Effects of constraint-induced movement therapy on gait, balance, and functional locomotor mobility

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

INTRODUCTION

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

METHODS AND ANALYSIS

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

ETHICS AND DISSEMINATION

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

PROSPERO REGISTRATION NUMBER

CRD42024518179.

Are challenging walking environments linked to falls or risk of falling in children with cerebral palsy? A systematic review

BACKGROUND

Children with cerebral palsy (CP) regularly fall over and this has negative effects on their physical and psychosocial wellbeing (e.g., reduced activity participation). However, the reasons for falls are not well understood. The way in which children negotiate challenging walking environments (e.g., uneven surfaces), may reveal more about how falls occur as these environments require gait modifications to maintain stability. Stability in challenging walking environments has been explored for children with CP; however, it remains unclear how these lead to falls.

RESEARCH QUESTION

Do challenging walking environments that mimic those faced in the real-world, contribute to increased fall occurrence and fall risk in children with CP?

METHODS

Five databases were searched, and 1386 records screened to include ambulatory children with CP, aged 5-18 years old, investigating dynamic walking in challenging environments, with outcomes of fall occurrence or fall risk. The full protocol for this review was registered on PROSPERO (CRD42021290456).

RESULTS

Sixteen studies met the inclusion criteria. One study reported occurrence of stumbles, two reported no falls. Fifteen studies identified gait alterations used by children with CP in challenging environments. Twenty-four gait characteristics were identified to be indicative of cautious walking strategies and seven gait characteristics identified to increase fall risk, suggesting a potential link. However, limited evidence exists as to whether this reflects falls faced in the real-world.

SIGNIFICANCE

Investigations into stability over challenging walking environments for children with CP are lacking any measures of fall occurrence. Investigations into the mechanisms that may contribute to high fall risk, or fall avoidance when negotiating obstacles, uneven surfaces, steep declines and stairs may reveal further causes of real-world falls, and in doing so inform future fall prevention techniques. Finally, understanding the multifaceted causes of falls in real-world challenging environments from the perspectives of children with CP is key for future research.

The effects of improvement in upper extremity function on gait and balance in children with upper extremity affected

BACKGROUND

This study aimed to investigate the effects of functional improvement in the upper extremity on gait and balance in children with upper extremity affected.

RESEARCH QUESTION

What are the effects of functional improvement in the upper extremity on gait and balance in children with upper extremity affected?

METHODS

Eighteen children with a diagnosis of rheumatologic diseases and 15 healthy children were evaluated with Shriners Hospital Upper Extremity Assessment, Jebsen-Taylor Hand Function Test, Abilhand Rheumatoid Arthritis Scale, 10-meter walk test and Childhood Health Assessment Questionnaire. For static balance assessment, the Biodex Balance was used. Ground reaction forces (peak forces (heel strike and push-off) and minimum force (loading response), single-limb support duration, Center-of-Force displacement and walking speed were evaluated with the Sensor Medica. Arm swing was evaluated with the Kinovea 2D motion analysis.

RESULTS

Before treatment, single-limb support duration and push-off force was higher and center-of-force displacement was lower on affected side compared to unaffected side in rheumatologic group. After the 6-week rehabilitation program, upper extremity function, quality of life and functional gait score improved. Single-limb support duration decreased on affected side and increased on unaffected side. On affected side, push-off force decreased. The arm swing parameters were similar before and after treatment.

SIGNIFICANCE

Improving upper extremity function can help with gait balance by decreasing the difference in walking and balance parameters between the affected and unaffected sides and providing for more symmetrical weight transfer.

Coordination of the upper and lower extremities during walking in children with cerebral palsy

BACKGROUND

Children with cerebral palsy indicate poor continuous gait inter-limb coordination compared to typically developing children. Limited research exists in the understanding of the coordinative relationship between the arms and legs of these children and if the phasing relationships between limbs can be improved.

RESEARCH QUESTION

Which motor control factors impact coordination in children with cerebral palsy and can coordination improve with intervention?

METHODS

This literature review provides a comprehensive overview of the current knowledge of continuous coordination in a pediatric, pathologic population with an emphasis on inter-limb coordination. Peer-reviewed research articles related to inter-limb coordination, with a focus on gait, were reviewed to identify relevant research and any gaps in the literature which could inform future study design. Consideration of the most appropriate analysis for evaluation of such movement is also presented.

RESULTS

The coordinative difficulties experienced by children with cerebral palsy may originate from the deficits in motor control, muscle tone, and weakness caused by damage to the central nervous system, which is vital in motor control of inter-limb coordination. Continuous inter-limb coordination in children with cerebral palsy may be improved with enhanced function of the upper extremities through intensive motor-learning based rehabilitation or botulinum toxin injection of the more-affected arm. Importantly, analysis of limb movements should include continuous measures of relative phase, as it provides a more detailed description of coordination compared to discrete measures.

SIGNIFICANCE

Improved upper extremity function may produce a positive change in the phasing relationship between the arms and legs. This type of coordination should be analyzed using relative phase analysis, as this type of analysis can provide more information compared to traditional spatiotemporal parameters. However, more research is required to fully understand the connection between improved upper extremity function and its positive impact on gait coordination in children with cerebral palsy.

Continuous inter-limb coordination deficits in children with unilateral spastic cerebral palsy

BACKGROUND

Continuous inter-limb coordination and the ability to offset perturbations to a movement pattern (i.e., stability) are important factors in efficient motor performance. Patients with movement disorders often show deficits in coordination and stability, although little is known about these features in children with cerebral palsy. The purpose of this study was to identify the continuous inter-limb coordination and stability deficits in children with cerebral palsy and determine if improvement occurs with upper extremity intervention.

METHODS

Children with cerebral palsy participated in bimanual or unimanual intensive therapy. Continuous inter-limb coordination between the arms and between the more-affected arm and leg was evaluated using relative phase analysis during four gross motor tasks, including in-place marching and standing with asymmetric and symmetric arm swing. A control group of children with cerebral palsy and a group of typically developing children were also evaluated.

FINDINGS

Children with cerebral palsy displayed coordination deficits compared to typically developing children (p<0.01), yet both groups presented similarly poor levels of stability (p=0.39). Compared to standing, adding legs to the task negatively impacted the coordination (p<0.01) and stability (p<0.01) of all children. Both groups improved coordination between the arms post-intervention (p<0.05 for all cases), however neither group improved stability (p>0.05 for all cases).

INTERPRETATION

Relative phase analysis successfully provided a sensitive measurement of coordination and stability in pathologic and non-pathologic populations. Findings indicate that all children have difficulty producing consistent movement patterns and suggest that both bimanual and unimanual interventions can improve continuous coordination in children with cerebral palsy.

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.

Locomotor patterns during obstacle avoidance in children with cerebral palsy

Previous studies mainly evaluated the neuromuscular pattern generation in cerebral palsy (CP) during unobstructed gait. Here we characterized impairments in the obstacle task performance associated with a limited adaptation of the task-relevant muscle module timed to the foot lift during obstacle crossing. Impaired task performance in children with CP may reflect basic developmental deficits in the adaptable control of gait when the locomotor task is superimposed with the voluntary movement.

Repeated episodes of pediatric constraint induced movement therapy with a gross motor training component: A prospective cohort study

PURPOSE

To examine the results of repeated episodes of 21-day pediatric constraint induced movement therapy (PCIMT) paired with gross motor training (GMT).

METHODS

Nineteen children, age 14 months - 6 years with unilateral upper extremity impairment enrolled in this cohort study to receive repeated episodes of 21 day PCIMT-GMT. Outcome measures included the Peabody Developmental Motor Scales-2 (PDMS-2), the Assisting Hand Assessment (AHA) and the Canadian Occupational Performance Measure (COPM).

RESULTS

All children demonstrated improvement in raw scores following each episode of PCIMT-GMT with a statistically significant change in the least squares estimated mean for all measures except the PDMS-2 total motor raw score and gross motor quotient for the preferred hand in the fourth episode (p< 0.05). Gains were noted on the Scaled Score for the AHA for 39/39 episodes, all greater than the smallest detectable difference. COPM Performance and Satisfaction scores for 17/17 episodes were above the clinically meaningful threshold. Additional improvements in scores were noted in all children with each repeated episode.

CONCLUSION

Children with unilateral upper extremity impairment demonstrate improvements in fine motor, gross motor, and bimanual skills, along with functional changes in participation in daily life, following PCIMT-GMT. Participation in repeated episodes can lead to further improvements.

Trunk Control in Children With Ataxic Cerebral Palsy

This study aimed to investigate the clinical characteristics of trunk control in children with ataxic cerebral palsy (CP). We included 15 children with ataxic CP with a mean age of 9.46 years (SD = 1.08 years, 5-17 years) and 15 healthy children with a mean age of 9.06 years (SD = 0.84 years, 5-13 years). While the small sample size and large age range used here were not ideal for generalizability, they were made necessary by the rarity of this clinical sample. We used the Gross Motor Function Classification System Expanded and Revised (GMFCS-E&R) to classify the children's functional levels, and we tested trunk control with the Trunk Control Measurement Scale (TCMS). We then used the Gross Motor Function Measurement-88 (GMFM-88) to assess their gross motor functions. We compared the total and subscale scores of the TCMS in healthy children and children with ataxic CP by using the Mann-Whitney U Test. We also analyzed differences between TCMS scores according to the children's GMFCS levels with the Mann-Whitney U Test and also compared TCMS scores with the GMFM-88 by means of Spearman correlation analysis. Spearman correlation analysis was used to compare the scores of the TCMS with the GMFM-88. Our results showed that healthy children showed significantly higher scores than children with ataxic CP in total and subscale scores of TCMS (p < .05).There was no significant difference between the TCMS scores in children of different GMFCS levels, but the GMFM-88B subscale was significantly correlated with the static sitting balance (r_ho = .568, p < .05) and dynamic sitting balance (r_ho = .547, p < .05) TCMS subscales and with the TCMS total score (r_ho = .590, p < .05). We concluded that trunk control, especially its dynamic aspects, was impaired in children with ataxic CP.

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.

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

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

ACTIVLIM-CP a new Rasch-built measure of global activity performance for children with cerebral palsy

OBJECTIVE

Children with cerebral palsy (CP) often have upper extremity (UE) and lower extremity (LE) impairments. While tools measuring separately UE and LE abilities are currently used, activities in which UE and LE are used in combination - numerous in everyday life - cannot be assessed because no instrument allows capturing global activity performance in children with CP. This study aimed to develop a clinical tool for measuring their global activity performance using the Rasch model.

STUDY DESIGN

The caregivers of 226 children with CP (2-18 years old) answered a 154-item experimental questionnaire. Within 4-6 weeks, 129 of them filled in the questionnaire a second time. Responses were analyzed using the Rasch RUMM2020 software.

RESULTS

The final 43 item scale presented a high reliability (R=0.98) and reproducibility (R=0.97). The item difficulty hierarchy was consistent over time and did not vary according to age, gender, or clinical form, allowing the follow-up of children from 2 to 18 years old.

CONCLUSIONS

ACTIVLIM-CP is a unidimensional scale specifically developed to measure global activity performance in children with CP providing a reliable tool to follow children's evolution and document changes related to neurorehabilitation, especially where a combination of UE and LE is targeted. Its responsiveness is still to be tested.

Design, Analysis, and Optimization of an Acute Stroke Gait Rehabilitation Device

Stroke is one of the leading causes of adult physical disability, and rehabilitation and hospitalization costs for stroke are among the highest for all injuries. Current rehabilitation techniques are labor intensive and time consuming for therapists and difficult to perform effectively. Research suggests that starting rehabilitation during the acute or subacute stage of recovery results in better outcomes than therapy delivered in the chronic stage. To improve the gait rehabilitation process, robot-assisted gait rehabilitation has gained much interest over the past years. However, many robot-assisted rehabilitation devices have limitations; one of which is being bulky and complex to handle. Large and expensive devices that require special training to operate are less attractive to clinics and therapists, and ultimately less likely to be available to patients especially at the early stage of stroke. To address these limitations, this research proposes a new gait rehabilitation device called the linkage design gait trainer (LGT). The device is based on a walking frame design with a simple four-bar linkage “end-effector” mechanism to generate normal gait trajectories during general walking and exercise. The design of the four-bar linkage mechanism was optimized for a particular gait pattern. A prototype of the device was developed and tested. The kinematics of the device itself and gait kinematics with and without assistance from the device were recorded and analyzed using an optical motion capture system. The results show the linkage mechanism is able to guide the leg of the user during over ground walking. There were some differences in the hip (20.5 deg RMS) and knee (14.8 deg RMS) trajectory between the person walking with and without the device assistance. The study demonstrated the concept and feasibility of this novel gait training device.

An exploratory study of gait and functional outcomes after neuroprosthesis use in children with hemiplegic cerebral palsy

PURPOSE

To evaluate the immediate orthotic, total and therapeutic effects of functional electrical stimulation (FES) neuroprosthesis use on clinic based measures of gait and function in children with hemiplegic cerebral palsy.

METHODS

Eleven children (mean 9 years 11 months) participated in an FES neuroprosthesis (Ness L300) intervention (4 week accommodation period followed by 12 weeks of daily use) and were assessed at baseline and post in stimulation off and stimulation on conditions. Measures included clinic based outcomes of gait and function.

RESULTS

No significant immediate orthotic effects were observed. Significant (p < 0.01) total effects were noted for dorsiflexion at initial contact, Six-Minute Walk Test (6MWT), and walking speed. A significant therapeutic effect was found for steps off path on the Standardized Walking Obstacle Course (SWOC).

CONCLUSIONS

Results support previous findings of neuroprosthesis total effects on gait and provide some evidence for effects on function. Therapeutic effects remain unclear. Implications for Rehabilitation In this study, children with hemiplegic CP did not demonstrate immediate improvements in gait or function at their first clinic visit using the FES neuroprosthesis device suggesting one visit using the device is not sufficient to determine potential benefits. Over time with daily use of the FES neuroprosthesis, ankle dorsiflexion in swing and at initial contact, walking speed and endurance increased with the device worn. Overtime, no carryover effects in ankle dorsiflexion in swing and at initial contact were noted at the end of the intervention period with the device off. Clinicians should consider purchasing units to loan or rent to individuals to trial a device at home before determining long-term potential for benefit.

Effects of modified constraint-induced movement therapy on the lower extremities in patients with stroke: a pilot study

PURPOSE

This study aimed to qualify the improvements of modified constraint-induced movement therapy (m-CIMT) on the lower limb of stroke patients via assessing the centre of mass (COM) displacement and the basic gait parameters.

METHODS

A total of 22 hemiplegic patients after stroke with first-time clinical cerebral infarction or haemorrhagic cerebrovascular accident were included in this study from May to December, 2014. The patients were randomly divided into m-CIMT group and the conventional therapy group (control group), and received corresponding training for five days/week for four weeks. The COM displacement and gait parameters were assessed by three-dimensional segmental kinematics method in pre-intervention and post- intervention therapy.

RESULTS

After four weeks of m-CIMT, the COM displacement on sagittal plane of paretic leg during stance phase was increased (pre: 91.04 ± 4.39 cm, post: 92.38 ± 4.58 cm, p < 0.05) and swing range of frontal plane was remarkably decreased (pre: 10.15 ± 3.05 cm, post: 7.83 ± 1.90 cm, p < 0.001). Meantime, the normalised swing range of COM in m-CIMT was superior to that in control group. Moreover, the gait parameters, including velocity (0.27 m/s), step width (0.10 m), step length (0.22 m) and swing time percentage (29.80%), were significantly improved by post-interventions of m-CIMT (p < 0.05).

CONCLUSION

The m-CIMT intervention improves the COM displacement in sagittal and frontal plane, as well as gait parameters. These suggest that m-CIMT intervention may be feasible and effective for the rehabilitation of hemiplegic gait. Implications for Rehabilitation Segmental kinematics method was used to estimate the displacement of the COM. m-CIMT interventions improved the COM displacement of patients after stroke. m-CIMT interventions improved the hemiplegic gait parameters.

The Influence of a Constraint and Bimanual Training Program Using a Variety of Modalities, on Upper Extremity Functions and Gait Parameters Among Children with Hemiparetic Cerebral Palsy: A Case Series

AIM

To assess the influence of an intensive combined constraint and bimanual upper extremity (UE) training program using a variety of modalities including the fitness room and pool, on UE functions as well as the effects of the program on gait parameters among children with hemiparetic cerebral palsy.

METHODS

Ten children ages 6-10 years participated in the program for 2 weeks, 5 days per week for 6 hr each day. Data from the Assisting Hand Assessment (AHA) for bimanual function , the Jebsen-Taylor Test of Hand Function (JTTHF) for unimanual function, the six-minute walk test (6MWT), and the temporal-spatial aspects of gait using the GAITRite walkway were collected prior to, immediately post and 3-months post-intervention.

RESULTS

A significant improvement was noted in both unimanual as well as bimanual UE performance; A significant improvement in the 6MWT was noted, from a median of 442 meter [range: 294-558] at baseline to 466 [432-592] post intervention and 528 [425-609] after 3 months (p = .03).

CONCLUSION

Combining intensive practice in a variety of modalities, although targeting to the UE is associated with substantial improvement both in the upper as well as in the lower extremity function.

Exercise interventions improve postural control in children with cerebral palsy: a systematic review

AIM

The aim of this study was to evaluate the efficacy and effectiveness of exercise interventions that may improve postural control in children with cerebral palsy (CP).

METHOD

A systematic review was performed using American Academy of Cerebral Palsy and Developmental Medicine (AACPDM) and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. Six databases were searched using the following keywords: ('cerebral palsy' OR 'brain injury'); AND ('postur*' OR 'balance' OR 'postural balance' [MeSH]); AND ('intervention' OR 'therapy' OR 'exercise' OR 'treatment'). Articles were evaluated based on their level of evidence and conduct.

RESULTS

Searches yielded 45 studies reporting 13 exercise interventions with postural control outcomes for children with CP. Five interventions were supported by a moderate level of evidence: gross motor task training, hippotherapy, treadmill training with no body weight support (no-BWS), trunk-targeted training, and reactive balance training. Six of the interventions had weak or conflicting evidence: functional electrical stimulation (FES), hippotherapy simulators, neurodevelopmental therapy (NDT), treadmill training with body weight support, virtual reality, and visual biofeedback. Progressive resistance exercise was an ineffective intervention, and upper limb interventions lacked high-level evidence.

INTERPRETATION

The use of exercise-based treatments to improve postural control in children with CP has increased significantly in the last decade. Improved study design provides more clarity regarding broad treatment efficacy. Research is required to establish links between postural control impairments, treatment options, and outcome measures. Low-burden, low-cost, child-engaging, and mainstream interventions also need to be explored.

Hand and Arm Bimanual Intensive Therapy Including Lower Extremity (HABIT-ILE) in Children With Unilateral Spastic Cerebral Palsy: A Randomized Trial

BACKGROUND

Intensive bimanual training results in more improvement in hand function in children with unilateral spastic cerebral palsy (USCP) than lower intensity conventional interventions. However, it is not known whether combined upper and lower extremity training in an intensive protocol is more efficacious for upper and lower functional abilities than conventional therapies provided in usual customary care.

OBJECTIVE

To determine the efficacy of Hand and Arm Bimanual Intensive Therapy Including Lower Extremity (HABIT-ILE) for children with USCP.

METHODS

Twenty-four children with USCP were randomized into 2 groups: an immediate HABIT-ILE group (IHG, initially receiving HABIT-ILE, 10 days = 90 hours), and a delayed HABIT-ILE group (DHG), which continued their conventional/ongoing treatment for an intended total duration of 90 hours. In phase 2, children in the DHG were crossed over to receive HABIT-ILE and children of the IHG were followed in their ongoing conventional therapy. Children were assessed using the Assisting Hand Assessment (AHA, primary outcome), the ABILHAND-Kids, and the Pediatric Evaluation of Disability Inventory. Dexterity (Box and Blocks Test [BBT]) and pinch strength were also measured. Locomotor abilities were assessed with Six-Minute Walk Test (6MWT, primary outcome) and ABILOCO-kids. Social participation was measured with the Assessment of Life-HABITs.

RESULTS

A 2 (groups) × 3 (test sessions) analysis of variance indicated significant improvements for primary outcomes (AHA, P < .001; 6MWT, P = .002) and all secondary assessments except BBT, step length and bodyweight distribution following HABIT-ILE, but not conventional therapy.

CONCLUSION

The findings suggest that combined upper and lower extremity in an intensive training protocol may be efficacious for improving both upper and lower extremity function in children with USCP.

Hand-arm bimanual intensive therapy including lower extremities (HABIT-ILE) for children with cerebral palsy

Hand-arm bimanual intensive therapy and constrained-induced movement therapy have shown evidence of effectiveness in improvement of upper extremity use in children with unilateral spastic cerebral palsy (CP). The effectiveness of interventions that are based on intensive practice of activities that combine UE and LE functions has not been reported. We propose that bimanual UE activities that simultaneously require trunk and LE postural adaptations uniquely address motor control limitations of children with unilateral spastic CP. The aim of this perspective is to present such an approach Hand Arm Bimanual Intensive Therapy Including Lower Extremities (HABIT-ILE). HABIT-ILE is unique in selection of tasks and activities that require simultaneous control and coordination of UE and LE movements. It is a motor-learning-based approach using problem solving and highly structured practice. During the intervention, activities and tasks are progressively graded toward more complex bimanual coordination for the UE and increasing demands of the LE. HABIT-ILE is provided in small groups for 90 hr using a camp model. Future research (randomized controlled trial) is needed to determine the effectiveness of HABIT-ILE.

Clinical tools to assess balance in children and adults with cerebral palsy: a systematic review

We aimed to review tools used to assess balance in clinical practice in children and adults with cerebral palsy (CP), to describe their content and measurement properties and to evaluate the quality of the studies that have examined these properties. CINAHL, Embase, and PubMed/MEDLINE were searched. The COnsensus-based Standards for selection of health Measurement INstruments (COSMIN) was used to assess the 'quality of studies' and the Terwee criteria were used to assess the 'result of studies'. Twenty-two clinical balance tools were identified from 35 papers. The content and focus of the tools varied significantly. There was moderate or limited levels of evidence for most of the measurement properties of the tools; the strongest level of evidence was found for the Trunk Control Measurement Scale and the Level of Sitting Scale, in the category 'maintain balance', the Timed Up and Go and the Segmental Assessment of Trunk Control in the categories 'achieve balance' and 'restore balance' respectively. Information on responsiveness was scarce. Further studies providing better evidence for reliability and responsiveness for clinical balance tools are needed. In the meantime, results of studies evaluating effects of treatment of balance in individuals with CP should be interpreted with caution.

Constraint-induced movement therapy effects on gross motor function of a child with triplegic cerebral palsy

BACKGROUND AND PURPOSE

The purpose of this case report is to describe physical therapy interventions used and gross motor functional outcomes achieved during a 3-week course of constraint-induced movement therapy for a child with cerebral palsy.

CASE DESCRIPTION

A 10-year-old boy with spastic triplegic cerebral palsy underwent fine and gross motor interventions to force use of the left extremities and right lower extremity.

INTERVENTION

For weeks 1 to 2, he received 2 occupational and physical therapy sessions each week. For weeks 3 to 5, he participated in constraint-induced movement therapy, while wearing a cast 90% of waking hours.

OUTCOMES

The Gross Motor Function Measure-88 score increased from 44.55% to 62.35% after treatment. Although he improved in one area of the Functional Independence Measure for Children, he demonstrated remarkable progress in his ability to bear weight and shift weight to his involved side in various developmental positions.