Effectiveness of hand-arm bimanual intensive training on upper extremity function in children with cerebral palsy: A systematic review

Effectiveness of hand-arm bimanual intensive therapy including lower extremities in the rehabilitation of children with cerebral palsy: a systematic review protocol

INTRODUCTION

Cerebral palsy (CP) is a paediatric disorder with permanent impairment of movement and posture with a prevalence of about 2.11 in 1000 births in the world. Given the therapeutic effect of hand-arm bimanual intensive therapy including lower extremities (HABIT-ILE) in children with CP, a systematic review of the available literature on this topic is warranted. The objective of this study is to systematically review the effectiveness of HABIT-ILE on upper extremity, lower extremity and trunk outcomes within the domains of body functions and structures, activity and participation of the International Classification of Functioning, Disability and Health in children with CP.

METHODS AND ANALYSIS

This study will be conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Searches will be conducted in six databases: MEDLINE, PubMed, Cochrane Library, Scopus, OT seeker and Web of Science for available published literature. The grey literature sources will include WorldCat, National Technical Information Service, Agency for Healthcare Research and Quality, Open Grey, WHO and OpenDOAR. Manual searches of citations of included papers will be performed to collect all experimental studies of HABIT-ILE in children with CP. The level of evidence for included articles will be classified according to the level of evidence in the guidelines for systematic reviews on the American Occupational Therapy Association website. Based on the study design of the included articles, the risk of bias will be assessed using the revised Cochrane risk-of-bias tool, the Cochrane Risk Of Bias In Non-randomised Studies - of Interventions tool and the quality assessment tool recommended by the American Occupational Therapy Association. In order to synthesise the data, narrative synthesis will be used, along with meta-analysis, if available.

ETHICS AND DISSEMINATION

As this study only reviewed previously published articles, ethical approval was not required. The findings will be published in a peer-reviewed scientific journal.

PROSPERO REGISTRATION NUMBER

CRD42024518179.

Retention of bimanual performance following hand arm bimanual intensive therapy in children with unilateral cerebral palsy: A six-month longitudinal study

Hand-arm bimanual intensive therapy (HABIT) enhances upper extremity (UE) function and bimanual coordination in children with unilateral cerebral palsy (UCP). Previous studies assessed immediate improvements in UE function using clinical and self-reported measures, which may not accurately reflect real-world UE performance and their long-term retention effects. Therefore, this study aims to investigate the retention of real-world bimanual performance gains over time following HABIT in children with UCP. Thirty children with UCP, age 6-16 years underwent HABIT (6 hours/day for 5 days). Bimanual performance was assessed using GT9X Link accelerometers, worn on bilateral wrists for 3 days pre-, post-, 3-, and 6-month of HABIT. Accelerometer-derived variables-use ratio (UR), magnitude ratio (MR), bilateral magnitude (BM), median acceleration (MA), and acceleration variability (AV)-quantified bimanual performance during real-world activities. UE function was measured with standardized assessments. A mixed model analysis with repeated measures and paired t-tests analyzed the differences real-world bimanual performance and UE function respectively. There was a significant main effect of time in UR (F = 2.72, p = 0.05), BM (F = 4.36, p = 0.007), and MA (F = 3.68, p = 0.016). Post-hoc analysis (mean differences, 95% confidence interval [CI]) revealed improvements immediately post- compared to pre-HABIT in BM (14.99, 4.35-25.63) and MA (7.46, 2.55-12.36). However, subsequent assessments at 3- and 6-months displayed a regression in these gains, suggesting a lack of retention. A decline was observed at 3 months) and 6 months (BM; 16.94, 6.3-27.4, MA; 6.51, 1.61-11.41) in BM and MA compared to post-HABIT. UE capacity measures also showed improvements (p < 0.05) post-HABIT. Although HABIT initially may enhance performance of real-world bimanual tasks, its benefits diminish within six months, suggesting a need for repeating HABIT every 3-6 months to retain long-term improvements.

UK research priority setting for childhood neurological conditions

AIM

To identify research priorities regarding the effectiveness of interventions for children and young people (CYP) with childhood neurological conditions (CNCs). These include common conditions such as epilepsies and cerebral palsy, as well as many rare conditions.

METHOD

The National Institute for Health and Care Research (NIHR) and the James Lind Alliance (JLA) champion and facilitate priority setting partnerships (PSPs) between patients, caregivers, and clinicians (stakeholders) to identify the most important unanswered questions for research (uncertainties). A NIHR-JLA and British Paediatric Neurology Association collaboration used the JLA PSP methodology. This consisted of two surveys to stakeholders: survey 1 (to identify uncertainties) and survey 2 (a prioritization survey). The final top 10 priorities were agreed by consensus in a stakeholder workshop.

RESULTS

One hundred and thirty-two charities and partner organizations were invited to participate. In survey 1, 701 participants (70% non-clinicians, including CYP and parent and caregivers) submitted 1800 uncertainties from which 44 uncertainties were identified for prioritization in survey 2; from these, 1451 participants (83% non-clinicians) selected their top 10 priorities. An unweighted amalgamated score across participant roles was used to select 26. In the final workshop, 14 health care professionals, 11 parent and caregivers, and two CYP ranked the 26 questions to finalize the top 10 priorities. Ten top priority questions were identified regarding interventions to treat CYP with CNCs and their associated comorbidities, for example, sleep, emotional well-being, and distressing symptoms.

INTERPRETATION

The results of this study will inform research into the effectiveness of interventions for children with neurological conditions.

Narrative Review of the Theoretical-Methodological Foundations of the TREINI Program

Scientific knowledge has advanced in the implementation of safe and beneficial interventions for children and adolescents with cerebral palsy (CP). Although the importance of interdisciplinary interventions that integrate all components of the International Classification of Functioning, Disability and Health (ICF) into family-centered practices is widely recognized, this approach is not yet widely adopted. Instead, many programs remain focused on isolated domains. This study presents the theoretical and methodological foundation of TREINI, an interdisciplinary and family-centered program developed for children and youth with CP and other neurodevelopmental disorders. TREINI incorporates intervention strategies that address all ICF domains. It is grounded in the biopsychosocial model of health and utilizes principles based on the best evidence in pediatric rehabilitation, including intensive training, task-oriented training, and a naturalistic learning environment. Unlike traditional rehabilitation approaches, the care provided by the TREINI program is delivered through an intensive and interdisciplinary approach, by a team working collaboratively in a single location. In addition to including evidence-based interventions, the TREINI program features two innovative components: the "City of Tomorrow", a naturalistic learning environment, and the "TREINI Exoflex" therapeutic suit, specifically designed to address deficiencies in the body functions and structures of children with CP and other neurodevelopmental disorders. This program has been carefully designed to support the process of neurological re-education and rehabilitation for children and adolescents with neuropsychomotor developmental delays.

Feasibility of At-Home Hand Arm Bimanual Intensive Training in Virtual Reality: Case Study

This single-participant case study examines the feasibility of using custom virtual reality (VR) gaming software in the home environment for low-dose Hand Arm Bimanual Intensive Training (HABIT). A 10-year-old with right unilateral cerebral palsy participated in this trial. Fine and gross motor skills as well as personal goals for motor outcomes were assessed before and after the intervention using the Box and Blocks Test, Nine-Hole Peg Test, and Canadian Occupational Performance Measure. Movement intensities collected via the VR hardware accelerometers, VR game scores, and task accuracy were recorded via the HABIT-VR software as indices of motor performance. The child and family were instructed to use the HABIT-VR games twice daily for 30 minutes over a 14-day period and asked to record when they used the system. The child used the system and completed the 14-hour, low-dose HABIT-VR intervention across 22 days. There was no change in Box and Blocks Test and Nine-Hole Peg Test scores before and after the intervention. Canadian Occupational Performance Measure scores increased but did not reach the clinically relevant threshold, due to high scores at baseline. Changes in motor task intensities during the use of VR and mastery of the VR bimanual tasks suggested improved motor efficiency. This case study provides preliminary evidence that HABIT-VR is useful for promoting adherence to HABIT activities and for the maintenance of upper extremity motor skills in the home setting.

Care Pathways in Rehabilitation for Children and Adolescents with Cerebral Palsy: Distinctiveness of the Adaptation to the Italian Context

BACKGROUND

In 2020, a multiprofessional panel was set up in collaboration with the Italian FightTheStroke Foundation family association to produce evidence-based recommendations for the management and neuromotor rehabilitation of persons with cerebral palsy aged 2-18 years to implement in clinical practice in Italy.

METHODS

The recommendations of these care pathways were developed according to the American Academy for Cerebral Palsy and Developmental Medicine guidelines for Care Pathways Development and the Grading of Recommendations Assessment Development and Evaluation working group for adoption, adaptation, or de novo development of recommendations from high-quality guidelines (GRADE-ADOLOPMENT).

RESULTS

Four strong positive recommendations were developed regarding comprehensive management, and twenty-four addressed neuromotor treatment.

CONCLUSIONS

A holistic, individualized approach was affirmed in terms of both multidimensional patient profile and interdisciplinary management in a network with the school where children and adolescents are integrated. It was defined that all motor rehabilitation approaches must be individually tailored considering age and developmentally appropriate activities as interventions and goals, in light of the reference curves addressing prognosis for Gross Motor Function and Manual Ability Classification Systems. Intervention must be structured with adaptations of the task and/or of the context (objects and environment) based on the analysis of the child's skills to support motivation and avoid frustration.

The application of virtual reality to home-based rehabilitation for children and adolescents with cerebral palsy: A systematic review and meta-analysis

BACKGROUND

Home-based rehabilitation enables children and families to participate in therapeutic activities built into their daily routines without the barriers of arrangement and transportation to facilities. Virtual reality is an emerging technology which has shown promising outcomes in rehabilitation.

PURPOSE

This systematic review aims to examine the feasibility and effects of virtual reality-enhanced home rehabilitation on Body functions and structures, Activity, and Participation outcomes in children and adolescents with cerebral palsy.

METHODS

Interventional studies were searched across five biomedical databases on November 26, 2022. Two independent reviewers conducted study selection, data extraction, and quality assessment. The Physiotherapy Evidence Database scale and National Institutes of Health Study Quality Assessment Tools were used to evaluate the quality of included studies. Meta-analysis was performed to examine the effects of the intervention.

RESULTS

Eighteen studies were included in this review. Home-based virtual reality rehabilitation appears feasible with effects on upper extremity and gross motor function, strength, bone density, cognition, balance, walking, daily activity performance, and participation. Meta-analyses revealed significant improvements in hand function (SMD = 0.41, p= .003), gross motor function (SMD = 0.56, p= .0002), and walking capacity (SMD = 0.44, p= .01) following home-based virtual reality intervention.

CONCLUSION

Home-based virtual reality may serve as an adjunct to conventional facility-based therapy to promote participation in therapeutic exercises and maximize rehabilitation outcomes. Further properly designed randomized controlled trials using valid and reliable outcome measures with adequately powered sample sizes are warranted to enhance the current body of evidence using home-based virtual reality in cerebral palsy rehabilitation.

The effect of proprioceptive neuromuscular facilitation on functional skills, muscle strength, and trunk control in children with cerebral palsy: A randomized controlled trial

BACKGROUND

Proprioceptive neuromuscular facilitation (PNF) is generally used for the lower limbs in children with Cerebral Palsy (CP). This study aimed to determine the effect of PNF and Neurodevelopmental Therapy (NDT) on functional abilities, muscle strength, and trunk control in children with CP.

METHODS

Thirty spastic CP children classified as either level I-II in the Gross Motor Function Classification System (GMFCS) or level I-II in the Manual Ability Classification System (MACS) were included. The PNF (n = 15) and the NDT group (n = 15) had physiotherapy for six weeks. The ABILHAND-Kids scale, the Purdue Pegboard Test (PBPT), the Nine-Hole Peg Test (9-HPT), and the Jebson-Taylor Hand Function Test (JTHFT) were employed. Pinch meters, Jamar handheld dynamometers, and digital muscular strength assessments were used.

RESULTS

The PNF group increased shoulder flexion (p < 0.05), adduction (p < 0.05), elevation (p < 0.05), scapular abduction (p < 0.05), elbow extension (right) (p < 0.05), grip (p < 0.05), and pinch strengths (left p < 0.05, right p < 0.05). The PNF group had significantly lower 9-HPT (p < 0.05), JTHFT (card turning), JTHFT (simulated feeding), JTHFT (lifting light cans), and JTHFT (lifting weight cans) durations (p < 0.05), and significantly higher PBPT (right-left) PBPT (bimanual), PBPT (assembly). (p < 0.05), ABILHAND (p < 0.05), and TCMS total scores (p < 0.001). While JTHFT (simulated feeding-left), JTHFT (stacking checkers-left), JTHFT (lifting light cans-left), and JTHFT (lifting weight cans-right/left) (p < 0.05) durations decreased in the NDT group, PBPT (right) (p < 0.05) had an increase in duration.

CONCLUSION

PNF improves trunk control, upper extremity functional skills, selective proximal muscle strength, and distal upper extremity muscle and grip strength.

Effect of Mirror Therapy on Upper Limb Function in Children and Adolescents with Hemiplegic Cerebral Palsy: A Systematic Review and Meta-Analysis

BACKGROUND

This review aimed to explore the effect of mirror therapy (MT) on upper limb function in children and adolescents with hemiplegic cerebral palsy (HCP).

METHODS

MEDLINE, CENTRAL, Scopus, PEDro, and Web of Science were systematically searched. PEDro scale  was used for the quality assessment of included trials. Risk of Bias assessment was done using Cochrane Risk-of-bias tool version 2. Meta-analysis was performed on four of the seven studies included.

RESULTS & CONCLUSION

The majority of the trials included in this review found MT efficacious in improving motor function in HCP. Quantitative analysis of the included trials using QUEST scores for evaluation of quality of upper extremity function revealed positive but non-significant difference between the groups (MD = -0.12; 95% CI = -2.57,2.33; Z = 0.09, p = .92). Pooled analysis of the included trials using BBT, however, favored control (MD = 4.98; 95% CI = 2.32,7.63; Z = 3.67, p = .0002).

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

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

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

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

Bimanual Movement Characteristics and Real-World Performance Following Hand-Arm Bimanual Intensive Therapy in Children with Unilateral Cerebral Palsy

The purpose of this study was to quantify characteristics of bimanual movement intensity during 30 h of hand-arm bimanual intensive therapy (HABIT) and bimanual performance (activities and participation) in real-world settings using accelerometers in children with unilateral cerebral palsy (UCP). Twenty-five children with UCP participated in a 30 h HABIT program. Data were collected from bilateral wrist-worn accelerometers during 30 h of HABIT to quantify the movement intensity and three days pre- and post-HABIT to assess real-world performance gains. Movement intensity and performance gains were measured using six standard accelerometer-derived variables. Bimanual capacity (body function and activities) was assessed using standardized hand function tests. We found that accelerometer variables increased significantly during HABIT, indicating increased bimanual symmetry and intensity. Post-HABIT, children demonstrated significant improvements in all accelerometer metrics, reflecting real-world performance gains. Children also achieved significant and clinically relevant changes in hand capacity following HABIT. Therefore, our findings suggest that accelerometers can objectively quantify bimanual movement intensity during HABIT. Moreover, HABIT enhances hand function as well as activities and participation in real-world situations in children with UCP.

Efficacy of Constraint-Induced Movement Therapy Versus Bimanual Intensive Training on Motor and Psychosocial Outcomes in Children With Unilateral Cerebral Palsy: A Randomized Trial

IMPORTANCE

Emerging research has demonstrated that constraint-induced movement therapy (CIMT) and bimanual intensive training (BIT) show promising effectiveness for children with unilateral cerebral palsy (UCP). Considering that neurorehabilitative programs have always been designed with long training periods, psychosocial outcomes have received scarce attention and thus have not been investigated sufficiently.

OBJECTIVE

To compare the efficacy of CIMT and BIT with 36-hr interventional dosages for both motor and psychosocial outcomes.

DESIGN

Randomized trial.

SETTING

Community.

PARTICIPANTS

Forty-eight children with UCP, ages 6 to 12 yr.

INTERVENTION

Both CIMT and BIT delivered via individual intervention for 2.25 hr/day, twice a week, for 8 wk.

OUTCOMES AND MEASURES

The Melbourne Assessment 2, Pediatric Motor Activity Log-Revised, Bruininks-Oseretsky Test of Motor Proficiency, ABILHAND-Kids measure, and Parenting Stress Index-Short Form were administrated at pretreatment, midterm, posttreatment, and 6 mo after intervention. An engagement questionnaire for investigating the child's engagement in the intervention was used to collect the perspectives of the children and the parents weekly.

RESULTS

Children with UCP who received either CIMT or BIT achieved similar motor improvements. The only difference was that CIMT yielded larger improvements in frequency and quality of use of the more affected hand at the 6-mo follow-up. Similar child engagement and parental stress levels were found in the two groups.

CONCLUSIONS AND RELEVANCE

This study comprehensively compared the efficacy of motor and psychosocial outcomes for 36-hr dosages of CIMT and BIT. The promising findings support the clinical efficacy and feasibility of the proposed protocols. What This Article Adds: The core therapeutic principle of CIMT (i.e., remind the child to use the more affected hand) may be more easily duplicated by parents. Parents may have overestimated their child's engagement and given relatively higher scores; therefore, occupational therapists should also consider the opinions of the children themselves.

Evidence-based management and motor rehabilitation of cerebral palsy children and adolescents: a systematic review

Background

Evidence regarding the management of several aspects of cerebral palsy improved in recent years. Still, discrepancies are reported in clinical practice. Italian professionals and stakeholders expressed the need of setting up updated, evidenced-based, shared statements, to address clinical practice in cerebral palsy rehabilitation. The objective of the present study was to provide an updated overview of the state of knowledge, regarding the management and motor rehabilitation of children and young people with cerebral palsy, as the framework to develop evidence-based recommendations on this topic.

Methods

Guidelines and systematic reviews were searched, relative to evidence-based management and motor treatment, aimed at improving gross motor and manual function and activities, in subjects with cerebral palsy, aged 2-18 years. A systematic search according to the Patients Intervention Control Outcome framework was executed on multiple sites. Independent evaluators provided selection and quality assessment of the studies and extraction of data.

Results

Four guidelines, 43 systematic reviews, and three primary studies were included. Agreement among guidelines was reported relative to the general requirements of management and motor treatment. Considering the subject's multidimensional profile, age and developmentally appropriate activities were recommended to set individual goals and interventions. Only a few approaches were supported by high-level evidence (i.e., bimanual therapy and constraint-induced movement therapy to enhance manual performance). Several task-specific active approaches, to improve gross motor function and gait, were reported (mobility and gait training, cycling, backward gait, and treadmill), based on low-level evidence. Increasing daily physical activity and countering sedentary behavior were advised. Based on the available evidence, non-invasive brain stimulation, virtual reality, action-observation therapy, hydrotherapy, and hippotherapy might be complementary to task or goal-oriented physical therapy programs.

Conclusion

A multiple-disciplinary family-centered evidence-based management is recommended. All motor rehabilitation approaches to minors affected by cerebral palsy must share the following fundamental characteristics: engaging active involvement of the subject, individualized, age and developmentally appropriate, goal-directed, skill-based, and preferably intensive and time-limited, but suitable for the needs and preferences of the child or young person and their family, and feasible considering the implications for themselves and possible contextual limitations.

The Efficacy of Two Models of Intensive Upper Limb Training on Health-Related Quality of Life in Children with Hemiplegic Cerebral Palsy Mainstreamed in Regular Schools: A Double-Blinded, Randomized Controlled Trial

BACKGROUND

Children with hemiplegic cerebral palsy (CP) are at risk of reduced upper limb function and poorer quality of life than their typically developing peers. Although upper limb impairments have potential negative impact on the health-related quality of life (HRQOL) in children with hemiplegic CP, the efficacy of upper limb rehabilitation approaches aiming to improve upper limb impairments on HRQOL has not been adequately investigated.

OBJECTIVE

This study compares the efficacy of two modes of activity-based upper limb rehabilitation (modified constraint-induced movement therapy [mCIMT] and bimanual training [BIM]) on HRQOL outcomes in children with hemiplegic CP mainstreamed in regular schools.

METHODS

Thirty children with hemiplegic CP aged between 7 and 11 years (mean age 8.53 ± 1.54 years) who had functional ability levels of I-III according to the Manual Ability Classification System (MACS), Gross Motor Classification System (GMFCS), and Communication Function Classification System (CFCS) were randomly assigned to receive mCIMT or BIM training. Result: Both mCIMT and BIM yielded statistically significant improvements in all HRQOL domains immediately after the 10-week interventions (P < .001), which were retained at 16 weeks.

CONCLUSION

While there were some differences in the intervention effects, both of these upper limb rehabilitation approaches based on intensive unimanual or bimanual activity may be beneficial for improving perceived life satisfaction related to physical activity, general mood, family, friends, and school among children with hemiplegic CP mainstreamed in regular schools.

Efficacy of Robot-Assisted Gait Therapy Compared to Conventional Therapy or Treadmill Training in Children with Cerebral Palsy: A Systematic Review with Meta-Analysis

BACKGROUND

Motor, gait and balance disorders reduce functional capabilities for activities of daily living in children with cerebral palsy (CP). Robot-assisted gait therapy (RAGT) is being used to complement conventional therapy (CT) or treadmill therapy (TT) in CP rehabilitation. The aim of this systematic review is to assess the effect of RAGT on gait, balance and functional independence in CP children, in comparison to CT or TT.

METHODS

We have conducted a systematic review with meta-analysis. A search in PubMed Medline, Web of Science, Scopus, CINAHL, PEDro and SciELO has been conducted for articles published until October 2022. Controlled clinical trials (CCT), in which RAGT was compared to TT or CT and assessed gait speed, step and stride length, width step, walking distance, cadence, standing ability, walking, running and jumping ability, gross motor function and functional independence in children with CP, have been included. Methodological quality was assessed with the PEDro scale and the pooled effect was calculated with Cohen's Standardized Mean Difference (SMD) and its 95% Confidence Interval (95% CI).

RESULTS

A total of 15 CCTs have been included, providing data from 413 participants, with an averaged methodological quality of 5.73 ± 1.1 points in PEDro. The main findings of this review are that RAGT shows better results than CT in the post-intervention assessment for gait speed (SMD 0.56; 95% CI 0.03 to 1.1), walking distance (SMD 2; 95% CI 0.36 to 3.65) and walking, running and jumping ability (SMD 0.63; 95% CI 0.12 to 1.14).

CONCLUSIONS

This study shows that the effect of RAGT is superior to CT on gait speed, walking distance and walking, running and jumping ability in post-intervention, although no differences were found between RAGT and TT or CT for the remaining variables.

Does bimanual task training benefit manual ability and hand function of children with bilateral spastic cerebral palsy?

PURPOSE

Sixty percent of children with bilateral cerebral palsy have impaired hand function. The study's purpose was to examine the benefits of bimanual task practice on the manual ability and hand function of children with bilateral spastic cerebral palsy.

METHODS

In this pre-post study design, 18 children with bilateral spastic cerebral palsy with an average age of 11.5 (+/-1.9) years, Manual Ability Classification System levels I-III and Bimanual Fine Motor Function levels I-III participated in bimanual task practice of upper extremities. The task practice included clay activities, paper manipulation and activities of daily needs. The children underwent 45-minute training sessions 3 times a week over 6 weeks. The outcome measures were ABILHAND-Kids, Quality of Upper Extremity Skills Test and grip strength.

RESULTS

Post-training, a mean change of 6.44 logits in ABILHAND-Kids, 11 points on the Quality of Upper Extremity Skills Test, and 3.3 and 3.1 kilograms grip strength in the dominant and nondominant hands respectively were observed with a statistical significance (p <  0.05).

CONCLUSION

Bimanual task training might be beneficial in improving manual ability, hand function and grip strength in children with bilateral spastic cerebral palsy.

Nintendo® Wii Therapy Improves Upper Extremity Motor Function in Children with Cerebral Palsy: A Systematic Review with Meta-Analysis

BACKGROUND

Nintendo^® Wii-based therapy (NWT) is a non-immersive virtual reality therapy used to recover upper extremity (UE) motor function in children with cerebral palsy (CP). We aimed primarily to elucidate the effectiveness of NWT in improving UE motor and functional impaired abilities in children with CP, compared to conventional therapy or no intervention. The secondary aim was to assess if NWT is more effective when used alone or combined with conventional therapy.

METHODS

A systematic review with meta-analysis was conducted from a bibliographic search in PubMed, Scopus, PEDro, Web of Science, and CINHAL, ending in October 2021, in accordance with PRISMA guidelines. We included randomized controlled trials that compared NWT vs. conventional therapy or no intervention in terms of their impact on different UE impaired abilities (grip strength, tip grip strength, UE dissociated movements, functional capacity in daily living activities, gross and fine motor dexterity, and grasping ability) in children with CP. Effect size was calculated with standardized mean difference (SMD) and its 95% confidence interval (95% CI).

RESULTS

Nine studies (276 participants) were included. NWT is more effective than conventional therapy at improving grip strength (SMD = 0.5, 95% CI 0.08, 0.91), tip grip strength (SMD = 0.95, 95% CI 0.3, 1.61), and grasping ability (SMD = 0.72, 95%CI 0.14, 1.3). NWT is more effective than conventional therapy at improving functional capacity in daily living activities (SMD = 0.83, 95% CI 0.07, 1.56). For fine manual dexterity, NWT was better than no intervention (SMD = 3.12, 95% CI 1.5, 4.7).

CONCLUSIONS

Our results indicate that NWT is effective at improving various UE impaired motor skills in children with CP.

Physical therapy in children with cerebral palsy in Brazil: a scoping review

AIM

To identify and assess published studies concerning physical therapy in Brazilian children and adolescents with cerebral palsy (CP) using the International Classification of Functioning, Disability and Health (ICF) framework.

METHOD

Articles in English and Portuguese published until October 2020, with no date restrictions, were searched in several different databases. Study characteristics, journal metrics, sample characteristics, and ICF domains explored intervention components and outcomes were extracted. Studies were classified according to the Oxford Centre for Evidence-Based Medicine hierarchy levels to characterize the evidence.

RESULTS

Ninety-four studies were included. Spastic CP with fewer limitations in gross motor abilities was the most reported; 67% of the studies had low levels of evidence and were published in journals without an impact factor. The three most frequent interventions were neurodevelopmental treatment, suit therapy, and transcranial direct current stimulation. Intervention components explored body functions and structures (73.4%), activity (59.6%), environment (2.1%). They did not explore participation (0%). The outcomes investigated addressed activity (79.8%), body functions and structures (67.0%), and participation (1.1%), but not environment (0%).

INTERPRETATION

Studies of physical therapy for Brazilian children and adolescents with CP focused on reducing impairments and activity limitations. Studies with higher levels of evidence and an expanded focus on participation and environmental factors are necessary.

Fisioterapia em crianças com paralisia cerebral no Brasil: uma revisão de escopo

OBJETIVO

Identificar e avaliar os estudos publicados sobre fisioterapia em crianças e adolescentes brasileiros com paralisia cerebral (PC), usando o modelo da Classificação Internacional de Funcionalidade, Incapacidade e Saúde (CIF). MÉTODO: Artigos em inglês e português publicados até outubro de 2020, sem restrição de data, foram pesquisados em diferentes bases bibliográficas. Foram extraídos dados sobre as características do estudo, métricas do periódico, características da amostra, domínios da CIF explorados a partir dos componentes e desfechos das intervenções. Para caracterizar as evidências, os estudos foram classificados de acordo com os níveis de evidência do Centro de Medicina Baseada em Evidência de Oxford.

RESULTADOS

Noventa e quatro estudos foram incluídos. Crianças com PC espástica e com menores limitações nas habilidades motoras grossas foram as mais reportadas; 67% dos estudos apresentaram baixos níveis de evidência e foram publicados em periódicos sem fator de impacto. As três intervenções mais frequentes foram o conceito neuroevolutivo Bobath/terapia do neurodesenvolvimento, a terapia com vestes e a estimulação transcraniana por corrente contínua. Os componentes das intervenções exploraram estruturas e funções do corpo (73,4%), atividade (59,6%) e ambiente (2,1%). Entretanto não exploraram a participação (0%). Os desfechos investigados abordaram atividade (79,8%), estruturas e funções do corpo (67,0%), participação (1%) e ambiente (0%). INTERPRETAÇÃO: Os estudos de intervenções fisioterapêuticas para crianças e adolescentes brasileiros com PC, apresentam maior foco em minimizar deficiências em estruturas e funções do corpo e limitações de atividades. São necessários mais estudos, com melhor nível de evidência e foco ampliado para a participação e os fatores ambientais.

Comparing the effects of modified constraint-induced movement therapy and bimanual training in children with hemiplegic cerebral palsy mainstreamed in regular school: A randomized controlled study

PURPOSE

The aim of this study was to compare the effects of modified constraint-induced movement therapy (mCIMT) and bimanual training (BIT) based on the International Classification of Functioning, Disability, and Health, Children and Youth (ICF-CY) conceptual framework.

RESEARCH METHOD

A total of 32 children (mean age 10.43 years [SD 2.9 years]; 15 girls, 17 boys) whose functional motor and communication levels, according to the Manual Ability Classification System, Gross Motor Function Classification System, and Communication Function Classification System, changed between level I and III were randomly distributed to one of the mCIMT or BIT groups with equivalent dosing frequencies and intensities (10 weeks, 3 days/week, 2.5 h/day). Upper extremity body function outcomes (handheld dynamometer), activity outcomes (Quality of Upper Extremity Skills Test, The Children's Hand-use Experience Questionnaire, ABILHAND-Kids, Pediatric Upper Extremity Motor Activity Log), and participation outcomes (Child and Adolescent Scale of Participation) were assessed before and after treatment, and at 16 weeks postintervention. The clinical trial number of the study is NCT04577391.

RESULTS

mCIMT resulted in more significant improvements in all outcomes than BIT at the immediate postintervention period (T2), which were maintained in the mCIMT group throughout the 16-week postintervention period (p<0.001; dm_CIMT > d_BIT).

CONCLUSION

The potential advantage of mCIMT versus BIT is the larger short-term effect sizes (ESs) and the more sustainable improvements.

Reliability and validity of a computer game-based tool of upper extremity assessment for object manipulation tasks in children with cerebral palsy

Introduction

A computer game-based upper extremity (CUE) assessment tool is developed to quantify manual dexterity of children with Cerebral Palsy (CP). The purpose of this study was to determine test-retest reliability of the CUE performance measures (success rate, movement onset time, movement error, and movement variation) and convergent validity with the Peabody Developmental Motor Scale version 2 (PDMS-2) and the Quality of Upper Extremity Skills Test (QUEST).

Methods

Thirty-five children with CP aged four to ten years were tested on two occasions two weeks apart.

Results

CUE performance measures of five chosen object manipulation tasks exhibited high to moderate intra-class correlation coefficient (ICC) values. There was no significant difference in the CUE performance measures between test periods. With few exceptions, there was no significant correlation between the CUE performance measures and the PDMS-2 or the QUEST test scores.

Conclusions

The high to moderate ICC values and lack of systematic errors indicate that the CUE assessment tool has the ability to repeatedly record reliable performance measures of different object manipulation tasks. The lack of a correlation between the CUE and the PDMS-2 or QUEST scores indicates that performance measures of these assessment tools represent distinct attributes of manual dexterity.

Parents' Perspectives on a Computer Game-Assisted Rehabilitation Program for Manual Dexterity in Children With Cerebral Palsy: Qualitative Analysis of Expectations, Child Engagement, and Benefits

Background

Children with motor impairments affecting the upper extremity benefit from task-specific therapy, such as constraint-induced movement therapy. However, there is a need to improve engagement and compliance with task-specific exercise programs that target manual dexterity for children with cerebral palsy (CP). A computer game–based rehabilitation (GRP) platform was developed that combines fine manipulation and gross movement exercises with engaging game activities appropriate for young children with CP.

Objective

The objectives of this qualitative analysis were to compare parents’ perspectives and opinions about expectations, challenges, and benefits between 2 interventions.

Methods

A mixed methods, randomized controlled trial (RCT) was conducted to examine the feasibility and estimate the effect size of 2 exercise programs for rehabilitation of manual dexterity of children with CP using either GRP or conventional therapy. Parents of 26 of the children who completed the GRP program (n=33) and parents of 15 of the children who completed the conventional therapy program (n=27) participated in the interviews. A general conductive approach was used to analyze the data recorded during the parents’ interviews.

Results

Five themes captured the range of the parent’s experiences, viewpoints, and ideas: (1) parents’ expectations, (2) child’s engagement with therapy, (3) positive effects of the interventions, (4) challenges, and (5) improving the protocol.

Conclusions

Parents from both groups recognized that their expectations related to improving children’s object handling and manipulation skills including participation in activities of daily life were addressed during the 16-week therapy program. Parents perceived a change in the children’s level of independence in their daily tasks at home, school, and leisure activities.

Trial Registration

ClinicalTrials.gov NCT02728375; https://clinicaltrials.gov/ct2/show/NCT02728375

Identifying mechanisms of change in a magic-themed hand-arm bimanual intensive therapy programme for children with unilateral spastic cerebral palsy: a qualitative study using behaviour change theory

Background

There has been much research into how to promote upper-limb skills to achieve functional independence in children with unilateral spastic cerebral palsy (USCP). One researched intervention is the Breathe Magic programme, which follows the protocol of hand-arm bimanual intensive therapy (HABIT) whilst, incorporating magic tricks to develop children’s motor skills and bimanual skills. However, whilst research has found the programme to be effective, there has been little consideration of how the intervention leads to a positive outcome: what the psychological, social and physical mechanisms of action are.

Methods

Qualitative semi-structured interviews with 21 children with USCP who participated in the Breathe Magic HABIT intervention, and focus groups with 17 parents and/or carers were undertaken. Analysis was conducted through the lens of the COM-B behaviour change model using a combined deductive framework and inductive thematic analysis. Reliability of coding was confirmed through random extraction and double coding of a portion of responses and the calculation of inter-rater reliability.

Results

Breathe Magic brings about change and positive outcomes by increasing children’s psychological and physical capabilities, providing social opportunities, and enhancing reflective and automatic motivation. Additionally, a number of enablers to engaging in the intervention were identified, particularly under psychological capabilities, social opportunities and both reflective and automatic motivation. Very few barriers were raised; those that were raised were of relatively low frequency of reporting.

Conclusions

By conducting a theory-based qualitative process evaluation, this study demonstrated the mechanisms of change behind the Breathe Magic HABIT intervention for children with USCP. Breathe Magic was found to be a well-structured combination of intended and unintended mechanisms of change. Overall, the success of Breathe Magic was observed through not only its intended mechanisms to enhance hand skills, but also through unintended psychological improvements in children’s hand function, as well as social and motivational benefits resulting from interaction between children and parents.