Normative and validation studies of the Nine-hole Peg Test with children

Identifying fine motor difficulties in children with acute lymphoblastic leukemia: a scoping review

PURPOSE

Survival rates for children diagnosed with acute lymphoblastic leukemia (ALL) have increased significantly over recent decades, and thus attention shifted toward understanding the adverse effects of cancer treatment. Chemotherapy has side effects that could affect muscle state and diminish motor performance. This scoping review was conducted to map the breadth of evidence for different tools used in fine motor skills assessment, the extent of upper extremity strength, and fine motor performance, highlighting the potential risk factors that may influence these skills.

METHODS

In March 2023, full-text studies that examined fine motor performance and/or upper extremity strength were identified via searches in PubMed, Science Direct, Scopus, Web of Science, and PEDro databases. The titles and abstracts of selected studies were screened according to the inclusion and exclusion criteria.

RESULTS

The search yielded initial 418 citations and 26 peer-reviewed articles were finally included in the review. Considerable heterogeneity was observed regarding the methods of evaluating fine motor skills. The results of this review indicate that children and adolescents with ALL experienced fine motor limitations and upper extremity weakness either during or after cessation of treatment.

CONCLUSION

This scoping review presents a broad overview of the literature addressing fine motor difficulties in the pediatric population with ALL. Results accentuate the need to incorporate strengthening and occupational therapy training to preserve muscle strength and minimize future fine motor problems along the course of chemotherapeutic treatment. Little evidence was reported regarding the risk factors that may impair muscle strength and motor performance.

Does the Effect of Mental Fatigue Created by Motor Imagery on Upper Extremity Functions Change with Diaphragmatic Breathing Exercises? A Randomized, Controlled, Single-Blinded Trial

Background and Objectives: This study focused on the impact of mental fatigue induced by motor imagery on upper limb function, an area with limited research compared to lower limb performance. It aimed to explore how diaphragmatic breathing exercises influence these effects. Materials and Methods: This study included 30 participants, and Group 1 participated in 12 sessions of diaphragmatic breathing exercises under the supervision of a physiotherapist; Group 2 did not receive any intervention. For all the participants, mental fatigue was induced with motor imagery before and after the intervention, and evaluations were performed before and after mental fatigue. Upper extremity functions were evaluated using isometric elbow flexion strength, hand grip strength, upper extremity reaction time and endurance, finger reaction time, the nine-hole peg test, shoulder position sense, light touch-pressure threshold, and two-point discrimination. Results: The study results showed that after mental fatigue, there was a decrease in isometric elbow flexion strength, nondominant hand grip strength, and nondominant upper extremity endurance, and an increase in nondominant tactile sensation (p < 0.05). No changes were found in two-point discrimination, nine-hole peg test time, and position sense on either side (p > 0.05). The effect of mental fatigue on isometric elbow flexion strength and nondominant grip strength showed significant improvement following diaphragmatic breathing exercises (p < 0.05). Conclusions: This study found that mental fatigue from motor imagery can impact elbow flexion, hand grip strength, upper extremity endurance, and tactile sensitivity. Breathing exercises may help improve strength parameters affected by mental fatigue. It is crucial to consider these effects on upper extremity functions in rehabilitation programs.

Combining conventional and smartphone technologies to evaluate the psychomotor status in chronic malnutrition: A cross-sectional pilot study in sub-Saharan Africa

Malnutrition remains a pressing health concern in developing nations, contributing to growth delay (stunting) and psychomotor impairments among the youth. Tanzania has the highest prevalence of stunting, yet the psychomotor status of its population has not been previously studied. To address this gap, we gathered anthropometric, nutritional, and psychomotor data from 211 children with the aim of assessing the reliability of digital tools as indicators of psychomotor performance in relation to the nutritional status. Collected anthropometric measures included middle-upper arm circumference (MUAC), triceps skinfold thickness (TST), and handgrip strength, while psychomotor variables were assessed using digital finger tapping test (DFTT), eye-tracking test (ETT), and nine-hole peg test (9HPT). Statistical analysis revealed significant associations between age and both MUAC and handgrip strength (R = 0.5, p < 0.001). Moreover, DFTT and 9HPT demonstrated a correlation with each other (p = 0.026) and with MUAC, handgrip strength, and age (p < 0.001). Notably, lower stature was independently linked to slower horizontal eye movements (p < 0.001). Findings underscores the crucial link between nutrition and psychomotor skills in Tanzanian children. Digital tests like DFTT, ETT, and the 9HPT show promise for assessing psychomotor performance. Addressing malnutrition requires comprehensive interventions. Future research should explore long-term effects of interventions in resource-limited settings.

Exploring 24-Hour Movement Behaviors in Early Years: Findings From the SUNRISE Pilot Study in Tunisia

PURPOSE

The International Study of Movement Behaviors in the Early Years (SUNRISE) was conducted in Tunisia to assess the proportion of preschoolers who met the World Health Organization guidelines for physical activity, sedentary behavior, and sleep. The study also evaluated the feasibility of the methods for the SUNRISE study.

METHODS

Five kindergartens were recruited from urban and rural areas in Tunisia. Physical activity and sleep duration were assessed using a waist-worn ActiGraph. Screen time and sleep quality were assessed via an interview-administered parent questionnaire. The NIH Toolbox was used.

RESULTS

A total of 112 preschoolers were assessed (50 boys, age = 4.1 [0.58]). Only 18% of children met all recommendations of the World Health Organization guidelines, while 53% met the sedentary screen time (in minutes per day), and 41% met physical activity recommendation (in minutes per day). Eighty-one percent of children met the sleep duration recommendation (in minutes per day). There was good compliance with the ActiGraph protocol.

CONCLUSIONS

This pilot study provided important insights into the feasibility of the study and the movement behaviors of Tunisian preschool children. The results suggest there is a need to promote healthy levels of physical activity and sedentary screen time in children, which should be a priority in public health initiatives, including preschool curricula, in Tunisia.

Hand function after neonatal stroke: A graph model based on basal ganglia and thalami structure

INTRODUCTION

Neonatal arterial ischemic stroke (NAIS) is a common model to study the impact of a unilateral early brain insult on developmental brain plasticity and the appearance of long-term outcomes. Motor difficulties that may arise are typically related to poor function of the affected (contra-lesioned) hand, but surprisingly also of the ipsilesional hand. Although many longitudinal studies after NAIS have shown that predicting the occurrence of gross motor difficulties is easier, accurately predicting hand motor function (for both hands) from morphometric MRI remains complicated. The hypothesis of an association between the structural organization of the basal ganglia (BG) and thalamus with hand motor function seems intuitive given their key role in sensorimotor function. Neuroimaging studies have frequently investigated these structures to evaluate the correlation between their volumes and motor function following early brain injury. However, the results have been controversial. We hypothesize the involvement of other structural parameters.

METHOD

The study involves 35 children (mean age 7.3 years, SD 0.4) with middle cerebral artery NAIS who underwent a structural T1-weighted 3D MRI and clinical examination to assess manual dexterity using the Box and Blocks Test (BBT). Graphs are used to represent high-level structural information of the BG and thalami (volumes, elongations, distances) measured from the MRI. A graph neural network (GNN) is proposed to predict children's hand motor function through a graph regression. To reduce the impact of external factors on motor function (such as behavior and cognition), we calculate a BBT score ratio for each child and hand.

RESULTS

The results indicate a significant correlation between the score ratios predicted by our method and the actual score ratios of both hands (p < 0.05), together with a relatively high accuracy of prediction (mean L1 distance < 0.03). The structural information seems to have a different influence on each hand's motor function. The affected hand's motor function is more correlated with the volume, while the 'unaffected' hand function is more correlated with the elongation of the structures. Experiments emphasize the importance of considering the whole macrostructural organization of the basal ganglia and thalami networks, rather than the volume alone, to predict hand motor function.

CONCLUSION

There is a significant correlation between the structural characteristics of the basal ganglia/thalami and motor function in both hands. These results support the use of MRI macrostructural features of the basal ganglia and thalamus as an early biomarker for predicting motor function in both hands after early brain injury.

Is mirror therapy combined with a routine physiotherapy protocol effective for children with obstetrical upper brachial plexus palsy?

STUDY DESIGN

Randomized controlled study.

INTRODUCTION

Mirror therapy is a rehabilitation strategy based on the repeated use of the mirror illusion and also one of the treatment choice of brachial plexus injuries.

PURPOSE

We aimed to determine the effects of mirror therapy combined with a routine rehabilitation program on upper limb motor function in children with obstetric brachial plexus injury.

METHODS

Twenty children with obstetric brachial palsy were included in this study. They were randomly allocated to either control (n = 10) or mirror therapy (n = 10) group. The following clinical tools were used to assess the upper extremity function: Active Movement Scale (AMS), Modified Mallet Scale (MMS), Hand Grip Strength (HGS) Test, Finger Grip Strength (FGSM) Test, Box and Block Test (BBT), Nine Hole Peg Test (9-HPT), and goniometric measurement. Both groups received the same routine physiotherapy program for 8 weeks. The study group underwent mirror therapy in addition to the rehabilitation program.

RESULTS

The mean age of the study population was 11.35 ± 4.12 years. There was no change in the goniometric values, AMS and MMS scores after the treatment in both groups (p > 0.05), except for the improvement of the wrist extension in the study group (p < 0.05). There was an increase in both HGS and FGS scores in the study group. Only FGS scores improved in the control group after the intervention (p < 0.05). 9-HPT and BBT scores improved in both groups (p < 0.05). All other parameters tested were comparable between the two groups after the treatment.

CONCLUSIONS

The results of this study did not show any additional benefits of mirror therapy combined with a rehabilitation protocol compared to routine physiotherapy treatment, but was not adequately powered to do so.

Functional recovery after reduced pediatric fractures of the forearm with respect to perceived limitations, common post-traumatic symptoms, range of motion, and dexterity: a prospective study

PURPOSE

Studies on functional recovery after pediatric forearm fractures are scarce. Outcome measures are usually (retrospectively) incorporated to compare treatments. How these parameters recover has only rarely fallen within the scope. Aim was to provide insight into "normal recovery" by evaluating how limitations, post-traumatic symptoms, range of motion (ROM) and dexterity recuperate.

MATERIALS AND METHODS

Prospective observational study regarding children 4 and 18 years with a reduced forearm fracture. Limitations, post-traumatic symptoms, ROM, and dexterity were evaluated 6 weeks, 3 and 6 months post-trauma. ROM of the unaffected side was used as a baseline.

RESULTS

Of 54 participants 25.9% and 5.9% perceived limitations after 3 respectively 6 months. Pain, swelling and hypertrichosis were common symptoms. Movements distal from the elbow were restrained 6 weeks post-trauma. Supination and palmar flexion were most affected, followed by dorsal flexion and pronation. Palmar flexion and pronation were still affected after 3 months and associated with treatment invasiveness. Dexterity was diminished at 6 weeks only.

CONCLUSIONS

Mild limitations are common. Further investigation of the association between pain, reduced sensitivity and hypertrichosis with treatment invasiveness is warranted. Regarding ROM supination, pronation, palmar and dorsal flexion should be incorporated in future studies. Dexterity is an unsuitable outcome measure.IMPLICATIONS FOR REHABILITATIONThis study relates to monitoring recovery from pediatric forearm fractures.Physicians ought to realize that one in four children experience limitations preceding 3 months post-trauma, in which case involvement of a hand therapist should be considered.Pain, swelling and especially hypertrichosis are common post-traumatic symptoms in children and should on itself not immediately raise concerns for complex regional pain syndrome (CRPS).To assess recovery of range of motion measuring pronation, supination, dorsal, and palmar flexion is sufficient.

Associations of actigraphy measures of sleep duration and continuity with executive function, vigilance, and fine motor control in children with snoring and mild sleep-disordered breathing

STUDY OBJECTIVES

Children with snoring and mild sleep-disordered breathing may be at increased risk for neurocognitive deficits despite few obstructive events. We hypothesized that actigraphy-based sleep duration and continuity associate with neurobehavioral functioning and explored whether these associations vary by demographic and socioeconomic factors.

METHODS

298 children enrolled in the Pediatric Adenotonsillectomy Trial, ages 3 to 12.9 years, 47.3% from racial or ethnic minority groups, with habitual snoring and an apnea-hypopnea index < 3 were studied with actigraphy (mean 7.5 ± 1.4 days) and completed a computerized vigilance task (Go-No-Go) and a test of fine motor control (9-Hole Pegboard). Caregivers completed the Behavior Rating Inventory of Executive Function. Regression analyses evaluated associations between sleep exposures (24-hour and nocturnal sleep duration, sleep fragmentation index, sleep efficiency) with the Behavior Rating Inventory of Executive Function Global Executive Composite index, pegboard completion time (fine motor control), and vigilance (d prime on the Go-No-Go), adjusting for demographic factors and study design measures.

RESULTS

Longer sleep duration, higher sleep efficiency, and lower sleep fragmentation were associated with better executive function; each additional hour of sleep over 24 hours associated with more than a 3-point improvement in executive function (P = .002). Longer nocturnal sleep (P = .02) and less sleep fragmentation (P = .001) were associated with better fine motor control. Stronger associations were observed for boys and children less than 6 years old.

CONCLUSIONS

Sleep quantity and continuity are associated with neurocognitive functioning in children with mild sleep-disordered breathing, supporting efforts to target these sleep health parameters as part of interventions for reducing neurobehavioral morbidity.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Pediatric Adenotonsillectomy for Snoring (PATS); URL: https://clinicaltrials.gov/ct2/show/NCT02562040; Identifier: NCT02562040.

CITATION

Robinson KA, Wei Z, Radcliffe J, et al. Associations of actigraphy measures of sleep duration and continuity with executive function, vigilance, and fine motor control in children with snoring and mild sleep-disordered breathing. J Clin Sleep Med. 2023;19(9):1595-1603.

Translation, Cross-Cultural Adaptation, and Psychometric Properties of Writing Readiness Inventory Tool in Context (WRITIC)

This article describes the translation and cultural adaptation process of the WRITIC (Writing Readiness Inventory Tool in Context) into European Portuguese. We examined the content and convergent validity, test-retest, and interrater reliability on the norm-referenced subdomain of the Portuguese (PT) WRITIC Task Performance (TP). To establish content validity, we consulted six experts in handwriting. Internal consistency was found with 70 children, test-retest reliability with 65, inter-rater reliability with 69, and convergent validity with 87. All participants were typically developing kindergarten children. Convergent validity was examined with the Beery–Buktenica Developmental Test of Visual-Motor Integration (Beery™VMI-6) and the Nine Hole Peg-Test (9-HPT). On content validity, we found an agreement of 93%, a good internal consistency with Cronbach’s alpha of 0.72, and an excellent test-retest and inter-rater reliability with ICCs of 0.88 and 0.93. Correlations with Beery™VMI-6 and 9-HPT were moderate (r from 0.39 to 0.65). Translation and cross-cultural adaptation of WRITIC into European Portuguese was successful. WRITIC-PT-TP is stable over time and between raters; it has excellent internal consistency and moderate correlations with Beery™VMI-6 and 9-HPT. This analysis of the European Portuguese version of WRITIC gives us the confidence to start the implementation process of WRITIC-PT in Portugal.

Ready for handwriting? A reference data study on handwriting readiness assessments

INTRODUCTION

Early evaluation of writing readiness is essential to predict and prevent handwriting difficulties and its negative influences on school occupations. An occupation-based measurement for kindergarten children has been previously developed: Writing Readiness Inventory Tool In Context (WRITIC). In addition, to assess fine motor coordination two tests are frequently used in children with handwriting difficulties: the modified Timed Test of In-Hand Manipulation (Timed TIHM) and the Nine-Hole Peg Test (9-HPT). However, no Dutch reference data are available.

AIM

To provide reference data for (1) WRITIC, (2) Timed-TIHM and (3) 9-HPT for handwriting readiness assessment in kindergarten children.

METHODS

Three hundred and seventy-four children from Dutch kindergartens in the age of 5 to 6.5 years (5.6±0.4 years, 190 boys/184 girls) participated in the study. Children were recruited at Dutch kindergartens. Full classes of the last year were tested, children were excluded if there was a medical diagnosis such as a visual, auditory, motor or intellectual impairment that hinder handwriting performance. Descriptive statistics and percentiles scores were calculated. The score of the WRITIC (possible score 0-48 points) and the performance time on the Timed-TIHM and 9-HPT are classified as percentile scores lower than the 15th percentile to distinguish low performance from adequate performance. The percentile scores can be used to identify children that are possibly at risk developing handwriting difficulties in first grade.

RESULTS

WRITIC scores ranged from 23 to 48 (41±4.4), Timed-TIHM ranged from 17.9 to 64.5 seconds (31.4± 7.4 seconds) and 9-HPT ranged from 18.2 to 48.3 seconds (28.4± 5.4). A WRITIC score between 0-36, a performance time of more than 39.6 seconds on the Timed-TIHM and more than 33.8 seconds on the 9-HPT were classified as low performance.

CONCLUSION

The reference data of the WRITIC allow to assess which children are possibly at risk developing handwriting difficulties.

Do handgrip strength and dexterity predict respiratory function in neuromuscular disease?

BACKGROUND

Neuromuscular diseases are acquired or inherited diseases that affect the function of the muscles in our body, including respiratory muscles.

OBJECTIVE

We aimed to discover more cost-effective and practical tools to predict respiratory function status, which causes serious problems with patients with neuromuscular disease.

METHODS

The Vignos and Brooke Upper Extremity Functional Scales were used to evaluate functional status for patient recruitment. The handgrip strength and dexterity of patients were measured using a dynamometer and nine-hole peg test. Respiratory function parameters: forced vital capacity, forced expiratory volume in one second, and peak expiratory flow were evaluated using spirometry.

RESULTS

The mean age of the 30 patients was 11.5 ± 3.79 years old. Significant relationships were found between nine-hole-peg-test scores and respiratory function parameters on both sides. Significant correlations were found between both handgrip strength and respiratory function parameters (p < 0.05). In the linear regression analysis, it was seen that the forced expiratory volume in 1 second, and peak expiratory flow values could be explained in different percentages (p < 0.05).

CONCLUSIONS

Handgrip strength and dexterity measurements can be used as indicators for estimating respiratory function parameters in terms of cost and accessibility, although it is known that they will not replace respiratory function tests.

Reliability and validity of the East Asian children's version of mini-MACS in children with cerebral palsy

Background

Mini-Manual Ability Classification System (Mini-MACS) was developed for children with cerebral palsy aged 1–4 years, but its validity and reliability in different cultures are unavailable yet. This study was to determine the reliability and validity of Mini-MACS in East Asian children with cerebral palsy and investigate the correlation between Mini-MACS and Gross Motor Function Classification System.

Methods

One hundred and four East Asian children with cerebral palsy aged 12–48 months were classified by one of their parents, an occupational therapist, and a physical therapist with Mini-MACS. The results were analyzed for inter-rater reliability by using intraclass correlation coefficient (ICC). The Nine-hole Peg Test was used for the criterion-related validity analysis, and parents retested their children after 2 weeks to evaluate test–retest reliability. Gross Motor Function Classification System levels were also collected to investigate the correlation with Mini-MACS.

Results

Good inter-rater reliability among the occupational therapist, physical therapist, and parents was found [ICC = 0.984 (95% confidence interval, CI, 0.976–0.989), 0.973 (95% CI 0.960–0.982), and 0.966 (95% CI 0.950–0.977), respectively; p &lt; 0.01]. The test–retest reliability in parents was almost perfect [ICC = 0.985 (95% CI 0.977–0.990), p &lt; 0.01]. Mini-MACS had consistency with the Nine-hole Peg Test (r = 0.582, 0.581, and 0.566, respectively; p &lt; 0.01). A correlation was found between Gross Motor Function Classification System and Mini-MACS (r = 0.626, 0.596, and 0.598, respectively; p &lt; 0.01).

Conclusion

The Mini-MACS demonstrates evidence that it is a valid and reliable tool to classify manual ability in East Asian children with cerebral palsy and is also positively related to the Gross Motor Function Classification System.

Bibliometric Analysis of Research on the Use of the Nine Hole Peg Test

Manual dexterity is essential for performing daily life tasks, becoming a primary means of interaction with the physical, social, and cultural environment. In this respect, the Nine Hole Peg Test (NHPT) is considered a gold standard for assessing manual dexterity. Bibliometrics is a discipline that focuses on analyzing publications to describe, evaluate, and predict the status and development trends in certain fields of scientific research. We performed a bibliometric analysis to track research results and identify global trends regarding the use of the NHPT. The bibliographic data were retrieved from the Web of Science database and then analyzed using the Bibliometrix R package, resulting in the retrieval of a total of 615 publications from 1988 to 2021. Among the 263 journals investigated, the most prolific were the Multiple Sclerosis Journal, Clinical Rehabilitation, and Multiple Sclerosis and Related Disorders. North America and Europe were the areas with the highest production of publications, with the United States (n = 104) ranking first in terms of the number of publications, followed by the United Kingdom (n = 62) and Italy (n = 62). The analysis of keywords revealed that there were two main lines of research, with one related to the study of recovery and disability of the upper limbs caused by certain diseases and another related to the study of reliability and validity. Structured information can be useful to understand the research trajectory and the uses of this tool.

Non-Immersive Virtual Reality as an Intervention for Improving Hand Function and Functional Independence in Children With Unilateral Cerebral Palsy: A Feasibility Study

Introduction

Non-immersive virtual reality (NIVR) is emerging as an advantageous intervention in the arena of neurorehabilitation. Promising results have been obtained by the application of NIVR in adults with various chronic neurological conditions such as stroke and Parkinson’s disease, but studies on the use of NIVR in children with unilateral cerebral palsy (CP) are limited.

Materials and methods

This preliminary study included 10 school-aged participants with unilateral CP who were allocated into experimental and control groups. In accordance with the allocation ratio of 1:1, there were five participants in each group. During six weeks of intervention, children in the experimental group received NIVR intervention in addition to conventional physiotherapy, while those in the control group received only conventional physiotherapy, with a goal to improve hand function and functional independence. Nine-hole peg test (9HPT), box and block test (BBT), ABILHAND kids, and self-care section of functional independence measure for children (WeeFIM) were used as outcome measures.

Results

There was significant improvement in all outcome measures in both groups. However, the improvement in the hand function and functional independence was significantly more in the experimental group than in the control group.

Conclusion

It can be concluded that NIVR intervention in the management of children with unilateral CP seems to be feasible and useful. Further research with a larger sample size must be undertaken to reinforce these preliminary findings.

A randomised placebo-controlled, double-blind phase II study to explore the safety, efficacy, and pharmacokinetics of sonlicromanol in children with genetically confirmed mitochondrial disease and motor symptoms ("KHENERGYC")

Background

Methods

The KHENERGYC trial will be a phase II, randomised, double-blinded, placebo-controlled (DBPC), parallel-group study in the paediatric population (birth up to and including 17 years). The study will be recruiting 24 patients suffering from motor symptoms due to genetically confirmed PMD. The trial will be divided into two phases. The first phase of the study will be an adaptive pharmacokinetic (PK) study with four days of treatment, while the second phase will include randomisation of the participants and evaluating the efficacy and safety of sonlicromanol over 6 months.

Discussion

Effective novel therapies for treating PMDs in children are an unmet need. This study will assess the pharmacokinetics, efficacy, and safety of sonlicromanol in children with genetically confirmed PMDs, suffering from motor symptoms.

Trial registration

clinicaltrials.gov: NCT04846036, registered April 15, 2021. European Union Clinical Trial Register (EUDRACT number: 2020–003124-16), registered October 20, 2020. CCMO registration: NL75221.091.20, registered on October 7, 2020.

Effects of 8 Weeks with Embodied Learning on 5–6-Year-Old Danish Children’s Pre-reading Skills and Word Reading Skills: the PLAYMORE Project, DK

The aim of this study was to investigate the effects of embodied learning on children’s pre-reading and word reading skills. We conducted a three-armed randomized controlled trial including two intervention groups and one control group. One hundred forty-nine children from grade 0 (5–6 years old) who had just started school were recruited from 10 different classes from four elementary schools. Within each class, children were randomly assigned to receive teaching of letter-sound couplings and word decoding either with whole-body movements (WM), hand movements (HM), or no movements (CON) over an 8-week period. Children were evaluated on pre-reading, word reading, and motor skills before (T1), immediately after (T2), and after 17–22 weeks of retention period (T3) following the intervention. Between-group analysis showed a significant improvement in children’s ability to name letter-sounds correctly from T1 to T2 (p < 0.001) and from T1 to T3 (p < 0.05) for WM compared to CON. HM and WM improved significantly in naming conditional letter-sounds from T1 to T2 (p < 0.01, p < 0.01) compared to CON and from T1 to T3 for the HM group compared to CON (p < 0.05). We did not find an effect on word reading or a correlation between motor skill performance and reading. Results from the present study suggest that there are beneficial effects of using whole-body movements for children. Hand motor movements indeed also had a performance effect on letter-sound knowledge; however, the whole-body movements had longer-lasting effects. We do not see an effect on whole word reading.

Haptic Feedback-Based Virtual Reality Intervention for a Child With Infantile Hemiplegia: A Case Report

Virtual reality (VR) refers to an advanced technology that provides real life-like experience in a virtual environment. Numerous commercially available systems provide gaming opportunities with VR, while a few also provide haptic feedback along with VR. In the recent past, VR has been explored as a viable intervention in the field of neurorehabilitation. Although there are promising results for adults with hemiplegia, the research involving children with infantile hemiplegia is in the nascent stage. Infantile hemiplegia is manifested by sensory and motor deficits predominantly on one side of the body resulting in adverse effects on the functionality of the affected side since early life. VR gaming has an intense, motivational component that encourages children to put sustained voluntary effort to use both upper extremities. A six-year-old male with infantile hemiplegia presented with difficulty in using the left upper extremity. Pre-intervention scores of the nine-hole peg test (9HPT) and box and block test (BBT) were used to evaluate the manual dexterity, while those of ABILHAND-kids and functional independence measure for children (WeeFIM self-care section) assessed the functional independence. The child underwent treatment for six weeks (five days/week), with each session lasting for 60 minutes/day that included VR gaming with haptic feedback for 30 minutes and conventional physiotherapy for 30 minutes. Post-intervention scores were recorded and were compared with pre-intervention scores. Marked improvement in left upper extremity function was noted not only objectively by the outcome measures but also subjectively by the parents as well as by the child. Moreover, the child remarked that he enjoyed the therapy sessions. The findings of this report would facilitate the design of further research in this area in the form of larger trials.

Reliability and agreement of the Nine Hole Peg Test in patients with unilateral spastic cerebral palsy

Upper extremity involvement is one of the most common motor impairments in children with unilateral spastic cerebral palsy (CP). One tool for the assessment of manual function in CP is the Nine Hole Peg Test (NHPT). However, the reliability of the NHPT in patients with unilateral CP is unknown. This study aimed to analyze the intra-rater inter-session reliability of the NHPT in unilateral spastic CP, for its use in clinical practice and research. A total of 27 participants with spastic unilateral CP were included. Reliability was verified by the intraclass correlation coefficient (ICC), standard error of measurement, and minimum detectable change. The agreement was analyzed by the Bland-Altman method. An excellent intra-rater reliability was observed for the non-affected side (ICC = 0.94) and the affected side (ICC = 0.96). The minimal detectable change was 4 and 12 s for the non-affected and affected side, respectively. There were no significant biases between repetitions.   Conclusions: The NHPT showed excellent intra-rater inter-session reliability in patients with spastic unilateral CP. In addition, the test shows adequate agreement and proportionally small errors to assess manual dexterity. What is Known: • The Nine Hole Peg Test (NHPT) is widely used to assess dexterity in patients with neurological conditions. • The NHPT has demonstrated appropriate measurement properties in healthy children and adults with neurological conditions. What is New: • The NHPT presents excellent reliability, small measurement errors, and adequate agreement for the assessment of patients with cerebral palsy. • The measurement error of the NHPT in unilateral cerebral palsy may be up to 13% of the total time to perform it.

An Italian Validation of ABILHAND-Kids for Children With Cerebral Palsy

Limitations in hand function are common among children with cerebral palsy (CP), with almost 50% presenting an arm-hand dysfunction. However, there is no standardized assessment tool available in Italian for evaluating bimanual performance for this population. Our objective in this study was to evaluate the psychometric properties of an Italian translation of the ABILHAND-Kids (ABILHAND-Kids-IT) among children with CP. We examined internal consistency using Cronbach's Alpha and Omega coefficients, and we investigated test-retest reliability with intraclass correlation coefficients (ICC). We performed explorative factor analysis (EFA) to investigate structural validity. We calculated Pearson's correlation coefficients between the ABILAND-Kids IT and the Manual Ability Classification System (MACS) to assess criterion validity; and, to demonstrate the score variability of the ABILHAND-Kids-IT, we used analyses of variance (ANOVAs) to compare the 181 children with CP in this sample with their levels on the MACS. We enrolled 181 children with CP in the study. EFA confirmed a uni-dimensional scale. We obtained internal consistency on both Cronbach's Alpha and Omega coefficient of 0.98, and a one-week test-retest reliability analysis revealed an ICC with 95% of confidence interval of .992. The ANOVA revealed significant score variability (p < 0.01) and the Pearson correlation coefficient comparing the ABILHAND-Kids-It score with the MACS was -0.929 (p < 0.01). We conclude that the ABILHAND-Kids-IT is valid and reliable for use with Italian children with CP.

Nusinersen by subcutaneous intrathecal catheter for symptomatic spinal muscular atrophy patients with complex spine anatomy

INTRODUCTION/AIMS

Intrathecal administration of nusinersen is challenging in patients with spinal muscular atrophy (SMA) who have spine deformities or fusions. We prospectively studied the safety and efficacy of nusinersen administration via an indwelling subcutaneous intrathecal catheter (SIC) for SMA patients with advanced disease.

METHODS

Seventeen participants commenced nusinersen therapy between 2.7 and 31.5 years of age and received 9 to 12 doses via SIC. Safety was assessed in all participants. A separate efficacy analysis comprised 11 nonambulatory, treatment-naive SMA patients (18.1 ± 6.8 years) with three SMN2 copies and complex spine anatomy.

RESULTS

In the safety analysis, 14 treatment-related adverse events (AEs) occurred among 12 (71%) participants; all were related to the SIC and not nusinersen. Device-related AEs interfered with 2.5% of nusinersen doses. Four SICs (24%) required surgical revision due to mechanical malfunction with or without cerebrospinal fluid leak (n = 2), and one (6%) was removed due to Staphylococcus epidermidis meningitis. In the efficacy analysis, mean performance on the nine-hole peg test improved in dominant (15.9%, P = 0.012) and nondominant (19.0%, P = 0.008) hands and grip strength increased by 44.9% (P = 0.031). We observed no significant changes in motor scales, muscle force, pulmonary function, or SMA biomarkers. All participants in the efficacy cohort reported one or more subjective improvement(s) in endurance, purposeful hand use, arm strength, head control, and/or speech.

DISCUSSION

For SMA patients with complex spine anatomy, the SIC allows for reliable outpatient administration of nusinersen that results in meaningful improvements in upper limb function, but introduces risks of technical malfunction and iatrogenic infection.

Validity and reliability of "Shriners Hospital for Children Upper Extremity Evaluation" in children with rheumatic diseases

INTRODUCTION/OBJECTIVES

The aim of this study was to investigate the validity and reliability of "Shriners Hospital for Children Upper Extremity Evaluation (SHUEE)" for children with rheumatic diseases.

METHODS

The study was carried out after obtaining the necessary permissions and retrospectively registered. The psychometric properties evaluated were reliability and concurrent validity. Reliability was determined by intra- and inter-observer agreement. Concurrent validity was performed using the Jebsen Taylor Hand Function Test (JTHFT), Abilhand-Rheumatoid Arthritis (Abilhand-RA), and Children Health Assessment Questionnaire (CHAQ). The validity and reliability of the evaluation were determined after the retest 1 week later.

RESULTS

Twenty children with rheumatic diseases were participated in to study. Intraclass coefficients ranged from 0.82 to 0.97 and the intraobserver reliability for SHUEE total and subscales were considered "excellent." Interobserver reliability was considered "excellent" for the SHUUE total score, spontaneous functional analysis and dynamic positional analysis, and "moderate" for grasp-release. A moderate negative correlation was determined between Spontaneous Functional Analysis and JTHFT (r =  - 0.63; p = 0.003).

CONCLUSION

SHUEE is a valid and reliable evaluation for children with rheumatic diseases. ClinicalTrials.org NCT04685434/21.12.2020 Key Points • SHUEE tends to be appropriate and acceptable to children with rheumatic diseases. • SHUEE can be used safely in the pediatric rheumatology group and it is beneficial in the clinical decision-making process. • SHUEE is a pioneering performance test that evaluates the quality of movement in pediatric rheumatology on a joint basis.

An evaluation of participation restrictions and associated factors via the ICF-CY framework in children with acute lymphoblastic leukemia receiving maintenance chemotherapy

Our aim was to determine impairments in physical functions, activity limitations, and participation restrictions with the International Classification of Functioning, Disability and Health version for Children and Youth (ICF-CY) framework in children with acute lymphoblastic leukemia (ALL) receiving treatment. Physical functions were assessed in terms of pain level, fatigue level, handgrip strength, and motor proficiency. Fine motor activities and lower extremity performance were assessed to determine activity limitations. Participation was assessed with a patient-reported questionnaire. Thirty children with ALL (mean age: 8.45 ± 3.33 years) were included. Pain and fatigue level were mild. Poor handgrip strength was found; their mean handgrip strength was 60% of the normative. Fifty-six percent of the children had below-average motor performance. Participation scores were considerably high, except for sport and physical functioning sub-score. Participation level was positively associated with bilateral coordination and duration after diagnosis, while negatively correlated with pain and fatigue level (p ˂ 0.05).Conclusion: The ICF-CY-based evaluation was useful to understand children's limitations in everyday life. Children with ALL need supportive interventions during treatments in terms of physical functioning and participation in activities. Children with ALL with higher pain and fatigue, poor bilateral coordination, and who were in earlier period after diagnosis had higher risk for participation restriction. What is Known: • Children with ALL had physical functioning limitations on treatments. • Participation restrictions were described in children with ALL off treatment. What is New: • The ICY-CY-based health and functioning evaluation allows health care professionals to globally determine limitations of everyday life in children with ALL on treatment. • Impairments in physical functions, pain severity, fatigue severity, and duration after diagnosis are associated with participation to everyday life in children with ALL on treatment.

Motor and Basic Cognitive Functions in Children with Acute Lymphoblastic Leukemia Undergoing Induction or Consolidation Chemotherapy

Children with acute leukemia (ALL) often suffer from several disease and treatment related side-effects during treatment. The aim of the present study was to determine the gross and fine motor functioning and basic cognitive performance of children (n = 25) with ALL who were undergoing induction or consolidation chemotherapy and to compare these characteristics to a normative group (n = 21) of age-matched typically developing children. We assessed the children's motor functions with the Bruininks-Oseretsky Test of Motor Proficiency Second Edition-Short Form and the Nine-hole Peg Test, and we used the Modified Mini-Mental State Exam (MMSE) to evaluate their cognitive performance. Compared to the normative group, children with ALL had lower scores on total motor proficiency and sub-tests scores of motor functions (p < .05), and on the Nine-hole Peg Test performance (p < .05); but their cognitive performance on the MMSE was not significantly different. Children with ALL would likely benefit from structured exercise and rehabilitative interventions during chemotherapy to prevent and/or ameliorate ALL-related motor dysfunction. We also suggest that their cognitive functioning should be further investigated with more extensive well-validated neurocognitive tests for children (e.g., the Wechsler intelligence scales).

The relationship between scoliosis and upper extremity functions in patients with Duchenne muscular dystrophy

Objectives

The aim of this study was to investigate the relationship between scoliosis and upper extremity functions in patients with Duchenne muscular dystrophy (DMD).

Patients and methods

Between January 2018 and July 2018, a total of 55 patients (54 males, 1 female; mean age: 9.9±2.9 years; range, 6 to 15 years) who were diagnosed with DMD based on the clinical, laboratory, muscle biopsy and molecular analysis results were included in this cross-sectional study. Scoliosis was evaluated and Cobb angles were measured. Functional Ambulation Scale and Brooke and Vignos scale scores were recorded. The ABILHAND-Kids questionnaire and Nine-Hole Peg Test (9-HPT) were used to assess the upper extremity functions. Hand grip strengths were also evaluated.

Results

The median ABILHAND-Kids scores and the hand grip strength values of the patients without scoliosis were significantly higher compared to those with scoliosis (p=0.002 and p=0.004 for right hand and p=0.012 for left hand, respectively). There was no statistically significant difference in the 9-HPT scores between the patients with and without scoliosis (p>0.05). We found a negative, significant correlation between the Cobb angle and ABILHAND-Kids scores in patients with scoliosis (r=-0.503; p=0.017).

Conclusion

Our study results show a moderate relationship between scoliosis and upper extremity functions. Scoliosis may adversely affect upper extremity functions in patients with DMD.

Motor-enriched learning for improving pre-reading and word recognition skills in preschool children aged 5-6 years - study protocol for the PLAYMORE randomized controlled trial

Background

Results from previous studies suggest that bodily movements, spanning from gestures to whole-body movements, integrated into academic lessons may benefit academic learning. However, only few studies have investigated the effects of movement integrated into reading practice. The PLAYMORE study aims to investigate the effects of two interventions focusing on a close and meaningful coupling between bodily movement and academic content on early pre-reading and word recognition skills in children. Further, the study aims to compare two interventions involving either hand movements (i.e. using arms and hands) or whole-body movements (i.e. using the whole body). Potential mediating factors underlying the link between bodily movement on early pre-reading and word recognition skills will be explored.

Methods/design

The PLAYMORE study will be conducted as a three-armed randomized controlled trial including children aged five to six years recruited from four schools in the Copenhagen area, Denmark. Stratified by class, children will be randomly allocated to one of three 8-week intervention/control periods: 1) teaching involving whole-body movements, 2) teaching involving hand movements (i.e. arms and hands) or 3) teaching involving minimal motor movements (i.e. seated on a chair using paper and pencil). Outcome measurements, including pre-reading and word recognition skills, will be collected before and after the intervention period to assess the intervention effects. This study protocol follows the SPIRIT guidelines.

Discussion

The PLAYMORE study will add to the current knowledge concerning the link between bodily movement and academic performance with important details about pre-reading and word recognition skills in preschool children. If effective, evaluation of the implementation of the PLAYMORE program should be conducted in order to investigate whether the effects can be transferred into standard school settings. The PLAYMORE study will lay the foundation for future research that have the potential to inform the political and scientific debate and importantly, to provide teachers with detailed information of how to implement movements effectively during teaching in order to support and motivate children in the process of learning to read.

Trial registration

The study was retrospectively registered in ClinicalTrials.gov (NCT04618822) the 5th of November 2020.

Exploring hand dexterity in children with myelomeningocele

PURPOSE

To assess hand dexterity in children with myelomeningocele (MMC) and to explore factors related to hand dexterity in these children.

METHODS

Ninety-four children with myelomeningocele, aged 4 to 18 years, were assessed. Demographic characteristics, disease factors, visual perception (Beery test of Visual Motor Integration), cognition (WeeFunctional Independence Measure), and self-care (Pediatric Evaluation of Disability Inventory) were assessed in relation to the Nine-Hole Peg Test (9HPT) for hand dexterity using Spearmen correlations and linear regressions.

RESULTS

The children's performance on the 9HPT in both hands was significantly slower than the norms for their age groups. Children without a shunt showed significantly better function in both hands (p = .005) than those with a shunt. Factors most related to hand dexterity were neurological spinal level of MMC, presence of shunt, age, cognitive ability, and years of mother's education.

CONCLUSION

Children with MMC appear to have poorer hand skills than typically developed children, which was related to pathology as well as functional and environmental factors. When addressing hand dexterity in children with MMC, it is important that rehabilitation professionals continue to work with these children as they get older, and put greater emphasis on parent education using materials that are adapted to varying educational levels.

The current outcomes and future challenges in pediatric vascularized composite allotransplantation

PURPOSE OF REVIEW

We review the outcomes and future challenges associated with pediatric vascularized composite allotransplantation, including follow-up data from our bilateral pediatric hand-forearm transplantation.

RECENT FINDINGS

In 2015, the first heterologous pediatric upper extremity hand-forearm transplant was performed at the Children's Hospital of Philadelphia, and in 2019, the first pediatric neck reconstructive transplantation was performed in Poland. The 5-year follow-up of the pediatric upper extremity recipient demonstrates similar growth rates bilaterally, an increase in bone age parallel to chronologic age, and perhaps similar overall growth to nontransplant norms. The pediatric upper extremity recipient continues to make gains in functional independence. He excels academically and participates in various extracurricular activities. Future challenges unique to the pediatric population include ethical issues of informed consent, psychosocial implications, limited donor pool, posttransplant compliance issues, and greater life expectancy and therefore time to inherit the many complications of immunosuppression.

SUMMARY

Currently, we recommend pediatric vascularized composite allotransplantation (VCA) for bilateral upper extremity amputees, preferably on immunosuppression already, and those patients who would have the most potential gain not available through standard reconstructive techniques while being able to comply with postoperative immunosuppression protocols, surveillance, rehabilitation, and follow-up.

Validation and diagnostic accuracy of coin rotation task for manual dexterity and coordination in children with specific learning disorder

BACKGROUND

This study aimed at determining validity, reliability, and diagnostic accuracy of Coin Rotation Task (CRT) in assessing manual dexterity and coordination of children with specific learning disorder (SLD).

METHODS

In this non-experimental cross-sectional study, 120 children (typically developing children = 60, children with SLD = 60, mean age ± SD =9.18 ± 0.55) were recruited. Test-retest reliability and construct validity of CRT were assessed. Multivariate regression analysis was performed on CRT scores by considering age and gender as covariates and children with SLD with mild dexterity impairment and severe dexterity impairment (SDI) as outcome variables. Receiver-operating characteristics (ROC) curve analysis was carried out to derive validity parameters.

RESULTS

Test-retest reliability of the CRT scores in both subtests were excellent in children with SLD (ICC_2,1: 0.93-0.95) and good to excellent in typically developing children (ICC_2,1: 0.72-0.82). Acceptable construct validity of CRT was also found. The CRT cut-off points were 23 (sensitivity= 89.29%, specificity= 70.37%) and 28 (sensitivity= 80.33%, specificity= 86.36%) for discriminating children with SLD and SDI from typically developing children in dominant and non-dominant hand, respectively.

CONCLUSIONS

The present study indicated good to excellent test-retest reliability, acceptable validity, and high diagnostic accuracy for diagnosing children with SLD based on their dexterity impairment level.Implications for RehabilitationThe Coin Rotation Task (CRT) was modified and validated for use in children.The CRT is a reliable and valid tool with high diagnostic accuracy.The CRT has a good ability for discriminating children with specific learning disorder with severe dexterity impairment form typically developing children.Treatment plans and research designs can be performed by using this valid, reliable, and easy to administer tool.

Does earlier splint removal truly affect functional recovery and kinesiophobia after tendon repair?

Splinting how the hand can be used in daily life. Therefore, earlier splint removal is thought to improve functional recovery. The aim of our study was to assess the outcomes of patients who removed their splint and started using their hand earlier and compare them to patients who received routine care. Patients with tendon repairs were divided into two groups: Group 1 (Early) started daily use of their hand at the 5th postoperative week and Group 2 (Later) at the 6th week. Patients received regular therapy consisting of an early motion protocol. Assessments were performed at three consecutive time points. Grip and pinch strength was measured and Nine-Hole Peg Test (9HPT) was performed. Disabilities of the Arm, Shoulder and Hand (DASH) and Tampa Scale for Kinesiophobia (TSK) were filled out. Both within-group and between-group analyses were performed. A total of 58 patients with flexor or extensor tendon repairs were analyzed. All parameters improved significantly over time within both groups (P<0.05). When the time effect was ignored, kinesiophobia, disability and functional results - except grip strength - were statistically better in Group 2 group than in Group 1 (P<0.05). Our results showed that, despite the clinically observed recovery, earlier splint removal and start of daily hand use did not truly improve the functional results. To us, this means that the remarkable advances in surgical techniques do not accelerate the physiological healing process. Therefore, clinical recommendations should always be supported with evidence-based data.

Hand grip strength and dexterity function in children aged 6-12 years: A cross-sectional study

STUDY DESIGN

Cross-sectional and clinical measurement.

INTRODUCTION

Assessment of hand function considers an essential part in clinical practice.

PURPOSE OF THE STUDY

To develop normative values of hand grip strength and dexterity function for 6-12-year-old children in Saudi Arabia.

METHODS

Grip strength and dexterity function was measured in 525 children using Grip Track hand dynamometer (JTECH Medical, Midvale, UT, USA) and 9-hole pegboard test respectively.

RESULTS

The grip strength and dexterity function was improved as age progressed regardless of gender. Across all age groups, the hand grip strength of boys was significantly higher than girls for dominant hand (31.75 ± 10.33 vs 28.24 ± 9.35; P < .001) and nondominant hand (31.01 ± 10.27 vs 27.27 ± 9.30; P < .001). The girls performed slightly faster than boys for dominant hand (19.70 vs 20.68; P < .05) and nondominant hand (21.79 vs 23.46; P < .05). In general, girls completed a 9-HPT faster than boys in the 2 of 7 age groups: 11 years (9-HPT scores = 2.10 seconds; P < .01) and 12 years (9-HPT scores = 1.93 seconds; P < .01).

DISCUSSION

The overall patterns of hand grip strength and dexterity function observed in the present study are similar to the previous studies that established acceleration of grip strength with advanced age, and faster performance scores in older children than younger children in both genders.

CONCLUSIONS

Norms of hand grip strength and dexterity enable therapists to identify some developmental characteristics of hand function among Saudi children, determine the presence of impairment, and compare scores from children in different clinical settings.

LEVEL OF EVIDENCE

Not applicable.

Intraindividual Variability Measurement of Fine Manual Motor Skills in Children Using an Electronic Pegboard: Cohort Study

Background

Pegboard tests are a powerful technique used by health and education professionals to evaluate manual dexterity and fine motor speed, both in children and adults. Using traditional pegboards in tests, the total time that, for example, a 4-year-old child needs for inserting pegs in a pegboard, with the left or right hand, can be measured. However, these measurements only allow for studying the variability among individuals, whereas no data can be obtained on the intraindividual variability in inserting and removing these pegs with one and the other hand.

Objective

The aim of this research was to study the intraindividual variabilities in fine manual motor skills of 2- to 3-year-old children during playing activities, using a custom designed electronic pegboard.

Methods

We have carried out a pilot study with 39 children, aged between 25 and 41 months. The children were observed while performing a task involving removing 10 pegs from 10 holes on one side and inserting them in 10 holes on the other side of a custom-designed sensor-based electronic pegboard, which has been built to be able to measure the times between peg insertions and removals.

Results

A sensor-based electronic pegboard was successfully developed, enabling the collection of single movement time data. In the piloting, a lower intraindividual variability was found in children with lower placement and removal times, confirming Adolph et al’s hypothesis.

Conclusions

The developed pegboard allows for studying intraindividual variability using automated wirelessly transmitted data provided by its sensors. This novel technique has been useful in studying and validating the hypothesis that children with lower movement times present lower intraindividual variability. New research is necessary to confirm these findings. Research with larger sample sizes and age ranges that include additional testing of children’s motor development level is currently in preparation.

Long-Term Results of Surgically Treated Radial Polydactyly - An Outcome Correlation Study

Background: Thumb polydactyly is one of the commonest congenital hand differences. Traditional surgeon-based outcome scores capture outcomes mainly on bodily structure and function. Outcomes on the long-term well-being of the patients in the domains of activity and participation are not fully studied. Methods: Forty-eight thumbs in forty-five Chinese patients with radial polydactyly underwent surgical treatment at or before 3 years old were recruited. Mean follow-up was 11.6 years. Surgical outcomes were collected and compared to the normal opposite thumb. The results were compiled into the Japanese Society for Surgery of the Hand (JSSH) score, Cheng score and Tada score. Patients' activity involving hands were assessed by both objective tools and patient-reported outcome measure while their health-related quality of life (HRQoL) was assessed by Patient- and Parent-reported Pediatric Quality of Life Inventory (PedsQL). Correlations between outcomes were analysed. Results: Overall, both parents and patients themselves reported good quality of life with mean score of 86.6% and 92.1% respectively in PedsQL. The combined surgical scores ranged from 52% good or excellent results using JSSH score to 100% good result using Cheng score. None of the outcomes on bodily structure and function showed positive correlation with patient's well-being. Negative correlation was noted in total passive range of movement, active movement and Cheng score. All patients reported no activity restriction. Writing test did not show significant slowing. The operated hands had significantly poorer fine motor dexterity than normal. No significant correlation is noted between activity outcomes and PedsQL. Conclusions: Outcomes on bodily structure, function and activity showed little correlation with patients' well-being after thumb polydactyly correction. It should be careful in using or analysing patient/parent-reported outcome measures on HRQoL as outcome assessment of surgical treatment of radial polydactyly.

Effect of aerobic exercise prior to modified constraint-induced movement therapy outcomes in individuals with chronic hemiparesis: a study protocol for a randomized clinical trial

BACKGROUND

Recovery of upper limb function in individuals after a stroke remains challenging. Modified constraint-induced movement therapy (m-CIMT) has strong evidence for increasing the use and recovery of sensorimotor function of the paretic upper limb. Recent studies have shown that priming with aerobic exercise prior to task-specific training potentiates upper limb recovery in individuals with stroke. This protocol describes a randomized clinical trial designed to determine whether priming with moderate-high intensity aerobic exercise prior to m-CIMT will improve the manual dexterity of the paretic upper limb in individuals with chronic hemiparesis.

METHODS

Sixty-two individuals with chronic hemiparesis will be randomized into two groups: Aerobic exercise + m-CIMT or Stretching + m-CIMT. m-CIMT includes 1) restraint of the nonparetic upper limb for 90% of waking hours, 2) intensive task-oriented training of the paretic upper limb for 3 h/day for 10 days and 3) behavior interventions for improving treatment adherence. Aerobic exercise will be conducted on a stationary bicycle at intervals of moderate to high intensity. Participants will be evaluated at baseline, 3, 30, and 90 days postintervention by the following instruments: Motor Activity Log, Nottingham Sensory Assessment, Wolf Motor Function Test, Box and Block Test, Nine-Hole Peg Test, Stroke Specific Quality of Life Scale and three-dimensional kinematics. The data will be tested for normality and homogeneity. Parametric data will be analyzed by two-way ANOVA with repeated measures and Bonferroni's adjustment. For nonparametric data, the Friedman test followed by the Wilcoxon test with Bonferroni's adjustment will be used to compare the ratings for each group. To compare the groups in each assessment, the Mann-Whitney test will be used.

DISCUSSION

This study will provide valuable information about the effect of motor priming for fine upper limb skill improvement in people with chronic poststroke hemiparesis, bringing new evidence about the association of two therapies commonly used in clinical practice.

TRIAL REGISTRATION

This trial was retrospectively registered (registration number RBR-83pwm3 ) on 07 May 2018.

Psychometric Evaluation of 2 New Upper Extremity Functional Strength Tests in Children With Cerebral Palsy

BACKGROUND

For children with unilateral spastic cerebral palsy (USCP), reduced muscle strength can lead to activity limitations. However, none of the existing measures of upper extremity strength measure strength in the context of functional activities in which strength must be maintained for several seconds.

OBJECTIVE

The objective of this study was to evaluate the psychometric properties of 2 newly developed functional hand and upper extremity muscle-strength tests (Cup-Task and Box-Task) in children aged 7 to 12 years with USCP.

DESIGN

A longitudinal study design was used.

METHODS

A standardized protocol with detailed descriptions of all procedures and measurements was used to determine test-retest reliability, interrater reliability, and criterion validity.

RESULTS

A total of 86 children (53 males, 33 females, mean age = 9.3 years) with USCP participated in this study, with a subset performing each measurement. Only the results of children who were able to perform the measurement were included for analysis. Excellent test-retest reliability (intraclass correlation coefficients = 0.887-0.944; 95% confidence intervals = 0.713-0.969) and interrater reliability (intraclass correlation coefficients = 0.896-0.960; 95% confidence intervals = 0.813-0.980) were observed. The Cup-Task Affected-Hand and Box-Task were moderately correlated with maximum isometric grip strength. The Cup-Task Nonaffected-Hand had a low correlation with maximum isometric grip strength.

LIMITATIONS

Age, sex, and manual ability were not normally distributed, which could have influenced the results.

CONCLUSIONS

For children with USCP who can perform the tasks, the Cup-Task and Box-Task are reliable and valid instruments for measuring functional upper extremity muscle strength.

The upper limb Physiological Profile Assessment: Description, reliability, normative values and criterion validity

A progressive decline in upper limb function is associated with ageing and disease. In this cross-sectional study we assessed the performance of 367 healthy individuals aged of 20 to 95 years across a battery of upper limb clinical tests, which we have termed the upper limb Physiological Profile Assessment (PPA). The upper limb PPA was designed to quantify the performance of the multiple physiological domains important for adequate function in the upper extremities. Included are tests of muscle strength, unilateral movement and dexterity, position sense, skin sensation, bimanual coordination, arm stability, along with a functional task. We report age and gender normative values for each test. Test-retest reliability ranged from good to excellent in all tests (intra-class correlation coefficients from 0.65 to 0.98) with the exception of position sense (0.31). Ten of the thirteen tests revealed differences in performance between males and females, twelve showed a decline in performance with increasing age, and eight discriminated between older people with and without upper limb functional impairment. Furthermore, most tests showed good external validity with respect to age, an upper limb functional test and self-reported function. This profiling approach provides a reference range for clinical groups with upper limb sensory and motor impairments and may assist in identifying undiagnosed deficits in the general population. Furthermore, the tests are sufficiently reliable to detect motor impairments in people with compromised upper limb function and evaluate the effectiveness of interventions.

The effect of Atlantic salmon consumption on the cognitive performance of preschool children - A randomized controlled trial

BACKGROUND AND AIMS

Long chain polyunsaturated n-3 fatty acids (LC-PUFA) are of functional and structural importance for brain development. Observational studies have shown positive relations between fatty fish consumption and cognitive performance in children, but Results from intervention studies using supplementary n-3 LC-PUFA are conflicting. Salmon is a good source of n-3 LC-PUFA, including eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). We tested the hypothesis that an increased dietary salmon intake results in better cognitive outcomes than a meat based diet.

METHODS

Children (n = 205, age 4-6 years) in this trial were individually randomized to eating meals containing farmed Atlantic salmon or meat three times weekly for 16 weeks. Pre- and post-intervention a cognitive test (Wechsler Preschool and Primary Scale of Intelligence, 3rd edition, WPPSI-III) and a fine-motor coordination test (Nine Hole Peg Test, 9-HPT) were performed. Biochemical analyses included glycerophospholipid fatty acid profiles in plasma and cheek cells, serum 25-hydroxyvitamin D, and urinary iodine concentration. Dietary intake before and during the study were determined using food frequency questionnaires.

RESULTS

Intakes of EPA, DHA, vitamin D and iodine were higher in the salmon than the meat group, but on biomarker level only EPA and DHA increased significantly in the salmon group compared to the meat group (p < 0.001). In general linear models no significant differences between the intervention groups were found in the scale scores of the WPPSI-III tests and the 9-HPT. In analyses of the raw scores, the salmon group showed significantly better improvement in two of the eight raw scores compared to the meat group (symbol search p = 0.038, picture concepts p = 0.047).

CONCLUSIONS

Intake of farmed Atlantic salmon led to a greater increase of the raw scores of the picture concept and symbol search subtests, while in the six other subtests raw scores were not different between the groups. This might indicate a modest positive association of salmon intake with the performance of preschool children in some subtests evaluating fluid intelligence but does not suggest an influence on global IQ development.

CLINICAL TRIAL REGISTRY NUMBER AND WEBSITE

ClinicalTrials.gov registration number: NCT01951937.

A continuous repetitive task to detect fatigability in spinal muscular atrophy

Background

To determine the value of a continuous repetitive task to detect and quantify fatigability as additional dimension of impaired motor function in patients with hereditary proximal spinal muscular atrophy (SMA).

Results

In this repeated measure case-control study 52 patients with SMA types 2–4, 17 healthy and 29 disease controls performed five consecutive rounds of the Nine-Hole Peg test to determine the presence of fatigability. We analysed differences in test performance and associations with disease characteristics. Five patients with SMA type 2 (22%) and 1 disease control (3%) could not finish five rounds due to fatigue (p = 0.01). Patients with SMA type 2 performed the test significantly more slowly than all other groups (p < 0.005) and disease controls were slower than healthy controls (p < 0.05). Patients with SMA type 2 performed round five 27% slower than round one, while healthy controls performed round five 14% faster than round one (p = 0.005). There was no difference between SMA type 3a, type 3b/4 or disease controls and healthy controls (p > 0.4). Time needed to complete each round during the five-round task increased in 15 patients with SMA type 2 (65%), 4 with type 3a (36%), 4 with type 3b/4 (22%), 9 disease controls (31%) and 1 healthy control (6%). There was no effect of age at disease onset or disease duration in SMA type 2 (p = 0.39). Test-retest reliability was high.

Conclusion

Fatigability of remaining arm function is a feature of SMA type 2 and can be determined with continuous repetitive tasks.

Protocol for a phase II, monocentre, double-blind, placebo-controlled, cross-over trial to assess efficacy of pyridostigmine in patients with spinal muscular atrophy types 2-4 (SPACE trial)

INTRODUCTION

Hereditary proximal spinal muscular atrophy (SMA) is caused by homozygous loss of function of the survival motor neuron 1 gene. The main characteristic of SMA is degeneration of alpha motor neurons in the anterior horn of the spinal cord, but recent studies in animal models and patients have shown additional anatomical abnormalities and dysfunction of the neuromuscular junction (NMJ). NMJ dysfunction could contribute to symptoms of weakness and fatigability in patients with SMA. We hypothesise that pyridostigmine, an acetylcholinesterase inhibitor that improves neuromuscular transmission, could improve NMJ function and thereby muscle strength and fatigability in patients with SMA.

METHODS AND ANALYSIS

We designed a monocentre, placebo-controlled, double-blind cross-over trial with pyridostigmine and placebo to investigate the effect and efficacy of pyridostigmine on muscle strength and fatigability in patients with genetically confirmed SMA. We aim to include 45 patients with SMA types 2-4, aged 12 years and older in the Netherlands. Participants receive 8 weeks of treatment with pyridostigmine and 8 weeks of treatment with placebo in a random order separated by a washout period of 1 week. Treatment allocation is double blinded. Treatment dose will gradually be increased from 2 mg/kg/day to the maximum dose of 6 mg/kg/day in four daily doses, in the first week of each treatment period. The primary outcome measures are a change in the Motor Function Measure and repeated nine-hole peg test before and after treatment. Secondary outcome measures are changes in recently developed endurance tests, that is, the endurance shuttle nine-hole peg test, the endurance shuttle box and block test and the endurance shuttle walk test, muscle strength, level of daily functioning, quality of and activity in life, perceived fatigue and fatigability, presence of decrement on repetitive nerve stimulation and adverse events.

ETHICS AND DISSEMINATION

The protocol is approved by the local medical ethical review committee at the University Medical Center Utrecht and by the national Central Committee on Research Involving Human Subjects. Findings will be shared with the academic and medical community, funding and patient organisations in order to contribute to optimisation of medical care and quality of life for patients with SMA.

TRIAL REGISTRATION NUMBER

NCT02941328.

Fear of movement and its effects on hand function after tendon repair

After tendon injuries, it has been observed clinically that patient-reported disability is more severe than the patient's actual performance. This is thought to result from a fear of movement (kinesiophobia) after surgery. The aim of this study was to investigate the presence of kinesiophobia in this patient population and its effects on the clinical outcomes. Patients (n=118) with tendon repairs were included. All the participants received early passive mobilization and were assessed at the end of the 8th week. Grip and pinch strengths were measured and the Nine-Hole Peg Test (9HPT) was conducted. Patients also filled out the Michigan Hand Outcomes Questionnaire (MHOQ) and Tampa Scale for Kinesiophobia (TSK). Patients were divided according to their kinesiophobia: Group 1 with low kinesiophobia (TSK<37) and Group 2 with high kinesiophobia (TSK≥37). The groups were compared on the assessed parameters. Fifty-nine percent of the patients had a high kinesiophobia level. The performance-based test results were similar between the groups (P>0.05). Patient-reported MHOQ and TSK scores were significantly lower in the high kinesiophobic group (P=0.001 and P=0.000, respectively). Patients with tendon repairs often develop kinesiophobia, which may contribute to difficulty when starting to re-use their hand in daily life. None of the objective results were affected by this fear of movement-only patient-reported disability. Clinicians should be aware that clinical outcomes may be affected by the patient's kinesiophobic thinking and must be cautious during treatment.

Dexterity and Finger Sense: A Possible Dissociation in Children With Cerebral Palsy

Both hand and finger sensory perception and motor abilities are essential for the development of skilled gestures and efficient bimanual coordination. While finger dexterity and finger sensory perception can be impaired in children with cerebral palsy (CP), the relationship between these two functions in this population is not clearly established. The common assumption that CP children with better sensory function also demonstrate better motor outcomes has been recently challenged. To study these questions further, we assessed both finger dexterity and finger gnosia, the ability to perceive one’s own fingers by touch, in groups of 11 children with unilateral (i.e., hemiplegic CP) and 11 children with bilateral spastic CP (i.e., diplegic CP) and compared them with typical children. In our sample, children with hemiplegia exhibited finger dexterity deficit in both hands and finger gnosia deficit only in their paretic hand. In contrast, children with diplegia exhibited finger gnosia deficits in both hands and finger dexterity deficit only in their dominant hand. Thus, our results indicated that children with spastic hemiplegia and diplegia present different sensory and motor profiles and suggest that these two subgroups of CP should be considered separately in future experimental and clinical research. We discuss the implications of our results for rehabilitation.

Fatty fish intake and cognitive function: FINS-KIDS, a randomized controlled trial in preschool children

BACKGROUND

Marine resources including fatty fish are important sources of n-3 long chain polyunsaturated fatty acids (n-3 LC-PUFAs), which are important for brain development. To our knowledge, this is the first randomized controlled trial (RCT) investigating the impact of fatty fish on cognition in preschool children. The purpose of the trial was to investigate whether an increased intake of fatty fish compared to meat improves cognitive function in children 4-6 years old.

METHODS

The children (n = 232) in this two-armed RCT, Fish Intervention Studies-KIDS (FINS-KIDS) were recruited from 13 kindergartens in Bergen, Norway. They were randomly assigned to lunch meals with fatty fish (herring/mackerel) or meat (chicken/lamb/beef) three times a week for 16 weeks. The fish and meat were weighed before and after the meals to record the exact consumption (dietary compliance). The primary outcome was cognitive function measured by the Wechsler Preschool and Primary Scale of Intelligence, 3rd edition (WPPSI-III) and fine-motor coordination measured by the 9-Hole Peg Test (9-HPT) at pre- and post-intervention. Biological samples (blood, urine, hair), and questionnaires to the caregivers were included at both time points. Linear mixed effect models with a random intercept for kindergarten were used to analyze changes from pre- to post-intervention in the primary outcome variables.

RESULTS

There were 218 children included in the trial (105 in the fish, and 113 in the meat group). The children consumed a mean (standard deviation) of 2070 (978) g fish or 2675 (850) g meat from the study meals (p < 0.0001). The fish group had a significant increase of red blood cell n-3 LC-PUFAs. The intervention had no effect on the WPPSI-III scores (mean change total raw score; fish group 17.7, 95% confidence interval (CI) 14.8-20.7 vs meat group 17.8, 95% CI 15.0-20.6, p = 0.97) in the main analyses. In the sub-analyses, adjusting for dietary compliance, the fish group showed a higher improvement on total raw score (20.4, 95% CI 17.5-23.3) compared to the meat group (15.2, 95% CI 12.4-18.0, p = 0.0060); docosahexaenoic acid mediated this effect.

CONCLUSIONS

There was no beneficial effect of fatty fish compared to meat on cognitive functioning in the preschool children. When considering dietary compliance, we found a beneficial effect of fatty fish on cognitive scores.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02331667 December 17, 2014.

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

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

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

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

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

An approach to vehicle design: In-depth audit to understand the needs of older drivers

The population of older people continues to increase around the world, and this trend is expected to continue; the population of older drivers is increasing accordingly. January 2012 figures from the DVLA in the UK stated that there were more than 15 million drivers aged over 60; more than 1 million drivers were aged over 80. There is a need for specific research tools to understand and capture how all users interact with features in the vehicle cabin e.g. controls and tasks, including the specific needs of the increasingly older driving population. This paper describes an in-depth audit that was conducted to understand how design of the vehicle cabin impacts on comfort, posture, usability, health and wellbeing in older drivers. The sample involved 47 drivers (38% female, 62% male). The age distribution was: 50-64 (n = 12), 65-79 (n = 20), and those 80 and over (n = 15). The methodology included tools to capture user experience in the vehicle cabin and functional performance tests relevant to specific driving tasks. It is shown that drivers' physical capabilities reduce with age and that there are associated difficulties in setting up an optimal driving position such that some controls cannot be operated as intended, and many adapt their driving cabins. The cabin set-up process consistently began with setting up the seat and finished with operation of the seat belt.

Independence in self-care activities in children with myelomeningocele: exploring factors based on the International Classification of Function model

PURPOSE

To investigate the relationship between disease factors, body functions and structures, activities, personal and environmental factors with independence in self-care activities in children with myelomeningocele (MMC), utilizing the International Classification of Function model.

METHOD

113 children with MMC, aged 3-18 years were assessed during an annual MMC-clinic visit. Data on the personal and environmental factors, disease factors, hand function, mobility, visual perception, cognition, and communication were assessed in relation to the Pediatric Evaluation of Disability Inventory (PEDI) self-care domain.

RESULTS

The mean PEDI caregiver assistance score was 22.1 (ranged between <10 and 62) well below the norms. The most significant determinant of dependence in self-care activities was the presence of hydrocephalus, a child with hydrocephalus scored a mean of 9.2 points less on the PEDI caregiver scale (p = 0.02). By using a linear regression, the most significant factors associated with the PEDI scores among children with hydrocephalus were the age of the child, function of the non-dominant hand, ambulation, and cognitive function.

CONCLUSION

In children with MMC the presence of hydrocephalus appears to be more significantly associated with functional independence than the neurological level. The International Classification of Function model provides an in-depth multidisciplinary model that facilitates in investigating independence in self-care activities in children with MMC. It is important to take personal factors and various functional impairments into account when working with these children to promote independence. Implications for Rehabilitation When working with children with myelomeningocele on independence in daily living activities, it is necessary that health professionals demonstrate a holistic view of the child and his/her disability. Health professionals should take into account information on all factors of the International Classification of Function, in order to help the children, achieve maximal independence. It is important for health professionals to consider presence or lack of hydrocephalus when working with children with myelomeningocele to achieve functional gains. Improving upper extremity function and cognitive ability in children with myelomeningocele may help promote independence in activities of daily living. It is necessary for health professionals to continue to work with children with myelomeningocele on maximizing independence as they get older, for it is possible for them to achieve independence at a later age. While this study did not explore participation, this is an essential part of the International Classification of Function and is generally related to function. Participation allows a child to be involved in life situations, contributes to life satisfaction and prepares children for critical adult roles. It is therefore important to assess and monitor this measure. Further studies should examine associations between independence in self-care activities and participation.

Test-Retest Reliability and Convergent Validity of Three Manual Dexterity Measures in Persons With Chronic Stroke

BACKGROUND

Decreased manual dexterity is common in persons after stroke. Different measures are used to assess manual dexterity, but a lack of knowledge exists about their reliability and how they are related.

OBJECTIVE

To evaluate the test-retest reliability and convergent validity of 3 manual dexterity measures after stroke.

DESIGN

A test-retest design.

SETTING

University Hospital.

PARTICIPANTS

Forty-five persons (mean age 65 years) with mild-to-moderate impairments in the upper extremity at least 6 months after stroke.

MAIN OUTCOME MEASURES

Manual dexterity was assessed on 2 occasions, 1 week apart using the Box and Block Test (BBT), the Nine-Hole Peg Test (NHPT), and the modified Sollerman Hand Function Test (mSHFT). The reliability of the BBT and NHPT was evaluated with the intraclass correlation coefficient together with systematic and random measurement errors. Reliability of the mSHFT was evaluated with the Kappa coefficient and the Svensson rank-invariant method (percent agreement and systematic and random disagreements). Convergent validity of the total scores was evaluated with the Spearman rank correlation coefficients (rho).

RESULTS

The intraclass correlation coefficient for the BBT and the NHPT ranged from 0.83 to 0.99. Significant systematic measurement errors were found for both tests and hands. The Kappa coefficient for the total sum score of the mSHFT was 0.95 for the more affected hand and 0.59 for the less affected hand. One of the 3 items showed systematic disagreements for both hands. The convergent validity (rho) for the more affected hand ranged from 0.41 (BBT versus mSHFT) to -0.68 (NHPT versus mSHFT).

CONCLUSION

The test-retest reliability of the BBT, NHPT and mSHFT was high but all measures showed learning effects. The relationships between the 3 measures indicate that they partly complement one another. The BBT may be preferred for persons with moderate impairments of the upper extremity and the NHPT and the mSHFT for persons with milder impairments. As the mSHFT has the advantage of reflecting activities in daily life it may be a suitable alternative to the NHPT.

LEVEL OF EVIDENCE

III.

Binocular low-contrast letter acuity and the symbol digit modalities test improve the ability of the Multiple Sclerosis Functional Composite to predict disease in pediatric multiple sclerosis

BACKGROUND

Outcome measures to capture disability, such as the Multiple Sclerosis Functional Composite (MSFC), were developed to enhance outcome measurements for clinical trials in adults with multiple sclerosis (MS). The MSFC initially included three components: a timed 25-foot walk [T25FW], 9-hole peg test [9HPT], and the Paced Auditory Serial Addition Task [PASAT]. Modifications to the original MSFC, such as adding binocular low-contrast letter acuity (LCLA) or substituting the symbol digit modalities test (SDMT) for the PASAT, improved the capacity to capture neurologic impairment in adults. Similar outcome scales for pediatric MS have not yet been established.

OBJECTIVE

To determine whether the three-component MSFC or a modified MSFC with LCLA and the SDMT better identifies neurological deficits in pediatric MS.

METHODS

We evaluated 5 measures (T25FW, 9HPT, Children's PASAT [ChiPASAT], SDMT, and binocular LCLA [Sloan charts, 1.25% contrast]) in children with MS (disease onset <18 years) and healthy controls. To be able to compare measures whose scores have different scales, Z-scores were also created for each test based on the numbers of standard deviations from a control group mean, and these individual scale scores were combined to create composite scores. Logistic regression models, accounting for age, were used to determine whether the standard 3-component MSFC or modified versions (including 4 or 5 metrics) best distinguished children with MS from controls.

RESULTS

Twenty pediatric-onset MS subjects, aged 6-21 years, and thirteen healthy controls, aged 6-19 years, were enrolled. MS subjects demonstrated worse scores on the 9HPT (p=0.004) and SDMT (p=0.001), but not the 25FTW (adjusted for height, p=0.63) or the ChiPASAT (p=0.10): all comparisons adjusted for age. Decreased (worse) binocular LCLA scores were associated with MS (vs. control status, p=0.03, logistic regression; p=0.08, accounting for age). The MSFC composite score for the traditional 3 components did not differ between the groups (p=0.28). Replacing the ChiPASAT with the SDMT (OR 0.72, p=0.05) better distinguished MS from controls. A modified MSFC-4 with the SDMT replacing the ChiPASAT and including binocular 1.25% LCLA had the greatest capacity to distinguish pediatric MS from controls (OR 0.89, p=0.04, logistic regression). Including all 5 metrics as a composite MSFC-5 did not improve the model (p=0.18).

CONCLUSIONS

A modified MSFC (25FTW, 9HPT, SMDT, and binocular 1.25% LCLA) is more sensitive than the traditional MSFC or its components to capture the subtle impairments that characterize pediatric MS and should be validated in order to be considered for future pediatric MS trials.