cerebral palsy (aged 5-16 years) with relatively mild motor impairment and compared their performance with age-matched control and premature children. Overall eye movements of children with CP are unexpectedly close to those of controls even though some oculomotor parameters are biased by the side of hemiplegia. Importantly, the difference in performance between children with CP and controls decreases with age, demonstrating that the oculomotor function of children with CP develops as fast as or even faster than controls for some visual tracking parameters. That is, oculomotor function spontaneously improves over the course of childhood. This evolution highlights the ability of lesioned brain of children with CP to compensate for impaired motor function beyond what would be achieved by normal development on its own.

Hand-arm bimanual intensive therapy including lower extremities (HABIT-ILE) for children with cerebral palsy

Hand-arm bimanual intensive therapy and constrained-induced movement therapy have shown evidence of effectiveness in improvement of upper extremity use in children with unilateral spastic cerebral palsy (CP). The effectiveness of interventions that are based on intensive practice of activities that combine UE and LE functions has not been reported. We propose that bimanual UE activities that simultaneously require trunk and LE postural adaptations uniquely address motor control limitations of children with unilateral spastic CP. The aim of this perspective is to present such an approach Hand Arm Bimanual Intensive Therapy Including Lower Extremities (HABIT-ILE). HABIT-ILE is unique in selection of tasks and activities that require simultaneous control and coordination of UE and LE movements. It is a motor-learning-based approach using problem solving and highly structured practice. During the intervention, activities and tasks are progressively graded toward more complex bimanual coordination for the UE and increasing demands of the LE. HABIT-ILE is provided in small groups for 90 hr using a camp model. Future research (randomized controlled trial) is needed to determine the effectiveness of HABIT-ILE.

Precision grip in congenital and acquired hemiparesis: similarities in impairments and implications for neurorehabilitation

Background: Patients with congenital and acquired hemiparesis incur long-term functional deficits, among which the loss of prehension that may impact their functional independence. Identifying, understanding, and comparing the underlying mechanisms of prehension impairments represent an opportunity to better adapt neurorehabilitation.

Objective: The present review aims to provide a better understanding of precision grip deficits in congenital and acquired hemiparesis and to determine whether the severity and type of fine motor control impairments depend on whether or not the lesions are congenital or acquired in adulthood.

Methods: Using combinations of the following key words: fingertip force, grip force, precision grip, cerebral palsy, stroke, PubMed, and Scopus databases were used to search studies from 1984 to 2013.

Results: Individuals with both congenital and acquired hemiparesis were able to some extent to use anticipatory motor control in precision grip tasks, even if this control was impaired in the paretic hand. In both congenital and acquired hemiparesis, the ability to plan efficient anticipatory motor control when the less-affected hand is used provides a possibility to remediate impairments in anticipatory motor control of the paretic hand.

Conclusion: Surprisingly, we observed very few differences between the results of studies in children with congenital hemiplegia and stroke patients. We suggest that the underlying specific strategies of neurorehabilitation developed for each one could benefit the other.

Pathophysiology of impaired hand function in children with unilateral cerebral palsy

Unilateral spastic cerebral palsy, caused by damage to the developing central nervous system, is characterized by motor impairments mainly lateralized to one side of the body, with hand impairments greatly contributing to functional limitations. The integrity of the motor areas and the corticospinal tract (CST) is often compromised. The specific etiology may drastically influence subsequent development of CST pathways. Here we describe the pathophysiology underlying impaired upper extremity function, with particular emphasis on the relation between CST damage and hand function. We also describe the resulting sensory and motor deficits, with an emphasis on studies of precision grip, which highlight impairments in motor execution, sensorimotor integration, motor planning, and bimanual coordination beyond dexterity impairments. We show that the type and extent of early brain damage and/or CST reorganization is highly predictive of the severity of these impairments. We discuss the clinical implications of these findings, including the intriguing possibility that the specific pathophysiology is predictive of treatment outcomes. We suggest that a 'one-treatment fits all approach' may be insufficient, and that future rehabilitation efforts will be best guided by closely relating treatment efficacy with the specific pathophysiology.

Precision grip control, sensory impairments and their interactions in children with hemiplegic cerebral palsy: a systematic review

Children with hemiplegic cerebral palsy (HCP) exhibit long-term functional deficits. One of the most debilitating is the loss of prehension since this may impair functional independence. This loss of prehension could be partly due to sensory deficits. Identifying the underlying causes of prehension deficits and their potential link with sensory disorders is important to better adapt neurorehabilitation. Here we provide an overview of precision grip and sensory impairments in individuals with HCP, and the relation between them, in order to determine whether the sensory impairments influence the type and magnitude of deficits as measured by studies of prehensile force control. Pubmed and Scopus databases were used to search studies from 1990 to 2012, using combinations of the following keywords: fingertip force; grip force; precision grip; sensory deficit; sensory impairment; tactile discrimination; with cerebral palsy. Of the 190 studies detected through the systematic search; 38 were finally included in the systematic part of this review. This review shows that sensory deficits are common and are likely underestimated using standard clinical assessments in HCP. Some studies suggest these deficits are the basis of predictive motor control impairments in these individuals. However, children with HCP retain some ability to use predictive control, even if it is impaired in the more affected hand. Intensive practice and initial use of the less affected hand, which has only subtle sensory deficits, has been shown to remediate impairments in anticipatory motor control during subsequent use of the more affected hand. Implications for motor and sensory rehabilitation of individuals with HCP are discussed.

Developmental improvements in dynamic control of fingertip forces last throughout childhood and into adolescence

While it is clear that the development of dexterous manipulation in children exhibits dramatic improvements over an extended period, it is difficult to separate musculoskeletal from neural contributors to these important functional gains. This is in part due to the inability of current methods to disambiguate improvements in hand strength from gains in finger dexterity (i.e., the dynamic control of fingertip force vectors at low magnitudes). We adapted our novel instrumentation to evaluate finger dexterity in 130 typically developing children between the ages of 4 and 16 yr. We find that finger dexterity continues to develop well into late adolescence and musculoskeletal growth and strength are poorly correlated with the improvements in dexterity. Importantly, because these behavioral results seem to mirror the known timelines of neuroanatomical development up to adolescence, we speculate that they reflect the functional benefits of such continual neural maturation. This novel perspective now enables the systematic study of the functional roles of specific neuroanatomical structures and their connectivity, maturity, and plasticity. Moreover, the temporal dynamics of the fingertip force vectors shows improvements in stability that provide a novel way to look at the maturation of finger control. From a clinical perspective, our results provide a practical means to chart functional development of dexterous manipulation in typically developing children and could be adapted for clinical use and for use in children with developmental disorders.

Sit-to-stand movement in children with hemiplegic cerebral palsy: relationship with knee extensor torque and social participation

This study aimed to investigate the relationship between sit-to-stand (STS) movement, knee extensor torque and social participation in children with cerebral palsy (CP). Seven spastic hemiplegic CP patients (8.0 ± 2.2 years), classified by the Gross Motor Function Classification System as I and II, and 18 typical children (8.4 ± 2.3 years) participated in this study. Trunk, hips, knees, and ankles angles and temporal variables of STS movement were obtained by means of kinematics evaluation. Isokinetic evaluation was performed at 60°/s in the concentric passive mode to measure knee extensors torque. Social participation was assessed by the Assessment of Life Habits for Children (LIFE-H) scale. Results showed that children with spastic hemiplegic CP have lower knee extensor torque in the affected limb and restriction in social participation in dimensions related with fine motor control and language skills when compared to their typical peers. Except for ankle excursion in frontal plane, and ankle excursion and range in transverse plane, patients were similar to typical children regarding the strategies adopted to perform the STS movement, as well as in the participation dimensions related with gross motor function. Moreover, we found a significant non-linear correlation between knee extensors torque and some lower limb and trunk angles for children with CP. Therefore, during evaluation and rehabilitation processes, impairments in body functions and structures should be related with how much they affect a child's ability to perform functional activities, so rehabilitation protocols could be focused on individual needs.

Intensive upper extremity training for children with hemiplegia: from science to practice

For children with hemiplegic cerebral palsy, bimanual abilities are central to independent function. Over the last decade, considerable attention has been given to 2 forms of extended practice therapy for the upper limb, constraint-induced movement therapy and intensive bimanual training. This article reviews the varying nature of these 2 approaches and the existing scientific rationale supporting them. Comparisons between these 2 intensive upper extremity training approaches indicate similar improvements in unimanual capacity and bimanual performance outcomes; however, when considering participant and caregiver goal achievement, evidence favors a bimanual approach. Careful selection of either therapy for this population requires consideration of individual and contextual factors in relation to treatment goals. The key ingredients and dose responses remain unknown. Treatment intensity, intrinsic motivation, and individualization of treatment are hypothesized as requisite in either approach.

Hand grip function assessed by the box and block test is affected by object surfaces

STUDY DESIGN

N/A.

BACKGROUND

One of the hand function assessment tools is the Box and Block Test (BBT).

PURPOSE

To examine if the BBT score is affected by grip surfaces.

METHODS

Thirteen adults performed the BBT with wooden, rubber-covered, and paper-covered blocks. The BBT scores and time for seven movements (finger closing, contact to lift-off, transport before barrier, transport after barrier, release, return, and reach) were compared across the three block types.

RESULTS

The mean BBT score was 8% higher for the rubber blocks than the paper and wooden blocks (p<0.01) due to the reduced time for contact to lift-off (when the finger touches a block until the block is lifted).

CONCLUSIONS

Hand function assessments should be controlled for object surfaces. Therapists may vary grip difficulties by changing object surfaces. Redesigning daily objects with high-friction surfaces may increase grip function.

LEVEL OF EVIDENCE

N/A.

Six years after a modified constraint induced movement therapy (CIMT) program--what happens when the children have become young adults?

The aim is to describe the development of hand function in young adults with unilateral cerebral palsy (CP), who participated in a 2-week Constraint Induced Movement Therapy (CIMT) camp 6 years earlier. Eleven participants, 16-21 years at follow-up, were assessed at three occasions during 2005 and once in 2011. At the 6-year follow-up, performance on the Assisting Hand Assessment and the Jebsen-Taylor Hand Function test remained unchanged (P > 0.05) from the first assessment before the camp. Grip strength (Grippit®) increased in both the involved (+80.9%) and non-involved hand (+94.4%) (P < 0.05), while performance on the Melbourne Assessment tended to decrease (-7%). In conclusion, it seems that young adults with unilateral CP maintain their hand function performance at the same level as in the early adolescent period. Interestingly, the grip strength increased over time also for the involved hand.

Arm and hand function in children with unilateral cerebral palsy: a one-year follow-up study

BACKGROUND

In children with unilateral cerebral palsy (CP), development of arm and hand function is often compromised by the underlying motor and sensory impairments. However, knowledge about the evolution of arm and hand function in this population is limited.

AIM

The aims were to map the evolution of scores on upper limb measures over one year in children with unilateral CP and to identify factors that influence time trends.

METHODS

Eighty-one children (43 males, 38 females; mean age 9y11mo (SD 3y3mo) range 5-15 y) were tested at baseline, at 6 and 12 months. According to the International Classification of Functioning, Disability and Health, body function measurements included passive range of motion, muscle tone, manual muscle strength and grip strength. Activity measurements included the Melbourne Assessment, the Jebsen-Taylor test, the Assisting Hand Assessment and the Abilhand-Kids questionnaire. Age, gender, etiology (congenital or acquired lesions) and Manual Ability Classification System (MACS) levels were analyzed as predictive factors, using mixed models.

RESULTS

Scores for grip strength (p = 0.001) and manual dexterity (Jebsen-Taylor test, p < 0.0001) increased significantly over time. MACS level (p = 0.03) and etiology (p = 0.02) had a significant influence on the time evolution of the Jebsen-Taylor scores. Other assessments showed no significant changes.

CONCLUSION

Motor impairments, movement quality and hemiplegic hand use in bimanual tasks do not spontaneously improve over one year, except for an age-related change in grip strength. However, an improvement was observed in manual dexterity, suggesting that some children can learn more adaptive movement strategies.

International Classification of Functioning, Disability and Health in children with cerebral palsy

PURPOSE

We intended to describe how concepts from recent models of disability have been studied for evaluation of children with cerebral palsy (CP) and their clinical implications.

METHOD

We revised studies that focused on the components of the International Classification of Functioning, Disability and Health (ICF) in children with CP.

RESULTS

Researchers have reported that children with CP exhibit impairments in various body functions/structures, limitations in functional activities performance and experience poorer participation outcomes than their typical peers. Moreover, it has been showed that participation of children with CP was affected by environmental factors.

CONCLUSION

Therefore, evaluation and rehabilitation processes should be focused on the quality of life improvement by emphasizing what a child can and wants to execute within the environment. Also, environmental factors should be recognized so that barriers could be minimized and adaptations to the environment achieved. However, few studies have verified the interrelationship between contextual factors and the functioning and disability domains in children with CP. This would allow us to know about approaches specifically designed for these children's needs.

Three-dimensional upper limb movement characteristics in children with hemiplegic cerebral palsy and typically developing children

The aim of this study was to measure which three-dimensional spatiotemporal and kinematic parameters differentiate upper limb movement characteristics in children with hemiplegic cerebral palsy (HCP) from those in typically developing children (TDC), during various clinically relevant tasks. We used a standardized protocol containing three reach tasks (forwards, upwards, and sideways), two reach-to-grasp tasks (with objects requiring different hand orientations), and three gross motor tasks. Spatiotemporal (movement duration, trajectory straightness, maximum velocity, and timing of maximum velocity), as well as kinematic parameters (discrete angles and waveforms of the trunk, scapula, shoulder, elbow and wrist), were compared between 20 children with HCP (age 10.9 ± 2.9 years) and 20 individually age-matched TDC (age 10.9 ± 3.0 years). Kinematic calculations followed the recommendations from the International Society of Biomechanics. Results showed that children with HCP had longer movement durations, less straight hand trajectories, and lower maximum velocities compared to the TDC. Timing of maximum velocity did not differ between both groups. The movement pathology in children with HCP was highlighted by increased trunk movements and reduced shoulder elevation during reaching and reach-to-grasp. We also measured an increased anterior tilting and protraction of the scapula in children with HCP, although differences were not significant for all tasks. Finally, compared to the TDC, children with HCP used less elbow extension and supination and more wrist flexion to execute all tasks. This study reported distinct 3D upper limb movement characteristics in children with HCP and age-matched TDC, establishing the discriminative ability of the measurement procedure. From a clinical perspective, combining spatiotemporal and kinematic parameters may facilitate the identification of the pathological movement patterns seen in children with HCP and thereby add to a well-targeted upper limb treatment planning.

Anticipatory postural adjustments in children with hemiplegia and diplegia

Anticipatory postural adjustments (APAs) play an important role in the performance of many activities requiring the maintenance of standing posture. However, little is known about if and how children with cerebral palsy (CP) generate APAs. Two groups of children with CP (hemiplegia and diplegia) and a group of children with typical motor development performed arm flexion and extension movements while standing on a force platform. Electromyographic activity of six trunk and leg muscles and displacement of center of pressure (COP) were recorded. Children with CP were able to generate anticipatory postural adjustments and produce directionally specific APAs and COP displacements similar to those described in adults and typically developing children. However, children with diplegia were unable to generate APAs of the same magnitude as children with typical development and hemiplegia and had higher baseline muscle activity prior to movement. In children with diplegia, COP was posteriorly displaced and peak acceleration was smaller during bilateral extension compared to children with hemiplegia. The outcomes of the study highlight the role of APAs in the control of posture of children with CP and point out the similarities and differences in anticipatory control in children with diplegia and hemiplegia. These differences may foster ideas for treatment strategies to enhance APAs in children with CP.

Lack of predictive control in lifting series of virtual objects by individuals with diplegic cerebral palsy

To date, research on the motor control of hand function in cerebral palsy has focused on children with hemiplegia, although many persons with diplegic cerebral palsy (dCP) have asymmetrically decreased hand function. We explored the predictive capabilities of the motor system in a simple motor task of lifting a series of virtual objects for five persons with spastic dCP and five age-matched controls. When a person lifts an object, s/he uses an expectation of the weight of the object to generate a motor command. We asked the study subjects to lift a series of increasing weights and determined whether they extrapolated from past experience to predict the next weight in the series, even though that weight had never been experienced. Planning of precision grasp was assessed by measurement of the grip force at the beginning of the lifting task and by estimating the motor command. Execution of precision grasp was assessed by measurement of the time interval between the onset of grip and the onset of movement. We found that persons with dCP demonstrated a lack of predictive feed-forward control in their lifting movements: they exhibited a significantly longer time between onset of grip and onset of movement than the control subjects and they did not predict the weight of the next object in the lifting task. In addition, for subjects with dCP, the time between the onset of grip and the onset of movement of the dominant hand correlated strongly with the outcome of a hand function test. We postulate that a higher-order motor planning deficit in addition to execution deficit are evident in the subjects with spastic diplegic.

Adults with a diagnosis of cerebral palsy: a mapping review of long-term outcomes

AIM

Cerebral palsy (CP) is recognized as a lifespan condition. This mapping review identifies outcomes that have been measured in adults with CP between 1970 and 2010 to determine if either the outcomes evaluated or the research methodologies have changed substantially.

METHOD

We performed a literature review. For studies to be included, participants had to be 16 years or older and 80% of the sample had to have a diagnosis of CP. Articles were grouped by decade, and outcomes were categorized using the International Classification of Functioning, Disability and Health (ICF) framework and terminology.

RESULTS

Fifty-eight articles were included in the mapping review. Both the number of studies and the types of outcomes investigated increased from 1970 to 2010. Outcomes representing the ICF component of Body Function and Structure were present across the period reviewed, whereas interest in contextual (personal or environmental) factors has primarily emerged since 2000.

INTERPRETATION

Gaps were identified by the mapping review. Large age ranges and heterogeneity of sample populations made it difficult to determine if the outcomes reported were due to ageing or the long-term consequences of CP. In addition, most reviewed articles described outcomes categorically, with few papers providing explanations or solutions to reported outcomes.

Best responders after intensive upper-limb training for children with unilateral cerebral palsy

OBJECTIVE

To delineate characteristics of best responders in a randomized trial comparing constraint-induced movement therapy (CIMT) to bimanual training for children with unilateral cerebral palsy.

DESIGN

Secondary analysis of a single-blind matched-pairs randomized comparison trial.

SETTING

Community sporting facilities in 2 Australian capital cities.

PARTICIPANTS

Children (n=64; mean age, 10.2±2.7y; 52% boys), matched for age, sex, side of hemiplegia, and upper-limb function, were randomized within pairs to CIMT or bimanual training. Sixty-one children who completed CIMT (n=31) or bimanual training (n=30) were included in this study.

INTERVENTIONS

Each intervention was delivered in day camps (total 60h over 10d) using a novel circus theme with goal-directed training.

MAIN OUTCOME MEASURES

Change between baseline, 3, and 26 weeks on the Melbourne Assessment of Unilateral Upper Limb Function (MUUL>7.4%), Assisting Hand Assessment (AHA>4 raw score points), and Canadian Occupational Performance Measure (COPM>2 points) defined best responders.

RESULTS

Poorer baseline hand function predicted a best response for unimanual capacity of the impaired upper limb (MUUL) immediately postintervention; however, at 26 weeks the odds of achieving a favorable outcome were 21 times greater for CIMT than bimanual training. A favorable response for bimanual performance (AHA) was predicted by immediate change in Jebsen-Taylor hand function test scores. Age (older), left-sided hemiplegia, and lower-baseline COPM performance scores significantly predicted favorable individualized outcomes.

CONCLUSIONS

Secondary analysis of a randomized trial directly comparing 2 upper-limb training models, found children with poorer hand function benefited most. Favorable outcomes for bimanual performance were associated with gains in movement efficiency and older children with left-sided hemiplegia achieved more favorable gains in perceived occupational performance.

Bimanual Training and Constraint-Induced Movement Therapy in Children With Hemiplegic Cerebral Palsy

Background. Constraint-induced movement therapy (CIMT) promotes hand function using intensive unimanual practice along with restraint of the less-affected hand. CIMT has not been compared with a treatment with equivalent dosing frequency and intensity in children with cerebral palsy (CP). Objectives. The authors report a randomized trial comparing CIMT and a bimanual intervention (hand-arm intensive bimanual therapy; HABIT) that maintains the intensity of practice associated with CIMT but where children are engaged in functional bimanual tasks. Methods. A total of 42 participants with hemiplegic CP between the ages of 3.5 and 10 years (matched for age and hand function) were randomized to receive 90 hours of CIMT or an equivalent dosage of functional bimanual training (HABIT) conducted in day-camp environments. A physical therapist blinded to treatment allocation tested hand function before and after treatment. The primary outcomes were changes in Jebsen-Taylor Test of Hand Function (JTTHF) and Assisting Hand Assessment (AHA) scores. Secondary measures included the Goal Attainment Scale (GAS). Results. Both the CIMT and HABIT groups demonstrated comparable improvement from the pretest to immediate posttest in the JTTHF and AHA ( P < .0001), which were maintained at 6 months. GAS, however, revealed greater progress toward goals for the HABIT group ( P < .0001), with continued improvement across test sessions for both groups ( P < .0001). Conclusions. Both CIMT and bimanual training lead to similar improvements in hand function. A potential benefit of bimanual training is that participants may improve more on self-determined goals.

Equivalent Retention of Gains at 1 Year After Training With Constraint-Induced or Bimanual Therapy in Children With Unilateral Cerebral Palsy

Objectives. To determine retention of treatment outcomes at 52 weeks following a matched-pairs randomized comparison trial of constraint-induced movement therapy (CIMT) and bimanual training (BIM). Methods. Sixty-four children (mean age = 10.2 ± 2.7 years, 52% male) were included. The Melbourne Assessment of Unilateral Upper Limb Function (MUUL), Assisting Hand Assessment (AHA), and Canadian Occupational Performance Measure (COPM) were the primary outcome measures. Evaluations were at baseline and at 26 and 52 weeks. Results. There were no baseline differences between groups on any measure. No significant differences were found between groups on primary outcomes at 52 weeks. Both groups retained the significant gains made from baseline to 26 weeks at the 1-year follow-up assessment for unimanual capacity on the MUUL, for bimanual performance on the AHA, and on the COPM. Conclusion. Intensive unimanual and bimanual training can both lead to long-term significant improvements in unimanual capacity, bimanual performance, and individualized outcomes. Gains established at 26 weeks were maintained at 12 months postintervention despite most children receiving no direct therapy during that time.

Botulinum toxin assessment, intervention and follow-up for paediatric upper limb hypertonicity: international consensus statement

The primary objective of this paper was to evaluate the published evidence of efficacy and safety of botulinum neurotoxin (BoNT) injections in paediatric upper limb hypertonia (PULH). Secondary objectives included the provision of clinical context, based on evidence and expert opinion, in the areas of assessment, child and muscle selection, dosing, and adjunctive treatment. A multidisciplinary panel of authors systematically reviewed, abstracted, and classified relevant literature. Recommendations were based on the American Academy of Neurology (AAN) evidence classification. Following a literature search, 186 potential articles were screened for inclusion, and 15 of these met the criteria and were reviewed. Grade A evidence was found to support the use of BoNT to reach individualized therapeutic goals for PULH. There is grade B evidence (probably effective) for tone reduction following BoNT injections and grade U evidence (inconclusive) for improvement in upper limb (UL) activity and function. BoNT injections were generally found to be safe and well tolerated with the most common side effect identified as a transient decrease in grip strength.