Intensive upper- and lower-extremity training for children with bilateral cerebral palsy: a quasi-randomized trial

A Cross-sectional Study of the Clinical Profile of Children With Cerebral Palsy in Benin, a West African Low-Income Country

Cerebral palsy is a common cause of pediatric motor disability. Although there are increasing amounts of data on the clinical profile of children with cerebral palsy in high-income countries, corresponding information about low-income countries and developing countries is lacking. Therefore, we aimed to describe the clinical spectrum of cerebral palsy in children in Benin, a representative West African low-income country. Our cross-sectional observational study included 114 children with cerebral palsy recruited from community-based rehabilitation centers and teaching hospitals (median age: 7 years, range 2-17; sex: 66% male). Data were collected through review of medical records and interviews with children's mothers. Assessment included risk factors, clinical subtypes according to the Surveillance of CP in Europe criteria, severity of motor outcome scored by the Gross Motor Function Classification System (GMFCS) and Manual Ability Classification System, comorbidities, and school attendance. We recorded a high prevalence of intrapartum adverse events. Seventeen percent of children had postneonatal cerebral palsy, with cerebral malaria being the most common cause. Most children were severely affected (67.5% as bilateral spastic; 54.4% as GMFCS IV or V), but severity declined substantially with age. Only 23% of the children with cerebral palsy had attended school. Poor motor outcomes and comorbidities were associated with school nonattendance. These results suggest that intrapartum risk factors and postnatal cerebral malaria in infants are opportune targets for prevention of cerebral palsy in Sub-Saharan low-income countries.

Protocol for a multisite randomised trial of Hand-Arm Bimanual Intensive Training Including Lower Extremity training for children with bilateral cerebral palsy: HABIT-ILE Australia

INTRODUCTION

Children with bilateral cerebral palsy often experience difficulties with posture, gross motor function and manual ability, impacting independence in daily life activities, participation and quality of life (QOL). Hand-Arm Bimanual Intensive Training Including Lower Extremity (HABIT-ILE) is a novel intensive motor intervention integrating upper and lower extremity training. This study aimed to compare HABIT-ILE to usual care in a large randomised controlled trial (RCT) in terms of gross motor function, manual ability, goal attainment, walking endurance, mobility, self-care and QOL. A within-trial cost-utility analysis will be conducted to synthesise costs and benefits of HABIT-ILE compared with usual care.

METHODS AND ANALYSIS

126 children with bilateral cerebral palsy aged 6-16 years will be recruited across three sites in Australia. Children will be stratified by site and Gross Motor Function Classification System and randomised using concealed allocation to either receiving HABIT-ILE immediately or being waitlisted for 26 weeks. HABIT-ILE will be delivered in groups of 8-12 children, for 6.5 hours per day for 10 days (total 65 hours, 2 weeks). Outcomes will be assessed at baseline, immediately following intervention, and then retention of effects will be tested at 26 weeks. Primary outcomes will be the Gross Motor Function Measure and ABILHAND-Kids. Secondary outcomes will be brain structural integrity, walking endurance, bimanual hand performance, self-care, mobility, performance and satisfaction with individualised goals, and QOL. Analyses will follow standard principles for RCTs using two-group comparisons on all participants on an intention-to-treat basis. Comparisons between groups for primary and secondary outcomes will be conducted using regression models.

ETHICS AND DISSEMINATION

Ethics approval has been granted by the Medical Research Ethics Committee of Children's Health Queensland Hospital and the Health Service Human Research Ethics Committee (HREC/17/QRCH/282) of The University of Queensland (2018000017/HREC/17/QRCH/2820), and The Cerebral Palsy Alliance Ethics Committee (2018_04_01/HREC/17/QRCH/282).

TRIAL REGISTRATION NUMBER

ACTRN12618000164291.

Interventions to improve upper limb function for children with bilateral cerebral palsy: a systematic review

AIM

To systematically review the efficacy of interventions on upper limb function in children 0 to 19 years of age with bilateral cerebral palsy on the basis of outcome measures of upper limb function and measures of activities and/or participation according to the International Classification of Functioning, Disability and Health.

METHOD

Cochrane, PubMed, Embase, CINAHL, and Web of Science were searched from inception to September 2017. Methodological quality and strength of evidence were analysed by two independent raters using Sackett's level of evidence and the American Academy for Cerebral Palsy and Developmental Medicine (AACPDM) guidelines.

RESULTS

Fifteen studies with a large variety of interventions and heterogeneity in outcome measures met the inclusion criteria. Twelve studies provided level IV evidence according to AACPDM guidelines. For three small randomized controlled trials the level of evidence was II. Only one of these trials showed strong methodological quality: a study on hand-arm bimanual intensive therapy including lower extremities.

INTERPRETATION

We identified a large variety of interventions, heterogeneity in outcome measures, and generally weak to moderate methodological quality for most studies. We recommend further research specifically aimed at bimanual-intensive, goal-directed, and task-specific training programmes for the upper limb in children with bilateral cerebral palsy, using either high-quality (multicentre) trials or well-designed single-case trials.

WHAT THIS PAPER ADDS

There is a large variety of interventions on upper limb function in children with bilateral cerebral palsy. Heterogeneity of outcome measures and interventions impeded firm conclusions about intervention efficacy. Most studies had low-level evidence and weak to moderate methodological quality. The strongest evidence from a small randomized controlled trial was for hand-arm bimanual intensive therapy including lower extremities.

Effects of Therapeutic Exercise Intensity on Cerebral Palsy Outcomes: A Systematic Review With Meta-Regression of Randomized Clinical Trials

Background and Objective: Intensive physical therapy or exercise has been associated with favorable cerebral palsy (CP) outcomes, but few studies have investigated the effects of exercise intensity on the improvement in CP outcomes. In this study, we assessed the effects of intensive exercise-based therapy on improvement in gross motor function in children with CP. Methods: We searched three databases for randomized clinical trials evaluating the effects of therapeutic exercise training by using Gross Motor Function Measurement (GMFM) 66 and 88 among children with CP. Studies that used interventions in addition to therapeutic exercise were excluded from the present meta-analysis. Exercise intensity was defined using the number of training hours per day and duration of intervention (in weeks). The effects of the number of daily training hours and program duration on GMFM improvement were evaluated using meta-regression. Results: The comprehensive search returned 270 references, and 13 of 270 references met our eligibility criteria. The 13 trials recruited 412 children with CP. These trials measured motor improvements by using GMFM-66 (n = 8) and GMFM-88 (n = 5). The GMFM scores in the children who received the therapeutic intervention did not show significantly greater improvement than those of the children who received standard care. Meta-regression analysis revealed that the improvement in GMFM scores was positively associated with the number of daily training hours (point estimate = 0.549; p = 0.031) and program duration (point estimate = 0.067; p = 0.075). Discussion and Conclusions: Intensive physical exercise improved CP outcomes in the intervention and standard therapy groups. The duration of therapeutic intervention improved CP outcomes among the children who received the therapeutic intervention, while an increase in the number of daily training hours improved in CP outcomes in the children who received standard therapy.

Effects of a training programme of functional electrical stimulation (FES) powered cycling, recreational cycling and goal-directed exercise training on children with cerebral palsy: a randomised controlled trial protocol

INTRODUCTION

Children with cerebral palsy (CP) experience declines in gross motor ability as they transition from childhood to adolescence, which can result in the loss of ability to perform sit-to-stand transfers, ambulate or participate in leisure activities such as cycling. Functional electrical stimulation (FES) cycling is a novel technology that may provide opportunities for children with CP to strengthen their lower limbs, improve functional independence and increase physical activity participation. The proposed randomised controlled trial will test the efficacy of a training package of FES cycling, adapted cycling and goal-directed functional training to usual care in children with CP who are susceptible to functional declines.

METHODS AND ANALYSIS

Forty children with CP (20 per group), aged 6-8 years and classified as Gross Motor Function Classification System (GMFCS) levels II-IV will be recruited across South East Queensland. Participants will be randomised to either an immediate intervention group, who will undertake 8 weeks of training, or a waitlist control group. The training group will attend two 1 hour sessions per week with a physiotherapist, consisting of FES cycling and goal-directed, functional exercises and a 1 hour home exercise programme per week, consisting of recreational cycling. Primary outcomes will be the gross motor function measure and Canadian occupational performance measure, and secondary outcomes will include the five times sit-to-stand test, habitual physical activity (accelerometry), power output during cycling and Participation and Environment Measure-Children and Youth. Outcomes will be assessed at baseline, postintervention (8 weeks) and 8 weeks following the intervention (retention).

ETHICS AND DISSEMINATION

Ethical approval has been obtained from Griffith University (2018/037) and the Children's Health Queensland Hospital and Health Service (CHQHHS) Human Research Ethics Committee (HREC/17/QRCH/88). Site-specific approval was obtained from CHQHHS research governance (SSA/17/QRCH/145). Results from this trial will be disseminated via publication in relevant peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ACTRN12617000644369p.

Modulation of gait inter-limb coordination in children with unilateral spastic cerebral palsy after intensive upper extremity intervention

Motor function difficulties associated with unilateral spastic cerebral palsy (USCP) impact gait inter-limb coordination between the upper and lower extremities. Two motor learning based, upper extremity treatments, Constraint Induced Movement Therapy (CIMT) and Hand Arm Bimanual Therapy (HABIT), have resulted in improvements in coordination and function between the arms in children with USCP. However, no study has investigated whether coordination between the upper and lower extremities improves after either intervention during a functional task, such as walking. Gait analysis was performed before and after participation in intensive (3 weeks, 90 h total) CIMT and HABIT interventions to determine if intensive upper extremity treatment can improve inter-limb coordination between the upper and lower extremities of children (n = 20, 6-17 years old) with USCP. While upper extremity clinical evaluations indicated hand function improvements, there were no changes in lower extremity parameters for either treatment. However, we found that 10 out of 11 children with a 2:1 arm swing-to-stride ratio at pre-test improved to a 1:1 ratio at post-test. Temporal synchronicity of contralateral limbs, swing displacement of the more affected arm, and arm swing side symmetry unexpectedly decreased. Positive changes in coordination were observed in children who demonstrated poor coordination during walking at pre-test, yet the changes were not robust. Principle component analysis did not indicate changes in limb coupling. While more coordinated, gross-motor training of the upper and lower extremity may reveal greater changes, lower extremity gait patterns were not improved in high functioning children with USCP.

Interrater Reliability of Activity Questionnaires After an Intensive Motor-Skill Learning Intervention for Children With Cerebral Palsy

OBJECTIVE

To investigate the reliability of parents-reported activity questionnaires after a motor-skill learning intervention for children with cerebral palsy (CP). We hypothesize that the intervention process might influence parental judgment.

DESIGN

Double-blind randomized trial.

SETTING

Conventional therapy was delivered in the usual context while intensive intervention was provided at the Catholic University of Louvain.

PARTICIPANTS

Children with CP (N=41; age range 5-18y, Gross Motor Function Classification System I-IV) were randomized to a control group (CG) (n=21, 2 dropouts) receiving conventional therapy or an intervention group (IG) (n=20) receiving hand-arm bimanual intensive therapy-including lower extremities (HABIT-ILE).

INTERVENTIONS

Conventional therapy (mostly neurodevelopmental) was delivered as ongoing treatment (1-5 times/wk). HABIT-ILE, based on motor-skill learning, was delivered over 2 weeks. All children were assessed at T1 (baseline), T2 (3wk after baseline) and T3 (4mo after baseline).

MAIN OUTCOMES MEASURES

ABILHAND-Kids and ACTIVLIM-CP questionnaires rated by parents (perception) and 2 examiners (videotapes).

RESULTS

Agreement (level/range) between examiners was systematically almost perfect (P≤.001). At baseline, moderate to almost perfect agreement (level/range) was observed between parents and examiners (P≤.001). At T2 and T3, a similar agreement (level/range) was observed for the CG. For the IG, a similar level of agreement was observed, but the range of agreement varied from poor to almost perfect (P≤.001), with parents estimating higher performance measures compared to examiners after intervention. Higher performance was associated with higher satisfaction scores of the child's functional goals at T3.

CONCLUSION

Parents and examiners have a similar perception of the child's performance at baseline and during conventional therapy. Their perceptions are less congruent after a motor-skill learning intervention, probably due to the goal-oriented process of the intervention. Therefore, our results favor the use of blind observations of home-videotaped items after intensive motor-skill learning interventions.

Is more frequent physical therapy associated with increased gross motor improvement in children with cerebral palsy? A national prospective cohort study

Purpose: To investigate the association between physical therapy frequency and gross motor improvement in children with cerebral palsy (CP).Materials and methods: This is a prospective cohort study of 442 children aged 2-12 years, Gross Motor Function Classification System levels I-V, from the Cerebral Palsy Follow-up Program and the Cerebral Palsy Register of Norway. Outcome was change in reference percentiles for the Gross Motor Function Measure (GMFM-66) between two subsequent assessments (N = 1056) analyzed in a linear mixed model.Results: It was a dose response association between physical therapy frequency and gross motor improvement. Mean change was 4.2 (95% CI: 1.4-7.1) percentiles larger for physical therapy 1-2 times per week and 7.1 (95% CI: 2.6-11.6) percentiles larger for physical therapy >2 times per week, compared to less frequent physical therapy when analyzed in a multivariable model including multiple child and intervention factors. The only statistically significant confounder was number of contractures which was negatively associated with gross motor improvement.Conclusions: When gross motor improvement is a goal for children with CP, more frequent physical therapy should be considered.Implications for rehabilitationIn general, the gross motor development of Norwegian children with cerebral palsy was as expected according to the reference percentiles for the GMFM-66.When gross motor improvement is a goal for children with cerebral palsy, high-frequency physical therapy should be considered.Contractures should be addressed in order to optimize gross motor improvement for children with cerebral palsy.

Responsiveness of the ACTIVLIM-CP questionnaire: measuring global activity performance in children with cerebral palsy

AIM

To investigate the responsiveness of the ACTIVLIM-CP questionnaire after two evidence-based interventions for children with cerebral palsy (CP).

METHOD

Seventy-five children with CP either participated in an intensive motor-skill learning intervention (hand-arm bimanual intensive therapy including lower extremities [HABIT-ILE], n=47) or received botulinum neurotoxin-A (BoNT-A) injection(s) into lower extremities combined with conventional physical therapy (n=28). All children were assessed three times: at baseline (T₀ ; before HABIT-ILE/the day of BoNT-A injection), at T₁ (last day of HABIT-ILE/6wks after BoNT-A injection), and at follow-up (T₂ ; 3-4mo after the beginning of intervention). Parents completed ACTIVLIM-CP and three other activity questionnaires. Responsiveness was analysed using group (based on intervention), subgroup (based on gross motor function level), and individual approaches.

RESULTS

For the HABIT-ILE group, significant improvements in ACTIVLIM-CP were observed for the T₀ -T₁ period (p<0.001) but not for the T₁ -T₂ period. No significant changes were found in the BoNT-A group during assessments (p=0.84). In the subgroup analysis for the HABIT-ILE group (T₀ -T₁ ), greater changes were demonstrated for children in Gross Motor Function Classification System levels III and IV (p<0.001, effect size=1.36). The individual approach was congruent with the group approach.

INTERPRETATION

ACTIVLIM-CP demonstrated high responsiveness after HABIT-ILE, showing that this scale may be used to investigate global activity performance in clinical trials focusing on improving daily life activities.

WHAT THIS PAPER ADDS

Good responsiveness of ACTIVLIM-CP questionnaire during intensive motor-skill learning intervention. Higher responsiveness for children in Gross Motor Function Classification System (GMFCS) levels III and IV versus I and II after intensive intervention. ACTIVLIM-CP is useful to identify children improving their performance after botulinum neurotoxin-A injection.

Development (of Walking): 15 Suggestions

Although a fundamental goal of developmental science is to identify general processes of change, developmental scientists rarely generalize beyond their specific content domains. As a first step toward a more unified approach to development, we offer 15 suggestions gleaned from a century of research on infant walking. These suggestions collectively address the multi-leveled nature of change processes, cascades of real-time and developmental events, the diversity of developmental trajectories, inter- and intraindividual variability, starting and ending points of development, the natural input for learning, and the roles of body, environment, and sociocultural context. We argue that these 15 suggestions are not limited to motor development, and we encourage researchers to consider them within their own areas of research.

Changes in Tactile Function During Intensive Bimanual Training in Children With Unilateral Spastic Cerebral Palsy

Recently, an intensive bimanual intervention using sensory enriched materials resulted in improved tactile function in children with unilateral spastic cerebral palsy (USCP), raising the question of whether the observed tactile function improvement was due to the sensory enriched environment or the bimanual intervention per se. The present study investigates whether a bimanual intensive intervention improves tactile function. Nineteen children with USCP received 90 hours of bimanual training without enriched environment. Primary outcomes: Manual Form Perception Test/MFPT, Grating Orientation Task/GOT. Children were assessed before, after the training, and at the 4-month follow-up. Significant improvements were observed in MFPT for the more affected hand ( P = .015). Larger stereognosis/MFPT improvements correlated with poorer baseline motor function. Intensive bimanual training alone was sufficient to improve stereognosis, though no improvement in GOT was observed. Present and previously published findings suggest that environmental tactile enrichment incorporated into a bimanual motor training may be needed to improve spatial discrimination/GOT in children with USCP.

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

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