Recovery from hemiparesis and unilateral spatial neglect after neonatal stroke. Case report and rehabilitation of an infant

Constraint-Induced Movement Therapy for Infants With or at Risk for Cerebral Palsy: A Scoping Review

IMPORTANCE

Although research shows that older children with hemiplegic cerebral palsy (CP) benefit from constraint-induced movement therapy (CIMT), the efficacy of CIMT among the infant population is unknown.

OBJECTIVE

To explore the existing evidence on CIMT for infants age 24 mo and younger with CP or at risk for CP.

DATA SOURCES

PubMed, CINAHL, Cochrane, and ProQuest were searched. Study Selection and Data Collection: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and American Occupational Therapy Association guidelines were used for abstracting data and assessing data quality. Two frameworks guided this scoping review. Studies met the following criteria: infants with hemiplegic CP, published in English between 2000 and 2020, peer reviewed, and addressed changes in upper limb function of the hemiplegic upper limb.

FINDINGS

Eight articles met the inclusion criteria: 2 randomized controlled trials, 1 retrospective cohort design, 1 pretest-posttest study, 2 single-subject studies, and 2 case studies. In this scoping review, we examined CIMT protocols for an overview of dosage, constraint, administration, parent training and education, and objective outcome measures.

CONCLUSIONS AND RELEVANCE

Existing literature supports CIMT protocols for infants with CP. However, much variability exists in protocol design and appropriate outcome measures among studies. Higher level research is needed to support the efficacy of CIMT among infants with CP. What This Article Adds: This scoping review summarizes the existing literature on CIMT for infants with hemiplegic CP. This information can help guide therapists to implement CIMT protocols in the clinical setting and to identify additional research to establish practice standards.

Comparing the effectiveness of bimanual and unimanual mirror therapy in unilateral neglect after stroke: A pilot study

BACKGROUND

Unilateral neglect in stroke patients is a major obstacle to rehabilitation, which is a great challenge for therapists.

OBJECTIVE

This study aimed to compare the effectiveness of bimanual mirror therapy (BMT) and unimanual mirror therapy (UMT), the two protocols of mirror therapy, for the reduction of the symptoms of unilateral neglect in stroke patients.

METHODS

Twenty-eight individuals were randomly assigned to the UMT or BMT groups. Both groups received mirror therapy for 30 minutes per day, 5 days a week, for a period of 4 weeks. The Star Cancelation Test (SCT), Line Bisection Test (LBT), Picture Scanning test (PST), and Korean Catherine Bergego Scale (K-CBS) were used to measure the change in unilateral neglect, and the Korean version of the Modified Barthel Index (K-MBI) was used to evaluate activities of daily living (ADL).

RESULTS

The results of SCT, LBT, PST, and K-CBS showed significant decreases in unilateral neglect in both groups (p <  0.05). K-MBI improved significantly in both groups (p <  0.05). There were significant differences between the two groups in the unilateral neglect tests (p <  0.05), but no significant difference in ADL evaluation (p >  0.05).

CONCLUSIONS

Mirror therapy protocols can be applied to treat unilateral neglect in stroke patients. However, BMT may be more beneficial for reducing the symptoms of unilateral neglect.

Early intervention evidence for infants with or at risk for cerebral palsy: an overview of systematic reviews

AIM

To perform an overview of systematic reviews and more recent randomized controlled trials (RCTs) on early motor interventions in infants aged 0 to 3 years with or at risk of cerebral palsy to inform current clinical and research efforts and provide a benchmark to assess future interventions ideally initiated within the first 6 months.

METHOD

Standardized searches of the PubMed, Embase, Scopus, and Web of Science databases were conducted for systematic reviews (2009-2020) and RCTs (2015-2020).

RESULTS

From 840 unique records, 31 full texts were reviewed, yielding three systematic reviews encompassing 46 studies, 16 with comparison groups, and six additional RCTs that met the criteria. Two enrichment- and activity-based approaches had medium effect sizes on motor development, only one with low risk of bias; two others had large task-specific effect sizes but some bias concerns; and three enriched environment studies with some bias concerns had medium effect sizes on cognitive development. Most had small or no effect sizes, bias concerns, and uncertain diagnostic determinations.

INTERPRETATION

Data synthesis revealed limited data quantity and quality, and suggest, although not yet confirmed, greater benefit from early versus later intervention. Research efforts with greater early diagnostic precision and earlier intervention are accelerating, which may transform future outcomes and practices. What this paper adds For over 50% of trials within the reviews, the intervention was compared to standard care with only two showing efficacy. Similar to results in older children, constraint-induced movement therapy (CIMT) emerged as efficacious with high effect sizes. CIMT was not superior to similarly intense bimanual training or occupational therapy. Goals-Activity-Motor Enrichment intervention initiated before 5 months of age was superior to equally intense standard care. Several other enriched environment strategies promoted cognitive and/or motor development.

Pediatric unilateral spatial neglect: A systematic review

PURPOSE

Unilateral spatial neglect (USN), an inability to attend to one side of space or one's body, is commonly reported in adult stroke survivors and is associated with poor outcomes. USN has been reported in pediatric survivors of stroke, but its impact is unclear. The purpose of this systematic review was to summarize and evaluate the literature regarding USN in pediatric stroke survivors.

METHODS

PRISMA guidelines, Scopus, CINAHL, PubMed, and other relevant databases were searched with terms including "children", "stroke", and "unilateral neglect", with the ages of participants limited from to birth to 18 years. Data were extracted from studies on the clinical presentation of pediatric USN, the assessment of this condition, treatment options, or USN recovery.

RESULTS

A total of 18 articles met inclusion criteria. There were no current prevalence data available. USN presents similarly in children compared to adults. Several different USN assessments were used, however, there were little data regarding treatment options. Furthermore, the data suggest that not all children fully recover.

CONCLUSION

This systematic review reveals a lack of quality research to inform the assessment and treatment of children with USN. Although the literature spans decades, there remain no guidelines for standardized assessment or treatment. Similar to adults, paper-and-pencil testing may be less able to identify USN than functional assessments. It is likely that there are children who struggle with undetected USN-related deficits years after their injuries. With a rise of pediatric stroke survivors, there is a pressing need for clinicians to be educated about USN in children, clinical presentations, assessments, and treatments.

Differences in coordination and timing of pre-reaching upper extremity movements may be an indicator of cerebral palsy in infants with stroke: A preliminary investigation

BACKGROUND

Neonatal stroke is a leading cause of hemiplegic cerebral palsy that occurs around the time of birth. Infants are diagnosed with cerebral palsy when motor impairments become clinically apparent, months or years after the stroke. Tools/methods for identifying high risk or diagnosis of cerebral palsy in infancy are improving.

METHODS

We measured spatial and temporal kinematics of pre-reaching upper extremity movements in 2-3 month old infants with neonatal stroke and typical development. We aimed to evaluate the feasibility of applying kinematics in this population and collect preliminary data to explore (1) if asymmetries are present in the infants with neonatal stroke, particularly those with a later diagnosis of cerebral palsy, and (2) to compare differences in the timing and coordination of their movements to infants with typical development, and infants with stroke and no cerebral palsy. Participants were 21 full-term infants, 10 with stroke (4 who later received a cerebral palsy diagnosis) age 72.1 (SD 9.3) days, and 11 typically developing, age 74.3 (SD 9.3) days.

FINDINGS

Results showed that infants with stroke and cerebral palsy demonstrated significant asymmetry in the average movement length (p = 0.0089) and hand path length (p = 0.0275) between their involved and uninvolved sides and moved less frequently (p = 0.09) and slower (p = 0.041) than infants with stroke and no cerebral palsy.

INTERPRETATION

Results suggest that kinematic analysis might detect asymmetries and motor impairment indicative of hemiplegic cerebral palsy earlier than current assessments and that asymmetry in speed, length and frequency of arm movements may be early indicators. This study is preliminary, limiting interpretation of the results.

[Long term outcome of perinatal stroke]

Neonatal Arterial Ischemic Stroke (NAIS) affects 6-17 newborns on 100 000-birth term neonates, most of these children keeping long-term motor and cognitive impairments. Based on a literature review, the objectives of this paper are to describe motor and cognitive outcomes after a NAIS and to propose a consensual monitoring of these children to improve their management. About 30 % of children after a NAIS will develop a unilateral cerebral palsy requiring a management by a team with expertise in physical medicine and rehabilitation. Unlike adults, especially after a left NAIS, children will not present aphasia but between 50 and 90 % will present disorders of speech and language in expression and/or reception. After NAIS, the global intellectual efficiency is usually preserved except when the size of the lesion is very important or when severe epilepsy occurs. Several studies are also in favor of vulnerability in visuospatial functions. To quantify impairments, activity limitations and participation restrictions resulting from this NAIS, early and at least yearly evaluations with reliable tools must be carried out systematically until puberty. A multidisciplinary team with a longitudinal follow-up, in all the different developmental dimensions, must conduct these evaluations in term of motor skills, cognitive impairment, behavior, autonomy, quality of life, and participation. Consequences on family functioning need to be evaluate in order to help children and family coping with this event.

Infant constraint induced movement therapy: Lessons learned from clinical implementation

Current evidence supports the efficacy of pediatric constraint induced movement therapy (CIMT) for toddlers and children but little has been published about its use in early intervention with children eighteen months and younger. This paper and case report describes the clinical experience of developing and executing a modified pediatric CIMT intervention with infants under 18 months old. This is an emerging area of practice that is showing positive trends with initial cases.

Effectiveness of motor interventions in infants with cerebral palsy: a systematic review

AIM

To systematically review the evidence on the effectiveness of motor interventions for infants from birth to 2 years with a diagnosis of cerebral palsy or at high risk of it.

METHOD

Relevant literature was identified by searching journal article databases (PubMed, Embase, CINAHL, Cochrane, Web of Knowledge, and PEDro). Selection criteria included infants between the ages of birth and 2 years diagnosed with, or at risk of, cerebral palsy who received early motor intervention.

RESULTS

Thirty-four studies met the inclusion criteria, including 10 randomized controlled trials. Studies varied in quality, interventions, and participant inclusion criteria. Neurodevelopmental therapy was the most common intervention investigated either as the experimental or control assignment. The two interventions that had a moderate to large effect on motor outcomes (Cohen's effect size>0.7) had the common themes of child-initiated movement, environment modification/enrichment, and task-specific training.

INTERPRETATION

The published evidence for early motor intervention is limited by the lack of high-quality trials. There is some promising evidence that early intervention incorporating child-initiated movement (based on motor-learning principles and task specificity), parental education, and environment modification have a positive effect on motor development. Further research is crucial.

Use of prism adaptation in children with unilateral brain lesion: Is it feasible?

INTRODUCTION

Unilateral visuospatial deficits have been observed in children with brain damage. While the effectiveness of prism adaptation for treating unilateral neglect in adult stroke patients has been demonstrated previously, the usefulness of prism adaptation in a pediatric population is still unknown. The present study aims at evaluating the feasibility of prism adaptation in children with unilateral brain lesion and comparing the validity of a game procedure designed for child-friendly paediatric intervention, with the ecological task used for prism adaptation in adult patients.

METHODS

Twenty-one children with unilateral brain lesion randomly were assigned to a prism group wearing prismatic glasses, or a control group wearing neutral glasses during a bimanual task intervention. All children performed two different bimanual tasks on randomly assigned consecutive days: ecological tasks or game tasks. The efficacy of prism adaptation was measured by assessing its after-effects with visual open loop pointing (visuoproprioceptive test) and subjective straight-ahead pointing (proprioceptive test).

RESULTS

Game tasks and ecological tasks produced similar after-effects. Prismatic glasses elicited a significant shift of visuospatial coordinates which was not observed in the control group.

CONCLUSION

Prism adaptation performed with game tasks seems an effective procedure to obtain after-effects in children with unilateral brain lesion. The usefulness of repetitive prism adaptation sessions as a therapeutic intervention in children with visuospatial deficits and/or neglect, should be investigated in future studies.

Characterization and intervention for upper extremity exploration & reaching behaviors in infancy

This article aims to: 1) highlight general exploration, reaching, and object exploration behaviors as key activities of daily living in infancy, 2) describe how knowledge of early warning signs for these behaviors may improve early assessment, and 3) discuss interventions that may advance performance of these behaviors. Early intervention should focus on improving performance of these behaviors because: a) these early, interrelated upper extremity behaviors serve an integral role in global learning and development in infancy, b) among at-risk populations, differences have been observed in the quantity and quality of performance of these behaviors and, in many cases, these differences are associated with related perceptual-motor and cognitive delays. This article highlights how early assessment and intervention can target these key early behaviors in populations at risk for upper extremity disabilities, such as those born preterm, with Down syndrome, brachial plexus palsy, or arthrogryposis multiplex congentia.

Implications of CI therapy for visual deficit training

We address here the question of whether the techniques of Constraint Induced (CI) therapy, a family of treatments that has been employed in the rehabilitation of movement and language after brain damage might apply to the rehabilitation of such visual deficits as unilateral spatial neglect and visual field deficits. CI therapy has been used successfully for the upper and lower extremities after chronic stroke, cerebral palsy (CP), multiple sclerosis (MS), other central nervous system (CNS) degenerative conditions, resection of motor areas of the brain, focal hand dystonia, and aphasia. Treatments making use of similar methods have proven efficacious for amblyopia. The CI therapy approach consists of four major components: intensive training, training by shaping, a "transfer package" to facilitate the transfer of gains from the treatment setting to everyday activities, and strong discouragement of compensatory strategies. CI therapy is said to be effective because it overcomes learned nonuse, a learned inhibition of movement that follows injury to the CNS. In addition, CI therapy produces substantial increases in the gray matter of motor areas on both sides of the brain. We propose here that these mechanisms are examples of more general processes: learned nonuse being considered parallel to sensory nonuse following damage to sensory areas of the brain, with both having in common diminished neural connections (DNCs) in the nervous system as an underlying mechanism. CI therapy would achieve its therapeutic effect by strengthening the DNCs. Use-dependent cortical reorganization is considered to be an example of the more general neuroplastic mechanism of brain structure repurposing. If the mechanisms involved in these broader categories are involved in each of the deficits being considered, then it may be the principles underlying efficacious treatment in each case may be similar. The lessons learned during CI therapy research might then prove useful for the treatment of visual deficits.

Upper limb function in everyday life of children with cerebral palsy: description and review of parent report measures

PURPOSE

To determine the role, in clinical practice and measurement of outcomes of upper limb interventions, of cerebral palsy-specific self- or parent-report measures of upper limb performance in everyday activities.

METHOD

Search of databases and handsearching for information on test development procedures, psychometric properties or relevant studies to inform study objectives.

RESULTS

Children's Hand-use Experience Questionnaire holds most promise for guiding treatment planning but requires more psychometric evidence. ABILHAND-Kids has the strongest evidence for reliability, validity and sensitivity to change; evaluates impact of intervention on bimanual performance and can be used for children with unilateral or bilateral cerebral palsy. The original and revised versions of the Pediatric Motor Activity Log (PMAL) evaluate unilateral rather than bimanual upper limb performance. Neither ABILHAND-Kids nor PMAL offer information to assist treatment planning. PMAL-R is the only measure for the 2-5-year age group. No measure was adequate for children younger than 2 years to ascertain parents' perception of upper limb function in everyday activities.

CONCLUSIONS

Understanding upper limb performance in everyday life, as perceived by children with cerebral palsy and their families, informs a comprehensive assessment and acknowledges the importance of the perspectives of child and family. Implications for Rehabilitation Cerebral palsy-specific self- or parent-report measures of upper limb performance in everyday life complement observational assessments in understanding upper limb performance CHEQ provides clinical information, ABILHAND-Kids is validated for children with unilateral and bilateral cerebral palsy and possesses the most robust psychometric properties, Revised PMAL measures unilateral upper limb use. No adequate measure for children under 2 years exists.

Pilot study of the efficacy of constraint-induced movement therapy for infants and toddlers with cerebral palsy

The evidence for Constraint-Induced Movement Therapy (CIMT) effectiveness for infants and toddlers with unilateral cerebral palsy is minimal. We performed a pilot study of CIMT using one-month usual care, one-month intervention, and one-month maintenance (return to usual care) phases on five infants (7- to 18-month old). For the CIMT phase, the infants received 2 hr of occupational therapy and 1 hr of parent-implemented home program for five days/week. The infants were casted for the first 23 days, and bimanual therapy was provided for the last three days. Fine motor skills for the more affected arm and gross motor skills improved significantly during the CIMT; these gains were maintained at one-month follow-up. Individual infant data show mixed effects. This pilot study provides initial evidence that CIMT is feasible for infants with unilateral cerebral palsy, and presents preliminary data for CIMT on fine and gross motor performance.

Spatial attention can transfer to the contralateral hemisphere in neonatal stroke patients: a case report following hemispherectomy

Patients suffer hemispatial neglect after stroke. However, whether the function of spatial attention is reorganized to the contralateral brain remains poorly understood. Here we present a case report of neonatal stroke to demonstrate the reorganization of spatial attention in the contralateral hemisphere using a series of tests including star cancellation task, line bisection test, the bells test, letter cancellation test, and drawing tests. The patient underwent right hemispherectomy for treatment of refractory epilepsy and did not have hemispatial neglect after surgery, supporting transfer of function prior to the operation. After analyzing the literature in this field, we proposed that the function of spatial attention may transfer to the contralateral side in childhood. Thus, this study sheds new light on the preserved function of spatial attention in neonatal stroke patients even when hemispherectomy is performed.

Rehabilitation of neglect: an update

Spatial neglect is a characteristic sign of damage to the right hemisphere and is typically characterized by a failure to respond to stimuli on the left side. With about a third of stroke victims showing initial signs of neglect, it is a frequent but also one of the most disabling neurological syndromes. Despite partial recovery in the first months after stroke one third of these patients remain severely disabled in all daily activities, have a poor rehabilitation outcome and therefore require specific treatment. The last decades have seen an intensive search for novel, more effective treatments for this debilitating disorder. An impressive range of techniques to treat neglect has been developed in recent years. Here, we describe those techniques, review their efficacy and identify gaps in the current research on neglect therapy.

Outcomes of perinatal arterial ischemic stroke and cerebral sinovenous thrombosis

Perinatal stroke can result in cerebral palsy, cognitive impairment, epilepsy, and sensory deficits. While some children only experience one type of disability, severe disabilities often cluster together. Death associated with perinatal stroke is rare, and often associated with other comorbidities. Clinical and radiographic factors can help predict outcome, but additional as-yet unknown factors appear to contribute to outcome as well. Rehabilitation can ameliorate deficits, and advances in rehabilitation technology and in adult stroke rehabilitation offer promise to pediatric perinatal stroke patients.

Cognitive rehabilitation for children with acquired brain injury

Cognitive deficits are frequent consequences of acquired brain injury (ABI) and often require intervention. We review the theoretical and empirical literature on cognitive rehabilitation in a variety of treatment domains including attention, memory, unilateral neglect, speech and language, executive functioning, and family involvement/education. Because there are more well-designed studies examining the efficacy of cognitive rehabilitation in adults with brain injury, the major findings from this body of literature are also highlighted. In addition, given that similar cognitive and behavioral concerns are often apparent in children with certain neurodevelopmental disorders, selected literature focusing on interventions for these groups of children is included. Limitations and challenges inherent in examining cognitive interventions in children with ABI are also discussed. Overall, despite the growing body of literature examining the efficacy of cognitive rehabilitation in children with ABI, there continues to be a great need to develop well-designed studies to examine the efficacy of these interventions.

Translation Research for the Rehabilitation of Left Spatial Neglect and Associated Disorders of Attention in Stroke Patients

The syndrome of unilateral neglect, typified by a lateralized attention bias and neglect of contralateral space, is an important cause of morbidity and disability after a stroke. In this review, we discuss the challenges that face researchers attempting to elucidate the mechanisms and effectiveness of rehabilitation treatments. The neglect syndrome is a heterogeneous disorder, and it is not clear which of its symptoms cause ongoing disability. We review current methods of neglect assessment and propose logical approaches to selecting treatments, while acknowledging that further study is still needed before some of these approaches can be translated into routine clinical use. We conclude with systems-level suggestions for hypothesis development that would hopefully form a sound theoretical basis for future approaches to the assessment and treatment of neglect.