Assisting Hand Assessment and Children's Hand-Use Experience Questionnaire -Observed Versus Perceived Bimanual Performance in Children with Unilateral Cerebral Palsy

Validation and reliability of Arabic version of Children's Hand-use Experience Questionnaire (CHEQ) for children with hemiparetic cerebral palsy

The aim was to assess validation and reliability of Arabic version of Children's Hand-use Experience Questionnaire (CHEQ) for children with hemiparetic cerebral palsy (HCP). Ninety-nine children aged 6-18 years diagnosed with HCP participated in the study. The CHEQ was used to evaluate the hand-use experiences of children with cerebral palsy (CP). In the expert opinion questionnaire, the average percentage score of agreement on grasp efficacy was 91.5%. The highest percentage (93.3%) was for time taken. Agreement on CHEQ ranged from 91.5 to 93.3% indicating that the content validity of the prototype is supported by the expert ratings. Fitting indices showed that the one-factor structure of the CHEQ has a good and acceptable fit in children with HCP aged 6-18 years. All factor loads of the CHEQ items were greater than 0.7 and significant. Cronbach's alpha coefficient in this study was 0.921, thus showing that the questionnaire had high internal consistency.

Bimanual hand use in children and adolescents with unilateral spastic cerebral palsy: an exploratory study

BACKGROUND

Individuals with unilateral spastic cerebral palsy (USCP) often show difficulties using their hands during activities of daily living.

OBJECTIVE

To investigate the factors that interfere with hand use during bimanual activities in children and adolescents with USCP.

METHODS

We conducted a cross-sectional study with 102 children and adolescents with USCP, aged 6 to 18 years. We collected information with the caregivers about the classification of the child's manual ability, according to the Manual Ability Classification System (MACS); child's age; side of the involvement; Children's Hand-Use Experience Questionnaire- CHEQ2.0. Cluster analysis identified groups of children and adolescents who performed CHEQ activities with or without assistance. Multiple linear regression analyses identified the contribution of the factors: age, sex, MACS level, side of hemiparesis, and clusters of assistance, on the outcomes of efficacy, time, and feeling bothered.

RESULTS

MACS and clusters of assistance explained the variance in efficacy (p<0.05; R2=0.31) and time (p<0.05; R2=0.37). MACS explained 22% of the variance in feeling bothered.  Children and adolescents with increased difficulty to perform activities that involve hand use (i.e., MACS III) and who receive assistance during most bimanual activities showed less efficacy of use, were slower in their performance, and presented greater feeling of being bothered.

CONCLUSION

Assistance in bimanual activities and MACS level contributed to explain the efficacy of use, time, and feeling bothered in performing bimanual activities. Intervention strategies aimed at promoting the performance of bimanual activities in the daily routine of children with USCP should consider these outcomes.

Functional Splinting efficacy in a Specific Task Home Program for Children with Cerebral Palsy. A Randomized Controlled Trial

BACKGROUND

The purpose of this study is to investigate whether wearing a functional hand splint adds benefit to carrying out a task-specific home program.

METHODS

Thirty-three children were randomly assigned to the Specific Task and Splint Group or to a comparison group. Participants were evaluated before and after 6 weeks of intervention and at 14 weeks of follow-up.

RESULTS

Both groups improved on the Assisting Hand Assessment and the Children's Hand-use Experience Questionnaire (AHA Units p = .000; CHEQ bimanual tasks p = .000; CHEQ grasp efficacy p = .000 and CHEQ time utilization p = .018). No differences were found between the groups after the intervention or after the follow-up.

CONCLUSIONS

Hand skills improved in both groups who received a task-specific home program. Wearing a functional hand splint did not appear to improve effectiveness in addition to the home program. This study is registered in ClinicalTrials.gov (NCT03282422).

Quality of patient- and proxy-reported outcomes for children with impairment of the upper extremity: a systematic review using the COSMIN methodology

Background

As patient-reported outcome measures (PROMs) have become of significant importance in patient evaluation, adequately selecting the appropriate instrument is an integral part of pediatric orthopedic research and clinical practice. This systematic review provides a comprehensive overview of PROMs targeted at children with impairment of the upper limb, and critically appraises and summarizes the quality of their measurement properties by applying the COnsensus-based Standards for selection of health Measurement INstruments (COSMIN) methodology.

Methods

A systematic search of the MEDLINE and EMBASE databases was performed to identify relevant publications reporting on the development and/or validation of PROMs used for evaluating children with impairment of the upper extremity. Data extraction and quality assessment (including a risk of bias evaluation) of the included studies was undertaken by two reviewers independently and in accordance with COSMIN guidelines.

Results

Out of 6423 screened publications, 32 original articles were eligible for inclusion in this review, reporting evidence on the measurement properties of 22 self- and/or proxy-reported questionnaires (including seven cultural adaptations) for various pediatric orthopedic conditions, including cerebral palsy (CP) and obstetric brachial plexus palsy (OBPP). The measurement property most frequently evaluated was construct validity. No studies evaluating content validity and only four PROM development studies were included. The methodological quality of these development studies was either ‘doubtful’ or ‘inadequate’. The quantity and quality of the evidence on the other measurement properties of the included questionnaires varied substantially with insufficient sample sizes and/or poor methodological quality resulting in significant downgrading of evidence quality.

Conclusion

This review provides a comprehensive overview of currently available PROMs for evaluation of the pediatric upper limb. Based on our findings, none of the PROMs demonstrated sufficient evidence on their measurement properties to justify recommending the use of these instruments. These findings provide room for validation studies on existing pediatric orthopedic upper limb PROMs (especially on content validity), and/or the development of new instruments.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41687-022-00469-4.

Cross-cultural adaptation and reliability of the Arabic version of Children’s Hand-use Experience Questionnaire (CHEQ)

Background

Validated outcome measures are essential for assessment and treatment of children with disabilities. The Children’s Hand-use Experience Questionnaire (CHEQ) was developed and validated for use in Western countries for children with unilateral hand dysfunction. This study aimed to perform a cross-cultural adaptation and investigate reliability for the Arabic CHEQ.

Methods

Translation and cross-cultural adaptation were performed in four phases: (i) forward-translation and reconciliation with feedback from parents and typically developing children from Jordan (n = 14); (ii) backward-translation and review; (iii) cognitive debriefing with parents and/or their children with unilateral hand dysfunction (n = 17); and (iv) review and proofreading. In the psychometric analyses, 161 children from Jordan (mean age [SD] 10y 8 m [5y 8 m]; 88 males) participated. Internal consistency was evaluated with Cronbach’s alpha. Test-retest reliability was evaluated in 39 children with intraclass correlation coefficient (ICC) and weighted kappa (κ).

Results

Synonyms of four words were added to accommodate for different Arabic dialects. On average, 93% of children with unilateral hand dysfunction and their parents understood the CHEQ items. One response alternative, ‘Get help’, to the opening question was unclear for 70% of the respondents and need further explanation. Two items about using a knife and fork were difficult to comprehend and culturally irrelevant. High internal consistency was demonstrated (Cronbach’s alphas 0.94- 0.97) and moderate to excellent ICC (0.77–0.93). For 18 individual items, κ indicated poor to good agreement (κ between 0.28 and 0.66).

Conclusions

After the suggested minor adjustments, the Arabic CHEQ will be comprehensible, culturally relevant and reliable for assessing children with unilateral hand dysfunction in Jordan.

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.

The effects of hand deformity on upper-limb function and health-related quality of life in children with spastic hemiplegic cerebral palsy

The aim of this study was to investigate the effect of hand deformity on upper-limb function and health-related quality of life (HRQOL) in children with hemiplegic cerebral palsy (CP). The study included 44 children with hemiplegic CP between the ages of 6 and 14 years (mean age, 10.04 years; SD, 3.1; 23 males, 21 females). The Manual Ability Classification System (MACS) and Gross Motor Function Classification System (GMFCS) were used, with the Zancolli classification to characterize hand deformities on the more affected side. Upper-limb function was assessed in terms of unilateral capacity (Quality of Upper Extremity Skills Test: QUEST) and bimanual performance (Children's Hand-use Experience Questionnaire: CHEQ), while HRQOL was evaluated on the KIDSCREEN-27 questionnaire. Comparison of bimanual performance and unilateral capacity in children with Zancolli level 1 and 2a hemiplegic CP found statistically significant differences (p < 0.01). There was also a significant difference on the HRQOL 'physical activities and health' subdomain, in favor of Zancolli level I deformity (p = 0.003), but not on the other HRQOL domains (p > 0.05). Upper-limb function and the HRQOL physical health domain were poorer with greater hand deformity in children with hemiplegic CP.

Tyneside Pegboard Test for unimanual and bimanual dexterity in unilateral cerebral palsy: association with sensorimotor impairment

AIM

We explored the psychometric properties of the recently developed Tyneside Pegboard Test (TPT) for unimanual and bimanual dexterity in children with unilateral cerebral palsy (CP) and investigated the impact of sensorimotor impairments on manual dexterity.

METHOD

In this cross-sectional study, the TPT was assessed in 49 children with unilateral CP (mean age 9y 8mo, SD 1y 11mo, range 6-15y; 30 males, 19 females; 23 with right unilateral CP). All participants additionally underwent a standardized upper limb evaluation at body function and activity level. We investigated: (1) known-group, concurrent, and construct validity and (2) impact of sensorimotor impairments including spasticity, grip force, stereognosis, and mirror movements using analysis of covariance, Spearman's rank correlation (r), and multiple linear regression (R² ) respectively.

RESULTS

TPT outcomes significantly differed according to the Manual Ability Classification System (p<0.001, known-group validity). Relationships were found between the unimanual TPT tasks and the Jebsen-Taylor Hand Function Test (r=0.86-0.88, concurrent validity). Bimanual TPT tasks were negatively correlated with the Assisting Hand Assessment, ABILHAND-Kids, and Children's Hand-use Experience Questionnaire (r=-0.38 to -0.78, construct validity). Stereognosis was the main determinant influencing all tasks (p<0.001, R² =37-50%). Unimanual dexterity was additionally determined by grip strength (p<0.05, R² =8-9%) and mirror movements in the more impaired hand (p<0.05, R² =4-8%). Bimanual dexterity was also explained by mirror movements in the more impaired hand (p<0.01, R² =10-16%) and spasticity (p=0.04, R² =5%).

INTERPRETATION

The TPT is a valid test to measure unimanual and bimanual dexterity in unilateral CP. The results further emphasize the importance of somatosensory impairments in children with unilateral CP. What this paper adds The Tyneside Pegboard Test is valid for measuring unimanual and bimanual dexterity in unilateral cerebral palsy. Children with poorer manual ability show worse unimanual and bimanual dexterity. Stereognosis is the main predictor of both unimanual and bimanual dexterity. Stronger mirror movements in the more impaired hand result in worse bimanual dexterity.

Interest of children with unilateral spastic cerebral palsy in bimanual daily activities

Background: Many bimanual activities are challenging for children with unilateral spastic cerebral palsy (USCP).Aims: To investigate hand use by children with USCP in daily activities of their interest.Material e methods: Sample included twenty children with USCP, aged 8 to 14 years old. Participants identified bimanual activities of their interest and no interest. Children's performance on these activities were videotaped. Videos were coded according to the affected extremity's forms and effectiveness of use, caregiver provision and types of assistance, and child's satisfaction. The relative proportions of each parameter were compared using the signed-rank test, considering the time spent in activities of interest and no interest.Results: We analyzed 116 activities. We found effects of interest in children's satisfaction (p = 0.003) and on the type of assistance (p = 0.03). Specifically, children demonstrated longer periods of satisfaction performing activities of their interest and caregiver physical assistance was provided for longer periods of time in activities of no interest. There were no effects on the other parameters.Conclusions: A model that illustrates the impact of a child's interest on the performance of daily bimanual activities is presented, grounded in our results and in the literature.

Upper Limb Function of Children with Unilateral Cerebral Palsy After a Magic-Themed HABIT: A Pre-Post-Study with 3- and 6-Month Follow-Up

Aims: To examine changes in upper limb function, and performance in everyday tasks, for children with unilateral cerebral palsy who participated in a magic-themed hand-arm bimanual intensive therapy (HABIT). Methods: Twenty-eight children participated; mean age 10 y 6 mo (SD 2 y 2 mo), n = 15 male and n = 13 female. Using a single group, pre-and post-test design, the magic-themed HABIT was delivered for 60 hours over 10 days. Bimanual and unimanual hand function were measured using the Assisting Hand Assessment (AHA) and Box and Blocks Test (BBT). Occupational performance was rated using the Canadian Occupational Performance Measure (COPM). Two parent questionnaires explored change in bimanual hand use in everyday activities; ABILHAND-Kids and Children's Hand-use Experience Questionnaire (CHEQ). Assessments were completed pre-, immediately post, 3 months and 6 months after the intervention. Results: Friedman's ANOVA revealed a significant improvement for COPM and CHEQ grasp subscale. Repeated measures ANOVA revealed a significant improvement in BBT, and ABILHAND-Kids, and no significant change for AHA. Conclusions: Children who participated in the magic-themed HABIT experienced improved occupational performance, unimanual skills, and parent ratings of performance in challenging everyday tasks.

To Explore the Validity of Change Scores of the Children's Hand-use Experience Questionnaire (CHEQ) in Children with Unilateral Cerebral Palsy

AIMS

To explore the validity of change scores of the Children's Hand-use Experience Questionnaire (CHEQ).

METHODS

Analysis of the CHEQ included 44 children (15 girls) between 6-16 years (median 9.0; IQR 8-11) with unilateral cerebral palsy, with baseline and post- (two-week intensive) intervention assessments using the Goal Attainment Scale (GAS) as external anchor for change. Hypotheses on the magnitude of expected change were formulated and correlation coefficients and effect sizes calculated. Receiver operating curve analysis was performed and the area under the curve (AUC) calculated to investigate the ability of CHEQ to discriminate between improvement and non-improvement according to GAS.

RESULTS

All hypotheses about the magnitude of change were confirmed supporting longitudinal validity of CHEQ scales to measure change in the perception of bimanual performance. AUCs for the Grasp efficacy and the Time utilization were slightly below, and for the Feeling bothered slightly above the threshold. The latter one accurately discriminating between children that improved and did not improve according to the GAS.

CONCLUSIONS

Evidence was found that CHEQ scales capture change in bimanual performance but with limited accuracy for two out of three scales. The validity of CHEQ change scores needs to be further explored in a wider population.

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.

Hand-Use-at-Home Questionnaire: validity and reliability in children with neonatal brachial plexus palsy or unilateral cerebral palsy

OBJECTIVE

To investigate construct validity and test-retest reliability of the parent-rated Hand-Use-at-Home questionnaire (HUH) in children with neonatal brachial plexus palsy or unilateral cerebral palsy.

DESIGN AND SUBJECTS

For this cross-sectional study, children with neonatal brachial plexus palsy or unilateral cerebral palsy, aged 3-10 years, were eligible.

MAIN MEASURES

The HUH, Pediatric Outcome Data Collection Instrument Upper Extremity Scale (neonatal brachial plexus palsy only), and Children's Hand-Use Experience Questionnaire (unilateral cerebral palsy only) were completed. The HUH was completed twice in subgroups of both diagnoses. Lesion-extent (indication of involved nerve rootlets in neonatal brachial plexus palsy as confirmed during clinical observation and/or nerve surgery) and Manual Ability Classification System levels (unilateral cerebral palsy) were obtained from the medical records. Spearman correlation coefficients between the HUH and all clinical variables, agreement, standard error of measurement, smallest detectable change and intra-class correlation were calculated.

RESULTS

A total of 260 patients participated (neonatal brachial plexus palsy: 181), of which 56 completed the second HUH (neonatal brachial plexus palsy: 16). Median age was 6.9 years for children with neonatal brachial plexus palsy, 116 had C5-C6 lesions. Median age for children with unilateral cerebral palsy was 6.4 years, 33 had Manual Ability Classification System Level II. The HUH correlated moderately with lesion-extent ( r_s =-0.5), Pediatric Outcome Data Collection Instrument Upper Extremity Scale ( r_s = 0.6) and Children's Hand-Use Experience Questionnaire ( r_s = 0.5) but weakly with Manual Ability Classification System levels ( r_s = -0.4). Test-retest reliability was excellent (intra-class correlation_2,1 = 0.89, standard error of measurement = 0.599 and smallest detectable change = 1.66 logits) and agreement was good (mean difference HUH1 - HUH2 = 0.06 logits).

CONCLUSION

The HUH showed good construct validity and test-retest reliability in children with neonatal brachial plexus palsy or unilateral cerebral palsy.