Constraint-Induced Movement Therapy for Cerebral Palsy: A Randomized Trial

Neuroimaging and Neurological Outcomes in Perinatal Arterial Ischemic Stroke: A Systematic Review and Meta-Analysis

BACKGROUND

Prediction of outcomes in perinatal arterial ischemic stroke (PAIS) is challenging. We performed a systematic review and meta-analysis to determine whether infarct characteristics can predict outcomes in PAIS.

METHODS

A systematic search was conducted using five databases in January 2023. Studies were included if the sample included children with neonatal or presumed PAIS; if infarct size, location, or laterality was indicated; and if at least one motor, cognitive, or language outcome was reported. The level of evidence and risk of bias were evaluated using the Risk of Bias in Non-Randomized Studies of Interventions tool. Meta-analyses were conducted comparing infarct size or location with neurological outcomes when at least three studies could be analyzed.

RESULTS

Eighteen full-text articles were included in a systematic review with nine included in meta-analysis. Meta-analyses revealed that small strokes were associated with a lower risk of cerebral palsy/hemiplegia compared with large strokes (risk ratio [RR] = 0.263, P = 0.001) and a lower risk of epilepsy (RR = 0.182, P < 0.001). Middle cerebral artery (MCA) infarcts were not associated with a significantly different risk of cerebral palsy/hemiplegia compared with non-MCA strokes (RR = 1.220, P = 0.337). Bilateral infarcts were associated with a 48% risk of cerebral palsy/hemiplegia, a 26% risk of epilepsy, and a 58% risk of cognitive impairment.

CONCLUSIONS

Larger stroke size was associated with worse outcomes across multiple domains. Widely heterogeneous reporting of infarct characteristics and outcomes limits the comparison of studies and the analysis of outcomes. More consistent reporting of infarct characteristics and outcomes will be important to advance research in this field.

Joystick-Operated Ride-On Toy Navigation Training for Children With Hemiplegic Cerebral Palsy: A Pilot Study

IMPORTANCE

Children with hemiplegic cerebral palsy (HCP) require intensive task-oriented training to make meaningful gains in affected upper extremity (UE) motor function.

OBJECTIVE

To evaluate the acceptability and utility of single joystick-operated ride-on toy (ROT) navigation training incorporated into a modified constraint-induced movement therapy (CIMT) camp for children with HCP.

DESIGN

Single group pretest-posttest design.

SETTING

Three-wk structured CIMT camp.

PARTICIPANTS

Eleven children with HCP between ages 3 and 14 yr.

INTERVENTION

Children received group-based CIMT for 6 hr/day, 5 days/wk, for 3 wk. As part of camp activities, children also received ROT navigation training for 20 to 30 min/day, 5 days/wk, for 3 wk.

OUTCOMES AND MEASURES

We assessed children's acceptance of ROT training by monitoring adherence and evaluating child engagement (affect and attention) during training sessions. The effects of ROT training combined with other camp activities on children's affected UE motor function were also assessed with the standardized Quality of Upper Extremity Skills Test (QUEST) and training-specific measures of ROT maneuvering accuracy.

RESULTS

Children demonstrated high levels of training adherence, positive affect, and task-appropriate attention across weeks. Positive engagement during ROT sessions was correlated with independent navigation. We also found medium- to large-sized improvements in QUEST scores and toy-maneuvering capabilities after the combined program.

CONCLUSIONS AND RELEVANCE

Our pilot data support the use of joystick-operated ROTs as child-friendly therapy adjuncts that can be incorporated into intensive UE training programs to improve adherence and motivation in therapy programs, boost treatment dosing, and promote affected UE motor function in children with HCP. Plain-Language Summary: This pilot study offers promising evidence that supports the use of modified single joystick-operated ride-on toys (ROTs) for children with hemiplegic cerebral palsy (HCP). The study used ROTs as one of several interventions that were part of a constraint-induced movement therapy (CIMT) camp program for children with HCP. The ROTs boosted children's motivation, their engagement with and adherence to training, and their practice in using their affected upper extremity (UE) for goal-directed activities in their natural settings. ROTs are accessible, age-appropriate, and easy-to-use devices for both occupational therapy clinicians and families to encourage children to use their affected UEs by challenging their perceptual, motor-planning, problem-solving, and movement-control skills in an enjoyable and engaging way. ROTs can be used within and outside conventional rehabilitation settings.

A Pilot Feasibility Study on the Use of Dual-Joystick-Operated Ride-on Toys in Upper Extremity Rehabilitation for Children with Unilateral Cerebral Palsy

Children with unilateral cerebral palsy (UCP) require task-oriented practice several hours per week to produce meaningful gains in affected upper extremity (UE) motor function. Clinicians find it challenging to provide services at the required intensity and sustain child engagement. This pilot study assessed the acceptance and utility of a child-friendly program using dual-joystick-operated ride-on toys incorporated into an intensive UE rehabilitation camp. Eleven children with UCP between four and 10 years received ride-on-toy navigation training for 20-30 min/day, five days/week, for three weeks as part of camp programming. We report session adherence and percent time children spent in task-appropriate attention/engagement across sessions. The overall effects of camp programming on children's motor function were assessed using the Shriner's Hospital Upper Extremity Evaluation (SHUEE) from pretest to posttest and using training-specific measures of bimanual UE use and navigational accuracy. Children showed excellent adherence and sustained task-appropriate engagement across sessions. The combined program led to improved navigational accuracy (p-values ≤ 0.007) as well as spontaneous affected UE use during bimanual activities outside the training context (p < 0.001). Our pilot study provides promising evidence for using modified, commercially available ride-on toys to incentivize rehabilitation and boost repetitive, task-oriented UE practice among children with UCP.

A Training Program Using Modified Joystick-Operated Ride-on Toys to Complement Conventional Upper Extremity Rehabilitation in Children with Cerebral Palsy: Results from a Pilot Study

The pilot study assessed the utility of a training program using modified, commercially available dual-joystick-operated ride-on toys to promote unimanual and bimanual upper extremity (UE) function in children with cerebral palsy (CP). The ride-on-toy training was integrated within a 3-week, intensive, task-oriented training camp for children with CP. Eleven children with hemiplegia between 4 and 10 years received the ride-on-toy training program 20-30 min/day, 5 days/week for 3 weeks. Unimanual motor function was assessed using the Quality of Upper Extremity Skills Test (QUEST) before and after the camp. During ride-on-toy training sessions, children wore activity monitors on both wrists to assess the duration and intensity of bimanual UE activity. Video data from early and late sessions were coded for bimanual UE use, independent navigation, and movement bouts. Children improved their total and subscale QUEST scores from pretest to post-test while increasing moderate activity in their affected UE from early to late sessions, demonstrating more equal use of both UEs across sessions. There were no significant changes in the rates of movement bouts from early to late sessions. We can conclude that joystick-operated ride-on toys function as child-friendly, intrinsically rewarding tools that can complement conventional therapy and promote bimanual motor functions in children with CP.

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.

Pertinence of Constraint-Induced Movement Therapy in Neurological Rehabilitation: A Scoping Review

Constraint-induced movement therapy (CIMT) is a neurorehabilitation technique that aims to restore motor function in patients with central nervous system injuries. Based on behavioral research conducted, CIMT has been found effective in restoring motor function in various conditions including stroke, cerebral palsy, traumatic brain injury (TBI), and more. The therapy combines neurological and behavioral mechanisms to induce neuroplastic changes and overcome learned nonuse. Modified CIMT (mCIMT) is a variant that focuses on sensorimotor functioning in the affected limb. This review summarizes studies on CIMT and mCIMT, with a focus on stroke, cerebral palsy, and other conditions. Results show that CIMT and mCIMT demonstrate significant improvements in motor function and quality of life. The studies underscore the importance of long-term research, comparative or combined therapies, and exploration of less-studied conditions like multiple sclerosis (MS) and brachial plexus injury. Overall, CIMT and mCIMT hold promise for neurorehabilitation, emphasizing the need for further investigation to enhance their effectiveness and application.

Evidence for Using ACQUIRE Therapy in the Clinical Application of Intensive Therapy: A Framework to Guide Therapeutic Interactions

Intensive therapies have become increasingly popular for children with hemiparesis in the last two decades and are specifically recommended because of high levels of scientific evidence associated with them, including multiple randomized controlled trials and systematic reviews. Common features of most intensive therapies that have documented efficacy include: high dosages of therapy hours; active engagement of the child; individualized goal-directed activities; and the systematic application of operant conditioning techniques to elicit and progress skills with an emphasis on success-oriented play. However, the scientific protocols have not resulted in guiding principles designed to aid clinicians with understanding the complexity of applying these principles to a heterogeneous clinical population, nor have we gathered sufficient clinical data using intensive therapies to justify their widespread clinical use beyond hemiparesis. We define a framework for describing moment-by-moment therapeutic interactions that we have used to train therapists across multiple clinical trials in implementing intensive therapy protocols. We also document outcomes from the use of this framework during intensive therapies provided clinically to children (7 months-20 years) from a wide array of diagnoses that present with motor impairments, including hemiparesis and quadriparesis. Results indicate that children from a wide array of diagnostic categories demonstrated functional improvements.

Outcomes Associated with a Single Joystick-Operated Ride-on-Toy Navigation Training Incorporated into a Constraint-Induced Movement Therapy Program: A Pilot Feasibility Study

Our research aims to evaluate the utility of joystick-operated ride-on-toys (ROTs) as therapeutic adjuncts to improve upper extremity (UE) function in children with hemiplegic cerebral palsy (HCP). This study assessed changes in affected UE use and function following a three-week ROT navigation training incorporated into an existing constraint-induced movement therapy (CIMT) camp in 11 children (3-14 years old) with HCP. We report changes in scores on the standardized Shriners Hospital Upper Extremity Evaluation (SHUEE) from pretest-to-posttest and changes from early-to-late sessions in percent time spent by the affected arm in: (a) "moderate-to-vigorous activity", "light activity" and "no activity" bouts based on accelerometer data and (b) "independent", "assisted", and "no activity" bouts based on video data. We also explored relationships between standardized measures and training-specific measures of affected UE activity. We found small-to-medium improvements in the SHUEE scores. Between 90 and 100% of children also showed medium-to-large improvements in affected UE activity from early-to-late sessions using accelerometers and small improvements via video-based assessments. Exploratory analyses suggested trends for relationships between pretest-posttest and training-specific objective and subjective measures of arm use and function. Our pilot data suggest that single joystick-operated ROTs may serve as motivating, child-friendly tools that can augment conventional therapies such as CIMT to boost treatment dosing, promote affected UE movement practice during real-world navigation tasks, and ultimately improve functional outcomes in children with HCP.

Investigating the Effect of Leap Motion on Upper Extremity Rehabilitation in Children with Cerebral Palsy: A Randomized Controlled Trial

In this randomized clinical trial, we look for the following questions' answer: How does the integration of LMC affect (1) upper extremity (UE) function, (2) grip strength, and (3) lateral and palmar pinch strength in children with cerebral palsy (CP), in comparison with conventional rehabilitation methods? Twenty patients were randomly assigned to LMC (case) or conventional (control) groups. The grip, lateral and palmar pinch forces increased in case group patients more than control group both at the end of intervention (P < .001 for all three), and at 20 weeks' follow-up (P values 0.035, 0.002, and 0.002). The Quality of Upper Extremity Skills Test (QUEST) score changes were similar between two groups, except for grasp score at the end of step 2 and 3 (P = .04 and 0.01, respectively). The addition of LMC to the rehabilitation program of patients with CP may improve the UE motor function outcomes.

Constraint-induced movement therapy alleviates motor impairment by inhibiting the accumulation of neutrophil extracellular traps in ischemic cortex

Stroke is a major cause of mortality and morbidity and most acute strokes are ischemic. Evidence-based medicine has demonstrated the effectiveness of constraint-induced movement therapy (CIMT) in the recovery of motor function in patients after ischemic stroke, but the specific treatment mechanism remains unclear. Herein, our integrated transcriptomics and multiple enrichment analysis studies, including Gene Ontology (GO), Kyoto Encyclopedia of Genes and Genomes (KEGG), and gene set enrichment analysis (GSEA) studies show that CIMT conduction broadly curtails immune response, neutrophil chemotaxis, and chemokine-mediated signaling pathway, CCR chemokine receptor binding. Those suggest the potential effect of CIMT on neutrophils in ischemic mice brain parenchyma. Recent studies have found that accumulating granulocytes release extracellular web-like structures composed of DNA and proteins called neutrophil extracellular traps (NETs), which destruct neurological function primarily by disrupting the blood-brain barrier and promoting thrombosis. However, the temporal and spatial distribution of neutrophils and their released NETs in parenchyma and their damaging effects on nerve cells remain unclear. Thus, utilizing immunofluorescence and flow cytometry, our analyses uncovered that NETs erode multiple regions such as primary motor cortex (M1), striatum (Str), nucleus of the vertical limb of the diagonal band (VDB), nucleus of the horizontal limb of the diagonal band (HDB) and medial septal nucleus (MS), and persist in the brain parenchyma for at least 14 days, while CIMT can reduce the content of NETs and chemokines CCL2 and CCL5 in M1. Intriguingly, CIMT failed to further reduce neurological deficits after inhibiting the NET formation by pharmacologic inhibition of peptidylarginine deiminase 4 (PAD4). Collectively, these results demonstrate that CIMT could alleviate cerebral ischemic injury induced locomotor deficits by modulating the activation of neutrophils. These data are expected to provide direct evidence for the expression of NETs in ischemic brain parenchyma and novel insights into the mechanisms of CIMT protecting against ischemic brain injury.

Rehabilitation for Pediatric Stroke in Low and Middle Income Countries: A Focused Review

Rehabilitation for pediatric stroke survivors can maximize a child's potential through each developmental stage of life. Timely diagnosis and referral to a rehabilitation specialist may harness opportunities to maximize brain plasticity, to help children adapt and learn, and to participate in and enjoy daily life to their capability. The aim of this focused review is to explore current rehabilitation models and evidence-based interventions for pediatric stroke survivors in Low- and Middle- Income Countries (LMICs) and to provide recommendations for future research and focused areas of improvement.There are several published pediatric stroke guidelines from the American Heart Association (AHA), Canada, Australia, and the United Kingdom (UK) which provide specific recommendations for rehabilitation, although the suggested intervention and services vary. There are no current guidelines developed in or contextually adapted for LMICs, although the current pediatric stroke guidelines emphasize the need to develop interventions that fit the cultural and environmental contexts. The World Health Organization (WHO) Rehabilitation 2030 initiative acknowledges profound unmet rehabilitation needs around the world, especially in LMICs. According to the WHO, LMICs have less than ten skilled rehabilitation professionals per one million people. Enhancing the understanding of rehabilitation services in LMICs could lead to nationally supported workforce education initiatives targeted to expand the number of locally trained therapy providers. This could improve access to and delivery of quality rehabilitation interventions to pediatric stroke survivors in these settings.

Rehabilitation in Pediatric Stroke: Cognition and Behavior

Pediatric stroke is associated with a range of maladaptive cognitive and behavioral outcomes that often require targeted intervention. Despite increasing research on neuropsychological outcomes over the past decade, evidence for effective therapies and interventions for the most commonly reported cognitive and behavioral challenges is still limited. The most widely prescribed interventions address more overt deficits in sensorimotor and speech/language functions, yet interventions for higher-order cognitive, linguistic and behavioral deficits are notably less defined. Moreover, concepts of rehabilitation in adult stroke cannot be easily translated directly to pediatric populations because the effect of stroke and recovery in the developing brain takes a very different course than in the mature brain. In pediatric stroke, neuropsychological deficits often emerge gradually over time necessitating a long-term approach to intervention. Furthermore, family and school context often play a much larger role. The goal of this review is to describe cognitive and behavioral interventions for perinatal and childhood stroke, as motor rehabilitation is covered elsewhere in this issue. We also discuss cognitive aspects of current rehabilitative therapies and technology. Acknowledging the current limited state of stroke-specific rehabilitation research in children, findings from pediatric acquired brain injury intervention and use of transdiagnostic approaches lend important insights. Because there is limited support for single domain (cognitive) trainings and translation of research rehabilitation programs to clinical practice can be challenging, the value of holistic multidisciplinary approaches to improve everyday function in children and adolescents following stroke is emphasized.

Facilitators and Barriers to Care for Patients with Disabilities in Primary Pediatrics

Nearly 20% of children in the United States have special health care needs, and they often experience disparities in health outcomes. This article reviews barriers to and facilitators of primary pediatric care for children within four defined categories of disability: (1) physical disabilities, both temporary and permanent; (2) chronic conditions requiring accommodations, including mental health conditions; (3) sensory disabilities and conditions; and (4) cognitive, educational, neurodevelopmental, and social disabilities. Primary care facilitators include interventions for both providers and patients that focus on time as a valued resource, provide psychosocial support, coordinate interdisciplinary teams of care, and provide training for providers. Barriers include exclusion of patients with disabilities from research trials and gaps in educational reform regarding ableism and hidden disabilities. Identified facilitators should be implemented on a larger scale, and barriers need to be addressed further so we may better support children with disabilities. [Pediatr Ann. 2022;51(6):e243-e253.].

Exploring the Intensity, Frequency, and Duration of Pediatric Constraint Induced Movement Therapy Published Research: A Content Analysis

Constraint Induced Movement Therapy (CIMT) utilizes a behavioral approach to neurorehabilitation involving constraint of an unaffected upper extremity which forces the use of the affected extremity. There is substantial evidence supporting the effectiveness of CIMT among both children and adults. The purpose of this study was to explore the frequency, intensity, and duration parameters across the published clinical outcomes related to pediatric CIMT (pCIMT) among children and youth populations. A content analysis approach was used to search the following databases Google Scholar, OT seeker, American Occupational Therapy Association special interest section, Medline, EbscoHost, and Cinhal. A total of 141 studies were identified via the initial search, with 51 studies meeting inclusion criteria. The findings revealed that 100% of the studies included restraint of the non-affected upper extremity, 73% incorporated repetitive task-oriented training, but less than half prescribed home practice strategies. Further, only 34% of the studies reviewed included all three components of CIMT. Outpatient hospital clinics and home-based settings were the most utilized settings for research studies. The mean minutes per session was M = 205.53, SD = 164.99. As part of the plan of care, the duration and frequency of therapy both had similar means (~M = 3.60) and standard deviations (~SD = 1.65). There was a significant variance of hours during (SD = 139.54) and outside of therapy (SD = 130.06). The results of this study, together with other emerging evidence, can assist practitioners in prescribing dosages dependent on the setting, the pediatric client, and their current functional status.

Childhood stroke

Stroke is an important cause of neurological morbidity in children; most survivors have permanent neurological deficits that affect the remainder of their life. Stroke in childhood, the focus of this Primer, is distinguished from perinatal stroke, defined as stroke before 29 days of age, because of its unique pathogenesis reflecting the maternal-fetal unit. Although approximately 15% of strokes in adults are haemorrhagic, half of incident strokes in children are haemorrhagic and half are ischaemic. The causes of childhood stroke are distinct from those in adults. Urgent brain imaging is essential to confirm the stroke diagnosis and guide decisions about hyperacute therapies. Secondary stroke prevention strongly depends on the underlying aetiology. While the past decade has seen substantial advances in paediatric stroke research, the quality of evidence for interventions, such as the rapid reperfusion therapies that have revolutionized arterial ischaemic stroke care in adults, remains low. Substantial time delays in diagnosis and treatment continue to challenge best possible care. Effective primary stroke prevention strategies in children with sickle cell disease represent a major success, yet barriers to implementation persist. The multidisciplinary members of the International Pediatric Stroke Organization are coordinating global efforts to tackle these challenges and improve the outcomes in children with cerebrovascular disease.