Effects of constraint-induced movement therapy in young children with hemiplegic cerebral palsy: an adapted model

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

IMPORTANCE

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

OBJECTIVE

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

DESIGN

Single group pretest-posttest design.

SETTING

Three-wk structured CIMT camp.

PARTICIPANTS

Eleven children with HCP between ages 3 and 14 yr.

INTERVENTION

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

OUTCOMES AND MEASURES

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

RESULTS

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

CONCLUSIONS AND RELEVANCE

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

Outcomes of a Parent-Delivered Baby-mCIMT Model for Infants at High Risk of Unilateral Cerebral Palsy Using Remote Coaching in Telerehabilitation

There is growing evidence of the positive effects of constraint-induced movement therapy (CIMT) for infants at high risk of unilateral cerebral palsy (UCP) when provided by parents with in-person coaching/supervision from occupational therapists during home visits. The aim of this study is to investigate whether Baby-mCIMT (modifiedCIMT) can be as effective if parents are coached/supervised remotely. In this case-control study, we recruited 20 infants and re-used 18 controls, 4-8-month-old infants in both groups at high risk of UCP. The same protocol regarding inclusion criteria, data collection, and training volume was used in both groups. The training was conducted for two 6-week periods, separated by a 6-week break, consisting of daily 30 min sessions conducted by parents, supported by therapist coaching once a week. The primary outcome was measured using the Hand Assessment for Infants (HAI). There was no difference in the change of HAI units (p = 0.803) or that of the affected-hand raw score (p = 0.942) between the two groups. The remote coaching method was well received by parents. In conclusion, this demonstrates that remote coaching/supervision is as effective as the in-person approach, requiring less time and effort for both families and healthcare providers.

Effectiveness of simple and basic home-based exercise programs including pediatric massage executed by caregivers at their homes in the management of children with spastic cerebral palsy: A randomized controlled trial

PURPOSE

This study aimed to assess the effectiveness of simple and basic home-based exercise programs (HEPs), including pediatric massage (PM), executed by caregivers at their homes in the management of children with spastic cerebral palsy (CP).

METHODS

Sixty-eight children with spastic CP (diplegia) aged 4-12 years were randomly assigned to PM and HEP groups for a randomized controlled trial continuing from November 01, 2021 to June 2022. Parents provided home-based exercises to both groups, five times a week for 12 weeks. However, the PM group was additionally provided with PM. Modified Ashworth Scale (MAS), Gross Motor Function Measure (GMFM-88) and Gross Motor Function Classification System (GMFCS) were used for evaluation of spasticity and gross motor activity at baseline as well as after six and 12 weeks of intervention. Comparative analysis of data was carried out with SPSS-20.

RESULTS

Mean age in HEP and PM groups was 6.65±2.12 and 7.09±2.22 years respectively. Data revealed homogeneity of both groups at the beginning of study. The PM group showed a statistically significant decrease in MAS scores after six and 12 weeks of intervention (p < 0.05) when compared with the HEP group, but similar changes did not happen in GMFM scores and GMFCS levels. However, comparative analysis revealed statistically significant change in GMFM scores and GMFCS levels (p < 0.05) when compared from baseline to 12 weeks of intervention in both groups.

CONCLUSION

PM along with HEPs can be used effectively to reduce spasticity and to improve gross motor ability if performed for a period of at least six and 12 weeks respectively. In conjunction with HEPs, PM has better outcomes in the management of tone and movement disorders of spastic CP than HEPs alone.

Evaluation of a computer game-assisted rehabilitation program for manual dexterity of children with cerebral palsy: Feasibility randomized control trial

BACKGROUND

There is a need for innovation to improve the engagement and compliance of rehabilitation programs for children with upper extremity (UE) motor impairments due to cerebral palsy (CP); a computer games-based rehabilitation platform (GRP) was developed to address this need. The GRP provides engaging task-specific exercises targeting manual dexterity (object handling and manipulation).

OBJECTIVE

To evaluate the therapeutic value and treatment effect size of an exercise program using the GRP in children with CP.

METHODS

A total of 63 children with CP, aged 4 to 10 years, were recruited. The Peabody Developmental Motor Scale-2 (PDMS-2) Grasp and Visual-Motor Integration (VMI) subscores and Computer game-based Upper Extremity (CUE) assessment of manual dexterity were used to assess participants before and after a 16-week intervention program, delivered three times per week. The experimental group (XG) received a computer games-based exercise program targeting object manipulation tasks. The active control arm (CG) consisted of task-specific training similar to the tasks used in constrained induced movement therapy.

RESULTS

There were only a few dropouts during the 16-week program, and compliance was high. Both groups showed significant improvements with medium to large effect sizes. Improvements in the PDMS-2 Grasp and VMI subscores observed in the XG were significantly greater than that in the CG. There were significant improvements (p < .01) in PDMS-2 grasp and VMI subscores for XG with moderate to large effect sizes (0.5-0.8). For CG, the Grasp and VMI subscores did improve but these changes were not statistically significant. There was a significant improvement observed in the majority of CUE object manipulation test scores for XG (p < .01) with moderate to large effect sizes (0.50-1.2) Although CG did show improvements in all CUE object manipulation test scores, the changes did not reach statistical significance (p < .01).

CONCLUSION

This study demonstrates the utility of the GRP to practice a broad range of object manipulation tasks in children with CP. The present findings are positive and support further research and development. The long-term effects of the GRP program in children with CP will need to be confirmed in a future randomized controlled trial. In addition to measures of structure and function, future trials should also include outcome measures such as health-related quality of life and level of participation to validate the findings.

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.

A protocol for a single-arm interventional study assessing the effects of a home-based joystick-operated ride-on-toy navigation training programme to improve affected upper extremity function and spontaneous use in children with unilateral cerebral palsy (UCP)

INTRODUCTION

Children with unilateral cerebral palsy (UCP) face significant limitations in upper extremity (UE) function and require effective interventions that promote intensive goal-directed practice while maximising motivation and adherence with therapy. This study builds on our past work and will assess the effects of a 6-week researcher-caregiver codelivered, home-based ride-on-toy navigation training (RNT) programme in young children with UCP. We hypothesise that the RNT programme will be acceptable, feasible to implement, and lead to greater improvements in unimanual and bimanual function when combined with conventional therapy, compared with conventional therapy provided alone.

METHODS AND ANALYSIS

15 children with UCP between 3 and 8 years will be recruited. During the 6-week control phase, participants will receive treatement-as-usual alone. During the subsequent 6-week intervention phase, in addition to conventional therapy, RNT will be provided 4-5 times/week (2 times by researchers, 2-3 times by caregivers), 30-45 min/session. We will assess UE function using standardised tests (Quality of Upper Extremity Skills Test and Shriner's Hospital Upper Extremity Evaluation), reaching kinematics, wrist-worn accelerometry, caregiver-rated ABILHAND-Kids questionnaire, and training-specific measures of movement control during RNT. Programme feasibility and acceptance will be assessed using device use metrics, child and caregiver exit questionnaires, training-specific measures of child engagement, and the Physical Activity Enjoyment Scale. All assessments will be conducted at pretest, following the control phase (midpoint), and after completion of the intervention phase (post-test).

ETHICS AND DISSEMINATION

The study is approved by the Institutional Review Board of the University of Connecticut (# H22-0059). Results from this study will be disseminated through peer-reviewed manuscripts in scientific journals in the field, through national and international conferences, and through presentations to parent advocacy groups and other support organisations associated with CP.

TRIAL REGISTRATION NUMBER

NCT05559320.

Development of Hand Use with and Without Intensive Training Among Children with Unilateral Cerebral Palsy in Scandinavia

AIM

To describe hand use development in children with unilateral cerebral palsy who did/did not participate in constraint-induced movement therapy (CIMT) before 7 years of age.

METHOD

The study included 334 participants (18 months-12 years) who were assessed with 1,565 Assisting Hand Assessments (AHAs) and categorized into no intensive training (NIT), CIMT (18 months-7 years), and Baby-CIMT (<18 months) groups.

RESULTS

AHA performance at 18 months (AHA-18) was positively associated with development regardless of training. The CIMT group had lower AHA-18 performance than the NIT group (p = .028), but higher stable limit (p = .076). The age when 90% of development was reached was highest in the CIMT group (p = .014). Although non-significant, the Baby-CIMT group had higher mean curve than NIT and CIMT combined (AHA-18 p = .459, limit p = .477).

CONCLUSION

The CIMT group improved more over time than the NIT group. Intensive training extended the window of development, and Baby-CIMT might promote early development.

The effect of parent-based occupational therapy on parents of children with cerebral palsy: a randomised controlled trial

Background/Aims

Parents of children with cerebral palsy face higher levels of stress, anxiety and depression, sadness, exhaustion and burnout. Parent-based therapies have been found to increase parents' satisfaction with therapy, parent–child interactions and reduced parental stress. This study examined the effects of parent-based occupational therapy on stress levels, coping skills, and emotional skills and competencies of parents of children with cerebral palsy.

Methods

A total of 15 children and their parents who were admitted to the paediatric rehabilitation unit for occupational therapy were divided into two groups (control group: n=7, study group: n=8) using the coin toss randomisation method. The control group received standard occupational therapy, while the study group received parent-based occupational therapy for 45 minutes a session, twice a week, until 10 sessions had been completed. Participants were evaluated before and after the intervention.

Results

The study group showed a decrease in stress levels (P=0.034) and increases in coping skills (P=0.016), and emotional skills and competencies (P=0.036). In addition, only an improvement in parents' stress levels (P=0.046) was observed in the control group.

Conclusions

The parent-based occupational therapy programme was more effective regarding stress levels, coping skills, emotional skills and competencies of the families of children with cerebral palsy compared to classical occupational therapy. This study is important in terms of demonstrating the benefits of parent-based occupational therapy for parents of children with cerebral palsy.

Neurodevelopmental Therapy for Cerebral Palsy: A Meta-analysis

BACKGROUND AND OBJECTIVE

Bobath therapy, or neurodevelopmental therapy (NDT) is widely practiced despite evidence other interventions are more effective in cerebral palsy (CP). The objective is to determine the efficacy of NDT in children and infants with CP or high risk of CP.

METHODS

Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Embase, and Medline were searched through March 2021. Randomized controlled trials comparing NDT with any or no intervention were included. Meta-analysis was conducted with standardized mean differences calculated. Quality was assessed by using Cochrane Risk of Bias tool-2 and certainty by using Grading of Recommendations Assessment, Development, and Evaluation.

RESULTS

Of 667 records screened, 34 studies (in 35 publications, 1332 participants) met inclusion. Four meta-analyses were conducted assessing motor function. We found no effect between NDT and control (pooled effect size 0.13 [-0.20 to 0.46]), a moderate effect favoring activity-based approaches (0.76 [0.12 to 1.40]) and body function and structures (0.77 [0.19 to 1.35]) over NDT and no effect between higher- and lower-dose NDT (0.32 [-0.11 to 0.75]). A strong recommendation against the use of NDT at any dose was made. Studies were not all Consolidated Standards of Reporting Trials-compliant. NDT versus activity-based comparator had considerable heterogeneity (I2 = 80%) reflecting varied measures.

CONCLUSIONS

We found that activity-based and body structure and function interventions are more effective than NDT for improving motor function, NDT is no more effective than control, and higher-dose NDT is not more effective than lower-dose. Deimplementation of NDT in CP is required.

Exploring Clinical and Neurophysiological Factors Associated with Response to Constraint Therapy and Brain Stimulation in Children with Hemiparetic Cerebral Palsy

BACKGROUND

Perinatal stroke causes hemiparetic cerebral palsy (HCP) and lifelong disability. Constraint-induced movement therapy (CIMT) and neurostimulation may enhance motor function, but the individual factors associated with responsiveness are undetermined.

OBJECTIVE

We explored the clinical and neurophysiological factors associated with responsiveness to CIMT and/or brain stimulation within a clinical trial.

METHODS

PLASTIC CHAMPS was a randomized, blinded, sham-controlled trial (n = 45) of CIMT and neurostimulation paired with intensive, goal-directed therapy. Primary outcome was the Assisting Hand Assessment (AHA). Classification trees created through recursive partitioning suggested clinical and neurophysiological profiles associated with improvement at 6-months.

RESULTS

Both clinical (stroke side (left) and age >14 years) and neurophysiological (intracortical inhibition/facilitation and motor threshold) were associated with responsiveness across treatment groups with positive predictive values (PPV) approaching 80%.

CONCLUSION

This preliminary analysis suggested sets of variables that may be associated with response to intensive therapies in HCP. Further modeling in larger trials is required.

Are they really motor learning therapies? A scoping review of evidence-based, task-focused models of upper limb therapy for children with unilateral cerebral palsy

PURPOSE

To identify the specific motor learning (ML) theories underpinning evidence-based, task-focused upper limb models of therapy for children with unilateral cerebral palsy; and to document the strategies used in the operationalisation of these theories.

MATERIAL AND METHOD

This scoping review searched for relevant studies using eight electronic databases. A list of 68 ML strategies and accompanying definitions was developed for data extraction. Three classifications; adequate, inadequate or not described were used to rate the description of ML strategies. A corresponding colour-coding system was used to provide a visual summary.

RESULTS

There is a limited description of the ML theories and strategies used to operationalise these theories in existing models of evidence-based upper limb therapy. Of 103 therapy protocols included, only 24 explicitly described the guiding ML theory. When described, there was significant variation in the underlying theories, leading to significantly different focus and content of therapy. Of the 68 ML strategies, only three were adequately described.

CONCLUSIONS

To support treatment fidelity and the implementation of evidence-based, task-focused models of upper limb therapy in clinical practice, future research needs to provide explicit details about the underlying theories and strategies used in the operationalisation of these theories.Implications for rehabilitationEvidence-based models of upper limb therapy purport to be based on motor learning theory, however, most provide a very limited description of the theories and strategies used.Dosage of practice is only one element that is specific to a therapy approach and other elements guided by the principles of type of task and type of feedback should be considered.To support the implementation of evidence-based approaches in clinical practice, and improve treatment fidelity, it is important for researchers to define the theories that guide therapy approaches and explicitly describe the strategies used to operationalise these theories.

Study Protocol: Multimodal Longitudinal Assessment of Infant Brain Organization and Recovery in Perinatal Brain Injury

PURPOSE

Perinatal brain injury is a primary cause of cerebral palsy, a condition resulting in lifelong motor impairment. Infancy is an important period of motor system development, including development of the corticospinal tract (CST), the primary pathway for cortical movement control. The interaction between perinatal stroke recovery, CST organization, and resultant motor outcome in infants is not well understood.

METHODS

Here, we present a protocol for multimodal longitudinal assessment of brain development and motor function following perinatal brain injury using transcranial magnetic stimulation and magnetic resonance imaging to noninvasively measure CST functional and structural integrity across multiple time points in infants 3 to 24 months of age. We will further assess the association between cortical excitability, integrity, and motor function.

DISCUSSION

This protocol will identify bioindicators of motor outcome and neuroplasticity and subsequently inform early detection, diagnosis, and intervention strategies for infants with perinatal stroke, brain bleeds, and related diagnoses.

HABIT+tDCS: a study protocol of a randomised controlled trial (RCT) investigating the synergistic efficacy of hand-arm bimanual intensive therapy (HABIT) plus targeted non-invasive brain stimulation to improve upper extremity function in school-age children with unilateral cerebral palsy

INTRODUCTION

Unilateral spastic cerebral palsy (USCP) is characterised by movement deficits primarily on one body side. The best available upper extremity (UE) therapies are costly and intensive. Thus, there is an urgent need for better, more efficient and thus more accessible therapies. Transcranial direct current stimulation (tDCS) is non-invasive and may enhance physical rehabilitation approaches. The aim of this study is to determine whether tDCS targeted to the hemisphere with corticospinal tract (CST) connectivity enhances the efficacy of UE training in children with USCP. Our central hypothesis is that hand-arm bimanual intensive therapy (HABIT) combined with a tDCS montage targeting the hemisphere with CST connectivity to the impaired UE muscles will improve UE function more than HABIT plus sham stimulation. We will test this by conducting a randomised clinical trial with clinical and motor cortex physiology outcomes.

METHODS AND ANALYSES

81 children, aged 6-17 years, will be randomised to receive 2 mA anodal tDCS targeted to the affected UE motor map, 2 mA cathodal tDCS to the contralesional motor cortex or sham tDCS during the first 20 min of each HABIT session (10 hours: 2 hours/day for 5 days). Primary outcomes will be Box and Blocks Test, Assisting Hand Assessment and motor cortex excitability, determined with single-pulse transcranial magnetic stimulation. Secondary outcomes include ABILHAND-Kids, Canadian Occupational Performance Measure, Cooper Stereognosis, Dimension of Mastery Questionnaire and Participation and Environment Measure-Children and Youth. All measures will be collected before, immediately and 6 months after treatment. A group × test session Analysis of Variance will test differences among groups on all measures.

ETHICS AND DISSEMINATION

The study has been approved by the BRANY Institutional Review Board (#18-10-285-512). We will leverage our subject and family relationships to maximise dissemination and share results with the academic and patient/family advocacy groups.

TRIAL REGISTRATION NUMBER

NCT03402854.

Modified constraint induced movement therapy in children with obstetric brachial plexus palsy: a systematic review

INTRODUCTION

Obstetric brachial plexus palsy (OBPP) is a flaccid paralysis occurring in the upper limb during birth. The OBPP includes mild lesions with complete spontaneous recovery and severe injuries with no regain of arm function. Among the most promising rehabilitation treatments aimed at improving upper extremity motor activities in individuals with neurological dysfunctions, there is the modified constraint-induced movement therapy (mCIMT). The aim of this systematic review is to assess and synthesize the critical aspects of the use of mCIMT in children with OBPP.

EVIDENCE ACQUISITION

This systematic review has been carried out according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analysis). A comprehensive search of the literature was conducted using PubMed, MEDLINE and Evidence Based Medicine Reviews, databases. We enclosed experimental and original articles, case reports and book chapters. Four articles were finally included.

EVIDENCE SYNTHESIS

One case report tested the feasibility of mCIMT to encourage use of the affected arm in a child with Erb-Duchenne palsy and documented the clinical changes observed. A case series had the purpose to determine if mCIMT in combination with botulinum toxin (BTX-A) improved arm function in 2 children with OBPP. A cohort study compared the use of mCIMT in 19 OBPP and 18 unilateral Cerebral Palsy. A prospective single-blind RCT described mCIMT versus conventional therapy in a group of 39 children with OBPP.

CONCLUSIONS

This systematic review on the use of mCIMT in children with OBPP shows that there is unanimous agreement that a program should last 2 weeks at least. However, there is no scientific evidence supporting a single common mCIMT protocol in the management of OBPP because of a considerable heterogeneity. Further high methodological studies regarding the application of mCIMT for OBPP and based on larger patients' sample should have the potential to optimize the appropriateness of care provided to infants with OBPP and, therefore, their quality of life.

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.

Modified constraint-induced movement therapy during hospitalization in children with perinatal brachial plexus palsy: A randomized controlled trial

STUDY DESIGN

Prospective single-blind, randomized controlled study.

INTRODUCTION

Children with perinatal brachial plexus palsy (PBPP) have motion limitations in the affected upper extremity. Modified constraint-induced movement therapy (mCIMT) is one of the treatment options used for the improvement of the function of the affected limb.

PURPOSE OF THE STUDY

The purpose of this study was to compare the effect of mCIMT and conventional therapy in improving active range of motion (ROM) and functional use of the affected upper extremity in children with PBPP with injuries to upper and middle trunks in the hospital environment.

MATERIALS

26 patients received conventional rehabilitation program (control group) and 13 patients participated in a mCIMT program (study group). Children had a mean age 56.3 months (range 4-10 years). The mCIMT included 1 hour therapy sessions emphasizing the affected arm use for 14 consecutive days during hospitalization. Their normal arm was also constrained for 6 hour per day. All the patients were assessed at the baseline, one day, one month, and three months after completion of therapy using active ROM, active movement scale, hand dynamometer, box and blocks test.

RESULTS

The mCIMT group improved more than the control group in shoulder internal rotation, forearm supination, elbow flexion active ROMs, hand grip strength, and in upper extremity function.

CONCLUSION

mCIMT has a potential to promote functional gains for children with PBPP; this approach should be widely applied within routine clinical practice.

Combined intensive therapies at home in spastic unilateral cerebral palsy with high bimanual functional performance. What do they offer? A comparative randomised clinical trial

Background:

Children with unilateral spastic cerebral palsy (USCP) receive different treatments, including the application of modified constraint induced movement therapy (mCIMT) or bimanual intensive therapy (BIT) to increase affected upper limb functionality. The aim of this study was to compare the effectiveness of two protocols with different proportions and orders of mCIMT/BIT within combined intensive home-therapy in children with USCP (6–8 years old) with high bimanual functional performance, applied by the family.

Methods:

The protocols were performed on 20 children with an average age of 7.12 years [standard deviation (SD): 0.70], allocated to two different combined therapies. The protocols were designed by 100 h of dose for 10 weeks: 80 h of mCIMT followed by 20 h of BIT (mCIMT-B group) and 80 h of BIT followed by 20 h of mCIMT (BIT-mCI group). Bimanual functional performance was measured with Assisting Hand Assessment Scale (AHA) and the affected upper limb-use experience with Children’s Hand-use Experience Questionnaire (CHEQ). Parent satisfaction and expectations with therapy were measured using a specific questionnaire. There were five assessment timepoints (week 0, week 4, week 8, week 10 and week 34).

Results:

There were no statistically significant (p > 0.05) inter- and intra-group changes in the bimanual functional performance of both groups. The affected upper limb-use experience obtained significant changes in BIT-mCI group, with statistically significant differences in the pairwise comparisons between week 0–10 and week 4–10 (p = 0.028) for use of the affected hand and the use of the affected hand to grasp between week 4 and week 8 (p = 0.028). Grasp efficacy and discomfort acquired statistically significant differences only in the BIT-mCI group for pairwise comparisons week 0–week 10/week 4–week 10 (p = 0.035). Although task execution time compared with a typically developing child of the same age obtained statistically significant differences only in the group mCIMT-B for pairwise comparisons week 0–week 8 (p = 0.03), week 0–week 10 (p = 0.03), week 4–week 8 (p = 0.04) and week 4–week 10 (p = 0.03). Family satisfaction and expectations acquired an increase between week 0 and week 10 (p ⩽ 0.02).

Conclusion:

Applying 80 h of BIT for 8 weeks in children with high bimanual functional performance USCP (6–8 years old), executed at home with family involvement would be sufficient to obtain improvements in affected upper limb-use experience, without the need to use combined protocols of 100 h. However, no statistically significant increase in bimanual functional performance would be obtained, with the basal situation of the child being a factor to consider for the execution of mCIMT and BIT.

Registration number and name of trial registry: [ClinicalTrials.gov identifier: NCT03465046]

Perinatal stroke: mapping and modulating developmental plasticity

Most cases of hemiparetic cerebral palsy are caused by perinatal stroke, resulting in lifelong disability for millions of people. However, our understanding of how the motor system develops following such early unilateral brain injury is increasing. Tools such as neuroimaging and brain stimulation are generating informed maps of the unique motor networks that emerge following perinatal stroke. As a focal injury of defined timing in an otherwise healthy brain, perinatal stroke represents an ideal human model of developmental plasticity. Here, we provide an introduction to perinatal stroke epidemiology and outcomes, before reviewing models of developmental plasticity after perinatal stroke. We then examine existing therapeutic approaches, including constraint, bimanual and other occupational therapies, and their potential synergy with non-invasive neurostimulation. We end by discussing the promise of exciting new therapies, including novel neurostimulation, brain-computer interfaces and robotics, all focused on improving outcomes after perinatal stroke.

A hybrid model of modified constraint induced movement therapy to improve upper extremity performance in children with unilateral upper extremity paresis: Retrospective case series

Introduction

The study aims were to assess impact of an intensive camp-based intervention using a hybrid model of modified constraint induced movement therapy with bimanual therapy in children with upper extremity impairment, and to see if improvements persisted over time.

Method

Twenty subjects participated. Eight subjects attended camp 2 years in a row, and 12 subjects attended camp only 1 year. The Assisting Hand Assessment and Children’s Hand-use Experience Questionnaire were administered before and after camp. Assisting Hand Assessment and Children’s Hand-use Experience Questionnaire scores were compared between assessments using linear mixed effects models, adjusting for covariates (age and Manual Ability Classification System level) and the repeated measures within subjects.

Results

Assisting Hand Assessment score improved during the intervention phase for subjects at all Manual Ability Classification System levels ( p ≤ 0.0001). Improvement was maintained long-term at 1 year post. Children’s Hand-use Experience Questionnaire scores for grasp efficacy and time taken were significantly improved during intervention but not maintained at 1 year post. The feeling bothered dimension showed no significant change over time.

Conclusion

A hybrid model of modified constraint induced movement therapy and bimanual therapy was effective in improving bimanual function for children with varying levels of neurologic hemiparesis, with changes maintained long-term.

Brain activation changes following motor training in children with unilateral cerebral palsy: An fMRI study

BACKGROUND

Intensive motor-learning-based interventions have demonstrated efficacy for improving motor function in children with unilateral spastic cerebral palsy (USCP). Although this improvement has been associated mainly with neuroplastic changes in the primary sensori-motor cortices, this plasticity may also involve a wider fronto-parietal network for motor learning.

OBJECTIVE

To determine whether hand-arm bimanual intensive therapy including lower extremities (HABIT-ILE) induces brain activation changes in an extensive network for motor skill learning and whether these changes are related to functional changes observed after HABIT-ILE.

METHODS

In total, 25 children with USCP were behaviourally assessed in manual dexterity and everyday activities before and after HABIT-ILE. Functional imagery monitored brain activity while participants manipulated objects using their less-affected, more-affected or both hands. Two random-effects-group analyses performed at the whole-brain level assessed the brain activity network before and after therapy. Three other random-effects-group analyses assessed brain activity changes after therapy. Spearman's correlations were used to evaluate the correlation between behavioural and brain activity changes.

RESULTS

The same fronto-parietal network was identified before and after therapy. After the intervention, the more-affected hand manipulation elicited a decrease in activity on the motor cortex of the non-lesional hemisphere and an increase in activity on motor areas of the lesional hemisphere. The less-affected hand manipulation generated a decrease in activity of sensorimotor areas in the non-lesional hemisphere. Both-hands manipulation elicited an increase in activity of both hemispheres. Furthermore, we observed an association between brain activity changes and changes in everyday activity assessments.

CONCLUSION

Brain activation changes were observed in a fronto-parietal network underlying motor skill learning with HABIT-ILE in children with USCP. Two different patterns were observed, probably related to different phases of motor skill learning, representing an increased practice-dependent brain recruitment or a brain activation refinement by more efficient means. CLINICALTRIALS.GOV: NCT01700777 &NCT02667613.

Efficacy of the use of unaffected hand containment in unimanual intensive therapy to increase visuomotor coordination in children with hemiplegia: a randomized controlled pilot study

Background:

The capacity of children with hemiplegia to be engaged in anticipatory action planning is affected. There is no balance among spatial, proprioceptive and visual information, thus altering the affected upper limb visuomotor coordination. The objective of the present study was to assess the improvement in visuomotor coordination after the application of a unimanual intensive therapy program, with the use of unaffected hand containment compared with not using unaffected hand containment.

Methods:

A simple blind randomized clinical trial was realized. A total of 16 subjects with congenital infantile hemiplegia participated in the study with an age mean of 5.54 years old (SD:1.55). Two intensive protocols for 5 weeks of modified constraint-induced movement therapy (mCIMT) or unimanual therapy without containment (UTWC) were executed 5 days per week (2 h/day). Affected upper limb visuomotor coordination (reaction time, task total time, active range, dynamic grasp) was measured before–after intensive therapy using a specific circuit with different slopes (10°/15°).

Results:

Statistically significant inter-group differences were found after the intervention, with clinically relevant results for the mCIMT group not seen in UTWC, in the following variables: reaction time 10°slope (p = 0.003, d = 2.44), reaction time 15°slope (p = 0.002, d = 2.15) as well as for the task total time 10°slope (p = 0.002, d = 2.25), active reach 10°slope (p = 0.002, d = 2.7), active reach 15°slope (p = 0.003, d = 2.29) and dynamic grasp 10°/15°slopes (p = <0.001, d = 2.69). There were not statistically significant inter-group differences in the total task time with 15°slope (p = 0.074, d = 1.27).

Conclusions:

The use of unaffected hand containment in mCIMT would allow improvements in the affected upper limb’s visuomotor coordination. Thus, it would favor clinical practice to make decisions on therapeutic approaches to increase the affected upper limb functionality and action planning in children diagnosed with infantile hemiplegia (4–8 years old).

Intervention bimanual stimulates the abilities in infants with asymmetry

Abstract Introduction: The cerebral palsy and brachial plexus injury may cause asymmetry in the use of the upper limbs (UL). This condition requires early treatment to reduce the impact of the child's life; therefore, several proposed interventions aim to increase their functional independence. The Constraint-Induced Movement Therapy (CIMT) and Hand-Arm Bimanual Intensive Therapy (HABIT) have been widely considered effective interventions to improve hand function. Objective: Investigate the effects of an intervention protocol based on the CIMT and HABIT theoretical foundations in the stimulation of manual function in infants with the UL asymmetry. Methods: Five infants (6-24 months) participated in the study. To evaluate the motor function of infants we used Pediatric Motor Activity Log (PMAL-R) and Manual Function Evaluation (AMIGO), and to assess the caregiver's perception of the participation of the infant in daily tasks, we used the Pediatric Disability Assessment Inventory (PEDI). All evaluations occurred before, immediately after the intervention, and after four months for follow-up recording, and were analyzed descriptively by Jacobson- Truax method. Results: The results between evaluation and reevaluation demonstrated evolution in all aspects studied. In the PEDI self-care session, an average of 38.6 (±8.4) - 44.2 (±7.4); PEDI Mobility: 28.8 (±20.3) - 36.28 (±21.7); PEDI Social Function: 40.1 (±10.2) - 42.3 (±8.9). The PMAL-R quantity and quality results evidence a highly positive clinical significance in all infants. Conclusion: The application of the modified restriction intervention protocol resulted in reliable and clinically significant changes in all cases.

Unimanual Intensive Therapy with or without Unaffected Hand Containment in Children with Hemiplegia. A Randomized Controlled Pilot Study

Children with hemiplegia have lower spontaneous use and quality of movement in the affected upper limb. The modified constraint-induced movement therapy (mCIMT) is applied to improve the affected upper limb function. The objective of this study was to study the efficacy of unaffected hand containment to obtain changes in the function of the affected upper limb after applying two unimanual therapies. A randomized controlled pilot study was performed with 16 children diagnosed with congenital infantile hemiplegia, with eight children randomized in each group (average age: 5.54 years; SD: 1.55). mCIMT and unimanual therapy without containment (UTWC) were applied, with a total of 50 h distributed in five weeks (two h/per day). Two assessments were performed (pre- and post-treatment) to evaluate the affected upper limb spontaneous use, measured with the Shiners Hospital Upper Extremity Evaluation (SHUEE), and the quality of movement, measured with the Quality of Upper Extremity Skills Test (QUEST scale). The progression of the variables was different in both groups. The results are expressed in the median of the improvement percent and interquartile range (IQR). The spontaneous use analysis showed an improvement percent of 31.65 (IQR: 2.33, 110.42) in the mCIMT group with respect to 0.00 (IQR: 0.00, 0.00) in the UTWC group. The quality of movement increased in the mCIMT and UTWC groups, 24.21 (IQR: 13.44, 50.39), 1.34 (IQR: 0.00, 4.75), respectively and the greatest increase was obtained in the grasp variable for both groups. The use of unaffected hand containment in mCIMT would produce improvements in the affected upper limb functionality in children with hemiplegia (4-8 years old) compared to the same protocol without containment (UTWC).

Application of Low-Intensity Modified Constraint-Induced Movement Therapy to Improve the Affected Upper Limb Functionality in Infantile Hemiplegia with Moderate Manual Ability: Case Series

OBJECTIVE

To assess the functionality of the affected upper limb in children diagnosed with hemiplegia aged between 4 and 8 years after applying low-intensity modified Constraint-Induced Movement Therapy (mCIMT).

METHODS

Prospective case series study. A mCIMT protocol was applied for five weeks, with two hours of containment per day. The study variables were quality of movement of the upper limb, spontaneous use, participation of the affected upper limb in activities of daily living, dynamic joint position, grasp-release action, grasp strength, supination and extension elbow movements. Four measurements were performed, using the quality of upper extremity test (QUEST) scale, the Shriners Hospital for Children Upper Extremity Evaluation (SHUEE) Evaluation, a hand dynamometer and a goniometer.

RESULTS

The sample was composed of eight children with moderate manual ability. Statistically significant differences were detected in all the studied variables (p < 0.05) between the pre-treatment and post-treatment results (Week 0-Week 5), except for upper limb dressing, putting on splints and buttoning up. In the first week, the changes were statistically significant, except for protective extension, grasp strength, grasp-release and all functional variables (level of functionality and participation of the patient's upper limbs) in the SHUEE Evaluation (p > 0.05). The greatest increase occurred in spontaneous use from Assessment 1 to Assessment 4 (p = 0.01), reaching 88.87% active participation in bimanual tasks. The quality of movement of the upper limb exhibited a significant value due to the increase in dissociated movements and grasp (p = 0.01).

CONCLUSION

A low dose (50 h) of mCIMT increased the functionality of children diagnosed with congenital hemiplegia between 4 and 8 years of age with moderate manual ability.

Intensive upper extremity training improved whole body movement control for children with unilateral spastic cerebral palsy

BACKGROUND

Children with unilateral spastic cerebral palsy (USCP) exhibit impaired bimanual coordination, gait control, and whole body movement control. Intensive upper extremity training has been found to be effective for improving upper extremity function. However, the effectiveness of the intensive upper extremity training on whole body movement control is not known.

RESEARCH QUESTION

The present study aimed to evaluate the effects of Constraint Induced Movement Therapy (CIMT) and Hand Arm Bimanual Intensive Therapy (HABIT) on bimanual coordination and gait control during a complex whole body task.

METHODS

Sixteen children with congenital hemiplegia (age 6-12 years; GMFCS: I-II, MACS: I-II) were randomly assigned to either CIMT or HABIT for 6 h per day training for 15 days. Children were asked to perform two whole body tasks (walking with and without a tray carrying) while 3-D kinematic analysis was performed before and after training.

RESULTS

After training, the HABIT group increased the symmetry in height of their hands during tray carrying (more leveled tray). Both CIMT and HABIT groups decreased the lateral motion of the tray. The CIMT group increased speed and stride length after training in both the walking and tray carrying tasks. Both groups also increased their minimum toe clearance (all p < 0.05).

SIGNIFICANCE

Two types of intensive upper extremity training have provided significant improvements to whole body movement control for children with USCP. Adhering to the specificity of practice concept, HABIT improved bimanual coordination after training during the whole body tray carrying tasks. Given extensive interactions between the upper and lower extremities in real-world activities, future studies should focus on the effects of such combined training.

Imaging Developmental and Interventional Plasticity Following Perinatal Stroke

Perinatal stroke occurs around the time of birth and leads to lifelong neurological disabilities including hemiparetic cerebral palsy. Magnetic resonance imaging (MRI) has revolutionized our understanding of developmental neuroplasticity following early injury, quantifying volumetric, structural, functional, and metabolic compensatory changes after perinatal stroke. Such techniques can also be used to investigate how the brain responds to treatment (interventional neuroplasticity). Here, we review the current state of knowledge of how established and emerging neuroimaging modalities are informing neuroplasticity models in children with perinatal stroke. Specifically, we review structural imaging characterizing lesion characteristics and volumetrics, diffusion tensor imaging investigating white matter tracts and networks, task-based functional MRI for localizing function, resting state functional imaging for characterizing functional connectomes, and spectroscopy examining neurometabolic changes. Key challenges and exciting avenues for future investigations are also considered.

Ipsilateral Corticospinal Tract Excitability Contributes to the Severity of Mirror Movements in Unilateral Cerebral Palsy: A Case Series

Mirror movements (MM) can be a clinical manifestation of unilateral cerebral palsy (UCP) causing involuntary movements when attempting to use either hand for functional activities. Atypical development of the corticospinal tract (CST) contributes to impairments in observed motor movements and functional activities. However, little is known about the underlying neurophysiology and contribution of the CST to MM. The current case study characterizes MM in 13 children and young adults with UCP ranging in age from 7 to 19 years and includes clinical and neurophysiologic variables. Clinical profiles included MM of each hand (ie, Woods and Teuber), bimanual coordination and hand use (Assisting Hand Assessment [AHA]), and perception of performance (Canadian Occupational Performance Measure [COPM]). We measured the strength of motor-evoked potentials (MEP) elicited from single-pulse transcranial magnetic stimulation (TMS) of each hemisphere to create a ratio of hemispheric responses. Our sample included three types of CST circuitry: ipsilateral (n = 5), bilateral (n = 3), and contralateral (n = 4). The MEP ratio ranged from 0 to 1.45 (median 0.11) with greater MM observed in participants with ratios greater than 0.5. We observed a positive relationship between the MEP ratio and the more-affected MM score, meaning participants with larger ipsilateral responses from contralesional stimulation (eg, the contralesional hemisphere was stimulated with TMS resulting in an ipsilateral MEP response), as compared with contralateral responses, displayed greater MM than those that did not. There was no relationship between MM and function as measured by the AHA or COPM. These findings suggest a role of the contralesional hemisphere to MM, which could serve as a therapeutic target for interventions.

Randomized controlled trial combining constraint-induced movement therapy and action-observation training in unilateral cerebral palsy: clinical effects and influencing factors of treatment response

Introduction:

Constraint-induced movement therapy (CIMT) improves upper limb (UL) motor execution in unilateral cerebral palsy (uCP). As these children also show motor planning deficits, action-observation training (AOT) might be of additional value. Here, we investigated the combined effect of AOT to CIMT and identified factors influencing treatment response.

Methods:

A total of 44 children with uCP (mean 9 years 6 months, SD 1 year 10 months) participated in a 9-day camp wearing a splint for 6 h/day and were allocated to the CIMT + AOT (n = 22) and the CIMT + placebo group (n = 22). The CIMT + AOT group received 15 h of AOT (i.e. video-observation) and executed the observed tasks, whilst the CIMT + AOT group watched videos free of biological motion and executed the same tasks. The primary outcome measure was bimanual performance. Secondary outcomes included measures of body function and activity level assessed before (T1), after the intervention (T2), and at 6 months follow-up (T3). Influencing factors included behavioural and neurological characteristics.

Results:

Although no between-groups differences were found (p > 0.05; η² = 0–16), the addition of AOT led to higher gains in children with initially poorer bimanual performance (p = 0.02; η² = 0.14). Both groups improved in all outcome measures after the intervention and retained the gains at follow up (p < 0.01; η² = 0.02–0.71). Poor sensory function resulted in larger improvements in the total group (p = 0.03; η² = 0.25) and high amounts of mirror movements tended to result in a better response to the additional AOT training (p = 0.06; η² = 0.18). Improvements were similar irrespective of the type of brain lesion or corticospinal tract wiring pattern.

Conclusions:

Adding AOT to CIMT, resulted in a better outcome for children with poor motor function and high amounts of mirror movements. CIMT with or without AOT seems to be more beneficial for children with poor sensory function.

Trial registration:

Registered at ClinicalTrials.gov on 22nd August 2017 (ClinicalTrials.gov identifier: NCT03256357).

A Pilot Study of Two Different Constraint-Induced Movement Therapy Interventions in Children With Hemiplegic Cerebral Palsy After Botulinum Toxin Injection During Preschool Education

Introduction: To establish a pilot study on applying two low dose (40 h) constraint-induced movement therapy (CIMT) interventions in children with hemiplegic cerebral palsy (CP) after botulinum toxin (BoNT-A) injection during preschool education. Methods: Five children with spastic CP (mean age: 5.31 years; Gross Motor Function Classification System level I and II) undergoing regular BoNT-A injections and rehabilitation programs were included. Participants were randomly allocated to one of two CIMT programs (40 h): a 2-week 4-hours/day CIMT program and a 4-week 2-hours/day CIMT program. One CIMT program was performed 1 month after a BoNT-A injection, and then the second program was implemented with the next injection. The outcomes were measured by changes in Goal Attainment Scaling (GAS), the grasp and Visual-Motor Integration (VMI) test in Peabody-Developmental Motor Scales (PDMS), the self-care scale on the Functional Skill Scale, and the Caregiver Assistance in Chinese Version of Pediatric Evaluation of Disability Inventory (PEDI-C), Anxiety and Oppositional Defiance Problems of Achenbach System of Empirically-Based Assessment before and after the CIMT interventions, and at every 2 months' follow-up thereafter. Results: The mean age of the participants was 5.31 years, BMI was 16.7 (kg/m²), VIQ was 86.4 ± 8.5, and dose of BoNT-A injection in the upper limb was 42 ± 26.6 units. Grasp, VMI, and self-care on the Functional Skill Scale were significantly better in the 4-week 2-hours/day CIMT program (p < 0.001, p = 0.001, p < 0.001). GAS, grasp, VMI, two 2 self-care scales of PEDI were significantly improved after the CIMT programs, and improvement continued for up to 4 months after the programs. There was no clinical evidence showing changes in the scores for anxiety and oppositional defiance problems during the study period. Conclusions: The preliminary findings, although limited, suggest a potential therapeutic role for the school-based CIMT program after BoNT-A injection. The 4-week 2-hours/day CIMT program might be better than a 2-week 4-hours/day program in terms of self-care and hand function when performed in kindergarten in this pilot study. Furthermore, this pilot study provides valuable information; therefore, it is crucial to include more CP children and blinded assessors for hand function and ADL in the future study.

Can Neonatal Systemic Inflammation and Hypoxia Yield a Cerebral Palsy-Like Phenotype in Periadolescent Mice?

Cerebral palsy (CP) is one of the most common childhood-onset motor disabilities, attributed to injuries of the immature brain in the foetal or early postnatal period. The underlying mechanisms are poorly understood, rendering prevention and treatment strategies challenging. The aim of the present study was to establish a mouse model of CP for preclinical assessment of new interventions. For this purpose, we explored the impact of a double neonatal insult (i.e. systemic inflammation combined with hypoxia) on behavioural and cellular outcomes relevant to CP during the prepubertal to adolescent period of mice. Pups were subjected to intraperitoneal lipopolysaccharide (LPS) injections from postnatal day (P) 3 to P6 followed by hypoxia at P7. Gene expression analysis at P6 revealed a strong inflammatory response in a brain region-dependent manner. A comprehensive battery of behavioural assessments performed between P24 and P47 showed impaired limb placement and coordination when walking on a horizontal ladder in both males and females. Exposed males also displayed impaired performance on a forelimb skilled reaching task, altered gait pattern and increased exploratory activity. Exposed females showed a reduction in grip strength and traits of anxiety-like behaviour. These behavioural alterations were not associated with gross morphological changes, white matter lesions or chronic inflammation in the brain. Our results indicate that the neonatal double-hit with LPS and hypoxia can induce subtle long-lasting deficits in motor learning and fine motor skills, which partly reflect the symptoms of children with CP who have mild gross and fine motor impairments.

Constraint-induced movement therapy in children with unilateral cerebral palsy

BACKGROUND

Unilateral cerebral palsy (CP) is a condition that affects muscle control and function on one side of the body. Children with unilateral CP experience difficulties using their hands together secondary to disturbances that occur in the developing fetal or infant brain. Often, the more affected limb is disregarded. Constraint-induced movement therapy (CIMT) aims to increase use of the more affected upper limb and improve bimanual performance. CIMT is based on two principles: restraining the use of the less affected limb (for example, using a splint, mitt or sling) and intensive therapeutic practice of the more affected limb.

OBJECTIVES

To evaluate the effect of constraint-induced movement therapy (CIMT) in the treatment of the more affected upper limb in children with unilateral CP.

SEARCH METHODS

In March 2018 we searched CENTRAL, MEDLINE, Embase, CINAHL, PEDro, OTseeker, five other databases and three trials registers. We also ran citation searches, checked reference lists, contacted experts, handsearched key journals and searched using Google Scholar.

SELECTION CRITERIA

Randomised controlled trials (RCTs), cluster-RCTs or clinically controlled trials implemented with children with unilateral CP, aged between 0 and 19 years, where CIMT was compared with a different form of CIMT, or a low dose, high-dose or dose-matched alternative form of upper-limb intervention such as bimanual intervention. Primarily, outcomes were bimanual performance, unimanual capacity and manual ability. Secondary outcomes included measures of self-care, body function, participation and quality of life.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts to eliminate ineligible studies. Five review authors were paired to extract data and assess risk of bias in each included study. GRADE assessments were undertaken by two review authors.

MAIN RESULTS

We included 36 trials (1264 participants), published between 2004 and 2018. Sample sizes ranged from 11 to 105 (mean 35). Mean age was 5.96 years (standard deviation (SD) 1.82), range three months to 19.8 years; 53% male and 47% participants had left hemiplegia. Fifty-seven outcome measures were used across studies. Average length of CIMT programs was four weeks (range one to 10 weeks). Frequency of sessions ranged from twice weekly to seven days per week. Duration of intervention sessions ranged from 0.5 to eight hours per day. The mean total number of hours of CIMT provided was 137 hours (range 20 to 504 hours). The most common constraint devices were a mitt/glove or a sling (11 studies each).We judged the risk of bias as moderate to high across the studies.

KEY RESULTS

Primary outcomes at primary endpoint (immediately after intervention)CIMT versus low-dose comparison (e.g. occupational therapy)We found low-quality evidence that CIMT was more effective than a low-dose comparison for improving bimanual performance (mean difference (MD) 5.44 Assisting Hand Assessment (AHA) units, 95% confidence interval (CI) 2.37 to 8.51).CIMT was more effective than a low-dose comparison for improving unimanual capacity (Quality of upper extremity skills test (QUEST) - Dissociated movement MD 5.95, 95% CI 2.02 to 9.87; Grasps; MD 7.57, 95% CI 2.10 to 13.05; Weight bearing MD 5.92, 95% CI 2.21 to 9.6; Protective extension MD 12.54, 95% CI 8.60 to 16.47). Three studies reported adverse events, including frustration, constraint refusal and reversible skin irritations from casting.CIMT versus high-dose comparison (e.g. individualised occupational therapy, bimanual therapy)When compared with a high-dose comparison, CIMT was not more effective for improving bimanual performance (MD -0.39 AHA Units, 95% CI -3.14 to 2.36). There was no evidence that CIMT was more effective than a high-dose comparison for improving unimanual capacity in a single study using QUEST (Dissociated movement MD 0.49, 95% CI -10.71 to 11.69; Grasp MD -0.20, 95% CI -11.84 to 11.44). Two studies reported that some children experienced frustration participating in CIMT.CIMT versus dose-matched comparison (e.g. Hand Arm Bimanual Intensive Therapy, bimanual therapy, occupational therapy)There was no evidence of differences in bimanual performance between groups receiving CIMT or a dose-matched comparison (MD 0.80 AHA units, 95% CI -0.78 to 2.38).There was no evidence that CIMT was more effective than a dose-matched comparison for improving unimanual capacity (Box and Blocks Test MD 1.11, 95% CI -0.06 to 2.28; Melbourne Assessment MD 1.48, 95% CI -0.49 to 3.44; QUEST Dissociated movement MD 6.51, 95% CI -0.74 to 13.76; Grasp, MD 6.63, 95% CI -2.38 to 15.65; Weightbearing MD -2.31, 95% CI -8.02 to 3.40) except for the Protective extension domain (MD 6.86, 95% CI 0.14 to 13.58).There was no evidence of differences in manual ability between groups receiving CIMT or a dose-matched comparison (ABILHAND-Kids MD 0.74, 95% CI 0.31 to 1.18). From 15 studies, two children did not tolerate CIMT and three experienced difficulty.

AUTHORS' CONCLUSIONS

The quality of evidence for all conclusions was low to very low. For children with unilateral CP, there was some evidence that CIMT resulted in improved bimanual performance and unimanual capacity when compared to a low-dose comparison, but not when compared to a high-dose or dose-matched comparison. Based on the evidence available, CIMT appears to be safe for children with CP.

Brain Lesions as a Predictor of Therapeutic Outcomes of Hand Function in Infants With Unilateral Cerebral Palsy

AIM

The present study aimed to investigate whether the response variability of infants to modified constraint-induced movement therapy and bimanual therapy are associated with different types of brain lesions.

METHOD

Infants with unilateral cerebral palsy (N = 22) ages 8-15 months (mean = 10.95, standard deviation = 2.15 months) were grouped according to having either a periventricular brain lesion or a middle cerebral artery infarct lesion. Improvement in hand function was analyzed based on the mini-Assistive Hand Assessment results.

RESULTS

Infants with periventricular brain lesion displayed greater positive response to upper limb treatment compared to those with middle cerebral artery infarct ( P = .02). A significant difference in improvement according to type of treatment was found in the middle cerebral artery infarct group but not in the periventricular brain lesion.

CONCLUSION

The present study showed an association between the type of brain lesion and the efficacy of upper limb treatment in infants. Infants with periventricular brain lesions displayed greater positive responses than those with middle cerebral artery infarct.

Effectiveness of Modified Constraint-Induced Movement Therapy Compared With Bimanual Therapy Home Programs for Infants With Hemiplegia: A Randomized Controlled Trial

OBJECTIVE. We examined the effectiveness of modified constraint-induced movement therapy (mCIMT) in treating infants with hemiplegic cerebral palsy and compared therapy outcomes with a nonconstraining bimanual therapy (BIM) of equal intensity.

METHOD. In a single-blinded randomized controlled trial, 33 infants with hemiplegia (mean corrected age = 11.1 mo, standard deviation = 2.2) received either mCIMT (n = 17) or BIM (n = 16). Both interventions included home programs encouraging the use of the affected hand during daily 1-hr play sessions for 8 wk. Outcome measures were administered pre- and posttreatment and included the Mini-Assisting Hand Assessment for babies and the Functional Inventory. At baseline, parents also filled out the Dimensions of Mastery Questionnaire.

RESULTS. Both groups demonstrated a significantly large and equal improvement in hand and gross motor function posttreatment (p &lt; .001) and high treatment compliance.

CONCLUSION. mCIMT and BIM are equally effective methods for treating infants with hemiplegia.

Transcranial Direct Current Stimulation (tDCS) Paired with Occupation-Centered Bimanual Training in Children with Unilateral Cerebral Palsy: A Preliminary Study

Objective

We investigated the preliminary efficacy of cathodal transcranial direct current stimulation (tDCS) combined with bimanual training in children and young adults with unilateral cerebral palsy based on the principle of exaggerated interhemispheric inhibition (IHI).

Methods

Eight participants with corticospinal tract (CST) connectivity from the lesioned hemisphere participated in an open-label study of 10 sessions of cathodal tDCS to the nonlesioned hemisphere (20 minutes) concurrently with bimanual, goal-directed training (120 minutes). We measured the frequency of adverse events and intervention efficacy with performance (bimanual-Assisting Hand Assessment (AHA)-and unimanual-Box and Blocks), self-report (Canadian Occupational Performance Measure (COPM), ABILHAND), and neurophysiologic (motor-evoked potential amplitude, cortical silent period (CSP) duration, and motor mapping) assessments.

Results

All participants completed the study with no serious adverse events. Three of 8 participants showed gains on the AHA, and 4 of 8 participants showed gains in Box and Blocks (more affected hand). Nonlesioned CSP duration decreased in 6 of 6 participants with analyzable data. Cortical representation of the first dorsal interosseous expanded in the nonlesioned hemisphere in 4 of 6 participants and decreased in the lesioned hemisphere in 3 of 4 participants with analyzable data.

Conclusions

While goal achievement was observed, objective measures of hand function showed inconsistent gains. Neurophysiologic data suggests nonlinear responses to cathodal stimulation of the nonlesioned hemisphere. Future studies examining the contributions of activity-dependent competition and cortical excitability imbalances are indicated.

Long-term neurodevelopmental outcome after perinatal arterial ischemic stroke and periventricular venous infarction

BACKGROUND

Long-term follow-up data after different vascular types of ischemic perinatal stroke is sparse. Our aim was to study neurodevelopmental outcomes following neonatal and presumed perinatal ischemic middle cerebral artery territory stroke (arterial ischemic stroke, AIS) and periventricular venous infarction (PVI).

METHODS

A prospective consecutive cohort of 40 term-born children with perinatal stroke (21 AIS, 19 PVI) was identified through the Estonian Paediatric Stroke Database. While 48% of the children with AIS were diagnosed during the neonatal period, all the children with PVI had presumed perinatal stroke. Outcomes based on the Paediatric Stroke Outcome Measure (PSOM) and Kaufman Assessment Battery for Children - Second Edition (K-ABC-II), in relation to extent and laterality of stroke, were defined.

RESULTS

At a median age of 7 years 6 months (range 3.6-13y), there was a trend towards worse neurodevelopmental outcome in participants with AIS when compared to PVI (mean total PSOM scores 3.1 and 2.2, respectively; p = 0.06). Combined deficits of motor, language and cognitive/behavioural functions were significantly more common among children with AIS (90%) when compared to children with PVI (53%, p = 0.007). General cognitive ability (by K-ABC-II) was significantly lower in the AIS subgroup (mean 79.6; 95% CI 72.3-87.0), but children with PVI (91.6; 95% CI 85.5-97.8) also had poorer performance than the age-equivalent normative mean. Large extent of stroke was associated with poorer neurodevelopmental outcome and lower cognitive performance in children following AIS but not in PVI.

CONCLUSION

In this national cohort, poor long-term neurodevelopmental outcome after perinatal ischemic stroke was seen irrespective of the vascular type or time of diagnosis of stroke. However, the spectrum of neurological deficits is different after perinatal AIS and PVI, with combined deficits more common among children following AIS.

Bilateral reaching deficits after unilateral perinatal ischemic stroke: a population-based case-control study

BACKGROUND

Detailed kinematics of motor impairment of the contralesional ("affected") and ipsilesional ("unaffected") limbs in children with hemiparetic cerebral palsy are not well understood. We aimed to 1) quantify the kinematics of reaching in both arms of hemiparetic children with perinatal stroke using a robotic exoskeleton, and 2) assess the correlation of kinematic reaching parameters with clinical motor assessments.

METHODS

This prospective, case-control study involved the Alberta Perinatal Stroke Project, a population-based research cohort, and the Foothills Medical Center Stroke Robotics Laboratory in Calgary, Alberta over a four year period. Prospective cases were collected through the Calgary Stroke Program and included term-born children with magnetic resonance imaging confirmed perinatal ischemic stroke and upper extremity deficits. Control participants were recruited from the community. Participants completed a visually guided reaching task in the KINARM robot with each arm separately, with 10 parameters quantifying motor function. Kinematic measures were compared to clinical assessments and stroke type.

RESULTS

Fifty children with perinatal ischemic stroke (28 arterial, mean age: 12.5 ± 3.9 years; 22 venous, mean age: 11.5 ± 3.8 years) and upper extremity deficits were compared to healthy controls (n = 147, mean age: 12.7 ± 3.9 years). Perinatal stroke groups demonstrated contralesional motor impairments compared to controls when reaching out (arterial = 10/10, venous = 8/10), and back (arterial = 10/10, venous = 6/10) with largest errors in reaction time, initial direction error, movement length and time. Ipsilesional impairments were also found when reaching out (arterial = 7/10, venous = 1/10) and back (arterial = 6/10). The arterial group performed worse than venous on both contralesional and ipsilesional parameters. Contralesional reaching parameters showed modest correlations with clinical measures in the arterial group.

CONCLUSIONS

Robotic assessment of reaching behavior can quantify complex, upper limb dysfunction in children with perinatal ischemic stroke. The ipsilesional, "unaffected" limb is often abnormal and may be a target for therapeutic interventions in stroke-induced hemiparetic cerebral palsy.

Does Dosage Matter? A Pilot Study of Hand-Arm Bimanual Intensive Training (HABIT) Dose and Dosing Schedule in Children with Unilateral Cerebral Palsy

AIM

We compared the efficacy of hand-arm bimanual intensive training (HABIT) in two doses (90 vs. 45 hours) and two schedules of the same dose (90 vs. 2 × 45 hours) on hand and daily functioning.

METHOD

Eighteen children with unilateral cerebral palsy were randomized to receive 6 hours of daily training over 3 weeks, totaling 90 hours (Group 90, n = 9) or receive 6 hours of daily training over 1.5 weeks, totaling 45 hours (Group 2 × 45, n = 9). After 6 months, Group 2 × 45 received an additional 45 hours. Hand (Jebsen-Taylor Test of Hand Function, Assisting Hand Assessment) and daily functioning tests (Canadian Occupational Performance Measure, Pediatric Evaluation of Disability Inventory) were administered before, immediately after, and 6 months after interventions.

RESULTS

Both groups demonstrated significant improvements in hand and daily functioning after 90 hours (Group 90) or the first 45 hours (Group 2 × 45), without differences between groups. However, more children from Group 90 obtained smallest detectable differences in the Assisting Hand Assessment. The addition of the second bout of 45 hours (Group 2 × 45) did not lead to further improvements.

CONCLUSIONS

As this study was powered to test for large differences between groups, future investigations on larger samples will be needed to compare differences at the two dosage levels.

Combining constraint-induced movement therapy and action-observation training in children with unilateral cerebral palsy: a randomized controlled trial

BACKGROUND

Upper limb (UL) deficits in children with unilateral cerebral palsy (uCP) have traditionally been targeted with motor execution treatment models, such as modified Constraint-Induced Movement Therapy (mCIMT). However, new approaches based on a neurophysiological model such as Action-Observation Training (AOT) may provide new opportunities for enhanced motor learning. The aim of this study is to describe a randomised controlled trial (RCT) protocol investigating the effects of an intensive treatment model, combining mCIMT and AOT compared to mCIMT alone on UL function in children with uCP. Additionally, the role of neurological factors as potential biomarkers of treatment response will be analysed.

METHODS

An evaluator-blinded RCT will be conducted in 42 children aged between 6 and 12 years. Before randomization, children will be stratified according to their House Functional Classification Scale, age and type of corticospinal tract wiring. A 2-week day-camp will be set up in which children receive intensive mCIMT therapy for 6 hours a day on 9 out of 11 consecutive days (54 h) including AOT or control condition (15 h). During AOT, these children watch video sequences showing goal-directed actions and subsequently execute the observed actions with the more impaired UL. The control group performs the same actions after watching computer games without human motion. The primary outcome measure will be the Assisting Hand Assessment. Secondary outcomes comprise clinical assessments across body function, activity and participation level of the International Classification of Function, Disability and Health. Furthermore, to quantitatively evaluate UL movement patterns, a three-dimensional motion analysis will be conducted. UL function will be assessed at baseline, immediately before and after intervention and at 6 months follow up. Brain imaging comprising structural and functional connectivity measures as well as Transcranial Magnetic Stimulation (TMS) to evaluate corticospinal tract wiring will be acquired before the intervention.

DISCUSSION

This paper describes the methodology of an RCT with two main objectives: (1) to evaluate the added value of AOT to mCIMT on UL outcome in children with uCP and (2) to investigate the role of neurological factors as potential biomarkers of treatment response.

TRIAL REGISTRATION

NCT03256357 registered on 21st August 2017 (retrospectively registered).

The Cognitive Orientation to daily Occupational Performance (CO-OP) Approach: Best responders in children with cerebral palsy and brain injury

BACKGROUND

Identifying the characteristics of individuals who are most likely to respond to a certain rehabilitation intervention is advantageous for the child, family, clinicians and the healthcare system.

AIM

To investigate the individual characteristics of children with cerebral palsy or brain injury who responded best to the Cognitive Orientation to daily Occupational Performance (CO-OP) Approach.

METHODS

Post hoc analyses were conducted on 30 participants who participated in CO-OP within a larger randomized controlled trial. Inclusion: cerebral palsy or brain injury; age 4-15 years; Manual Abilities Classification System (MACS) I-IV; goals related to hand function; sufficient cognitive, language and behavioral ability to undertake CO-OP. Outcome measures were the Canadian Occupational Performance Measure (COPM) and Goal Attainment Scale (GAS) collected immediately following the two week intervention period.

RESULTS

Following CO-OP, 67% (n = 20) of participants showed a statistically significant response on the COPM, and 73%(n = 22) on the GAS. Nine participants were classified as best responders. When compared to non-responders, best responders were more likely to be female (p = .025) and to have received a higher dose of CO-OP (p = .028). Neither age nor MACS were predictors of response.

CONCLUSION

To be successful in CO-OP, children should meet the prerequisites of CO-OP, particularly the language and cognitive ability to set goals and communicate effectively with the therapist. In this small sample, children with comorbidities were less likely to achieve goals, females were more likely to respond and dose of therapy was important to success.

Transcranial direct current stimulation and constraint-induced therapy in cerebral palsy: A randomized, blinded, sham-controlled clinical trial

We investigated the safety, feasibility, and efficacy of transcranial direct current stimulation (tDCS) combined with constraint-induced movement therapy (CIMT) in children and young adults with unilateral cerebral palsy. Twenty participants were randomized to receive active or sham tDCS. The intervention consisted of 10 consecutive weekday sessions of tDCS applied to the non-lesioned hemisphere (20 min) concurrently with CIMT (120 min). Participants, caregivers, and interventionists were blinded to group assignment. The primary safety outcome investigated adverse events. The primary behavioral outcome was the Assisting Hand Assessment. All 20 participants (mean age = 12.7 yrs, range = 7.4-21.6 years) were evaluated for the primary outcomes. No serious adverse events occurred, and the most commonly reported minor adverse events were headache and itchiness. Both groups demonstrated a significant improvement in hand function after the intervention, although no significant effect of tDCS was observed (between-group difference = -2.18, 95% CI = [-6.48, 2.12], p = 0.30). Although hand function improved overall, no significant differences between intervention groups were found. Children with preserved corticospinal tract circuitry from the lesioned hemisphere, compared to those without, showed greater improvement in hand function (mean difference = 3.04, 95% CI = [-0.64, 6.72], p = 0.099). Our study demonstrates the safety and feasibility of serial sessions of tDCS, and presents preliminary evidence for the effect of CST circuitry on outcomes following tDCS/CIMT. Future work in children with unilateral cerebral palsy should focus on the optimal dosing and consider individual brain circuitry when describing response to combined interventions.

CLINICAL TRIALS REGISTRATION

Clinicaltrials.govNCT 02250092.

A randomized controlled trial to compare two methods of constraint-induced movement therapy to improve functional ability in the affected upper limb in pre-school children with hemiplegic cerebral palsy: CATCH TRIAL

OBJECTIVE

To determine the feasibility and short-term efficacy of caregiver-directed constraint-induced movement therapy to improve upper limb function in young children with hemiplegic cerebral palsy.

DESIGN

Randomized controlled trial with masked assessment.

SETTING

Community paediatric therapy services.

SUBJECTS

Pre-school children with hemiplegic cerebral palsy.

INTERVENTIONS

Caregiver-directed constraint-induced movement therapy administered using either 24-hour short-arm restraint device (prolonged) or intermittent holding restraint during therapy (manual).

MAIN MEASURES

Primary measures include Assisting Hand Assessment (AHA) at 10 weeks. Secondary measures include adverse events, Quality of Upper Extremity Skills Test and Pediatric Quality of Life Inventory. Feasibility measures include recruitment, retention, data completeness and adherence.

RESULTS

About 62/81 (72%) of eligible patients in 16 centres were randomized (prolonged restraint n = 30; manual restraint n = 32) with 97% retention at 10 weeks. The mean change at 10 weeks on the AHA logit-based 0-100 unit was 9.0 (95% confidence interval (CI): 5.7, 12.4; P < 0.001) for prolonged restraint and 5.3 (95% CI: 1.3, 9.4; P = 0.01) for manual restraint with a mean group difference of 3.7 (95% CI: -1.5, 8.8; P = 0.156) (AHA smallest detectable difference = 5 units). No serious related adverse events were reported. There were no differences in secondary outcomes. More daily therapy was delivered with prolonged restraint (60 vs 30 minutes; P < 0.001). AHA data were complete at baseline and 10 weeks.

CONCLUSION

Caregiver-directed constraint-induced movement therapy is feasible and associated with improvement in upper limb function at 10 weeks. More therapy was delivered with prolonged than with manual restraint, warranting further testing of this intervention in a longer term trial.

Genetic Variation in the Dopamine System Influences Intervention Outcome in Children with Cerebral Palsy

Background

There is large variation in treatment responses in children with cerebral palsy. Experimental and clinical results suggest that dopamine neurotransmission and brain-derived neurotrophic factor (BDNF) signalling are involved in motor learning and plasticity, which are key factors in modern habilitation success. We examined whether naturally occurring variations in dopamine and BDNF genes influenced the treatment outcomes.

Methods

Thirty-three children (18–60 months of age) with spastic unilateral cerebral palsy were enrolled in the study. Each child had participated in a training programme consisting of active training of the involved hand for 2 h every day during a 2-month training period. The training outcome was measured using Assisting Hand Assessment before and after the training period. Saliva was collected for genotyping of COMT, DAT, DRD1, DRD2, DRD3, and BDNF. Regression analyses were used to examine associations between genetic variation and training outcome.

Findings

There was a statistically significant association between variation in dopamine genes and treatment outcome. Children with a high polygenic dopamine gene score including polymorphisms of five dopamine genes (COMT, DAT, DRD1, DRD2, and DRD3), and reflecting higher endogenous dopaminergic neurotransmission, had the greatest functional outcome gains after intervention.

Interpretation

Naturally occurring genetic variation in the dopamine system can influence treatment outcomes in children with cerebral palsy. A polygenic dopamine score might be valid for treatment outcome prediction and for designing individually tailored interventions for children with cerebral palsy.

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Naturally occurring variation of dopamine genes is associated with treatment outcomes in children with cerebral palsy.

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Children with polymorphisms reflecting higher endogenous dopaminergic neurotransmission had the greatest functional gains.

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A polygenic dopamine score might be valid to predict treatment outcome.

New evidence-based therapies including active motor learning and training for children with cerebral palsy improve motor function at a group level, but there are also large inter-individual variations. Naturally occurring variations in dopamine and BDNF genes affect motor learning and cortical plasticity.

This study showed that naturally occurring genetic variation of five dopamine genes was associated with the outcome of a 2-month long active upper limb motor training intervention in children with unilateral cerebral palsy. The results suggest that a polygenic dopamine gene score can be used to predict the outcome of motor training programmes for children with cerebral palsy.

At-home and in-group delivery of constraint-induced movement therapy in children with hemiparesis: A systematic review

BACKGROUND

Constraint-induced movement therapy (CIMT) is increasingly recognized as an effective therapy for children with hemiparesis. However, the effectiveness of CIMT outside the standard rehabilitation protocol in clinical settings is less known. The aim of this systematic review was to investigate the effectiveness of CIMT conducted at home or in a group.

METHODS

We searched CINAHL, PubMed and ScienceDirect in August 2017 to select articles of studies investigating the impact of CIMT performed at home and in a group on affected upper-limb ability, occupational performance, and quality of life of children. Quality was evaluated with the PEDro scale.

RESULTS

Among 374 reports of studies, 30 met the criteria; 15 examined CIMT at home and 15 in a group. CIMT with the 2 delivery models, at home or in a group, had a positive effect on the affected upper-limb ability and occupational performance. The quality of evidence was high for both these outcomes. However, the evidence was weaker and the results too limited to conclude on the impact on quality of life. The data also suggested that the glove may not be the best type of constraint.

CONCLUSIONS

CIMT performed at home or in a group may be a promising intervention for rehabilitation for children with hemiparesis, but more studies on the impact on quality of life are warranted.

Impaired Voluntary Movement Control and Its Rehabilitation in Cerebral Palsy

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

REACH: study protocol of a randomised trial of rehabilitation very early in congenital hemiplegia

OBJECTIVES

Congenital hemiplegia is the most common form of cerebral palsy (CP). Children with unilateral CP show signs of upper limb asymmetry by 8 months corrected age (ca) but are frequently not referred to therapy until after 12 months ca. This study compares the efficacy of infant-friendly modified constraint-induced movement therapy (Baby mCIMT) to infant friendly bimanual therapy (Baby BIM) on upper limb, cognitive and neuroplasticity outcomes in a multisite randomised comparison trial.

METHODS AND ANALYSIS

150 infants (75 in each group), aged between 3 and 6 months ca, with asymmetric brain injury and clinical signs of upper extremity asymmetry will be recruited. Children will be randomised centrally to receive equal doses of either Baby mCIMT or Baby BIM. Baby mCIMT comprises restraint of the unimpaired hand using a simple restraint (eg, glove, sock), combined with intensive parent implemented practice focusing on active use of the impaired hand in a play-based context. In contrast, Baby BIM promotes active play requiring both hands in a play-based context. Both interventions will be delivered by parents at home with monthly home visits and interim telecommunication support by study therapists. Assessments will be conducted at study entry; at 6, 12 months ca immediately postintervention (primary outcome) and 24 months ca (retention). The primary outcome will be the Mini-Assisting Hand Assessment. Secondary outcomes include the Bayley Scale for Infant and Toddler Development (cognitive and motor domains) and the Hand Assessment of Infants. A subset of children will undertake MRI scans at 24 months ca to evaluate brain lesion severity and brain (re)organisation after intervention.

ETHICS AND DISSEMINATION

Full ethical approvals for this study have been obtained from the relevant sites. The findings will be disseminated in peer-reviewed publications.

TRIAL REGISTRATION NUMBER

Australian and New Zealand Clinical Trials Registry: ACTRN12615000180516, Pre results.

[Brain plasticity and early rehabilitative care for children after neonatal arterial cerebral infarction]

Currently, in the literature of the evidence based medicine, little data are available to confirm the benefit and the specific procedures of an early intervention for a neonatal arterial ischemic stroke. However, data about the effect of an early physical rehabilitation program on the cerebral plasticity, and preliminary results of clinical studies in children with cerebral palsy strongly suggest the benefit of an early rehabilitation with a multidisciplinary approach. The type of the rehabilitation and its frequency must be determined because a wide variability in the practices exists. A comprehensive care, of the children and his family is necessary to limit the orthopaedics but also the social consequences of a neonatal stroke.

Constraint-induced movement therapy of upper limb of children with cerebral palsy in clinical practice: systematic review of the literature

ABSTRACT The purpose of the present study was to perform a systematic review of the literature to investigate how and with what modifications or adaptations constraint-induced movement therapy has been employed in clinical practice for therapeutic interventions in children with cerebral palsy. Searches were conducted of the CAPES (Brazilian fostering agency) periodical portal, Pubmed, Bireme, Science Direct, Scielo and PEDro databases for relevant articles published between January 2010 and May 2016. The articles retrieved were evaluated, scored and qualified by two blinded reviewers using the Physical therapy Evidence Database Scale. The searches led to the retrieval of 102 articles, 12 of which were included in the present systematic review. A table was created containing information on the study groups, inclusion criteria, intervention, intervention frequency, difficulties encountered, evaluations and outcomes. Considerable variety was found in the therapeutic intervention models. The findings of the present review demonstrate that constraint-induced movement therapy in pediatric clinical practice is not employed in its original form. Although the studies analyzed did not have a common methodology regarding the use of this type of therapy, the method has been adapted with considerable flexibility, providing promising, positive results regarding the therapeutic intervention of the paretic upper limb in children with cerebral palsy.

Hand Function in Young Children with Cerebral Palsy: Current Practice and Parent-Reported Benefits

AIMS

To (1) describe characteristics of current interventions to improve hand function in young children with Cerebral Palsy (CP), and explore factors associated with (2) increased likelihood of hand and ADL training and (3) child benefits of training.

METHODS

A cross-sectional design was used with parent-reported data and data from the Norwegian CP Follow-up Program (CPOP). A total of 102 children (53% of the cohort of newly recruited children in the CPOP, mean age: 30.3 months, SD: 12.1) were included. Hand function was classified according to the Mini-Manual Ability Classification System (Mini-MACS). Data were analyzed with descriptive statistics, cross-tables and direct multiple logistic regressions.

RESULTS

The majority of the children performed training of hand skills and ADL. Parents reported high amounts of training, and training was commonly integrated in everyday activities. Both parents (OR = 5.6, p < .011) and OTs (OR = 6.2, p < .002) reported more hand training for children at Mini-MACS levels II-III compared to level I. Parents reported larger child benefits when training was organized as a combination of training sessions and practice within everyday activities (OR = 7.090, p = .011).

CONCLUSIONS

Parents reported that the children's everyday activities were utilized as opportunities for training, hence describing the intensity of therapy merely by counting minutes or number of sessions seems insufficient.