Measuring changes of manual ability with ABILHAND-Kids following intensive training for children with unilateral cerebral palsy

Development of a manual for an upper extremity intensive rehabilitation program for pediatric hemiplegia in Japan and assessment of its effectiveness and usability

OBJECTIVES

The aim of this study was to develop a manual for an upper extremity intensive rehabilitation program for pediatric hemiplegia in Japan, and to clarify its effectiveness and usability.

METHODS

The manual was created through discussions among nine experts with sufficient pediatric clinical experience in Japan. A total of 39 children with hemiplegia aged 2 to 16 years underwent 44 intensive therapy sessions using the manual. Each child's upper limb function was assessed pre-, post- and 6-month after the intervention using the Canadian Occupational Performance Measure (COPM), ABILHAND-Kids, the Quality of Upper Extremity Skills Test (QUEST), and Box and Block Test (BBT). Questionnaire assessments were also conducted to evaluate usability of the manual.

RESULTS

All four indices showed statistically significant improvements from pre- to post-intervention; COPM improved by 4 points in both performance and satisfaction; the ABILHAND-Kids logit score improved by 0.78; the total QUEST score improved by 2.8 in total score; and BBT improved by 5 on the affected side and 6 on the non-affected side. These effects were maintained 6 months later. Most therapists responded that the manual is useful, and most children and their parents were satisfied with the rehabilitation.

CONCLUSIONS

An upper extremity intensive rehabilitation program for pediatric hemiplegia using our manual was clinically effective. The manual was useful for therapists, and the level of satisfaction among parents and children who received the therapy was high.

Magic-themed motor training for daily bimanual task performance in children with unilateral spastic cerebral palsy: A systematic review and meta-analysis

AIM

To evaluate the effectiveness of magic-themed interventions in improving daily bimanual task performance in children with unilateral spastic cerebral palsy (CP) and to elucidate the variability in outcomes.

METHOD

This systematic literature review searched databases including Embase, MEDLINE, Scopus, Cochrane Central, and CINAHL. Outcome measures selected for the meta-analysis included the Children's Hand-use Experience Questionnaire, its three subscales, and the Besta subscale C. The overall efficacy of magic-themed interventions was analysed using Hedges' g as the summary measure for these outcomes. Subgroup analysis compared the efficacy of different modes of training, and a meta-regression investigated the impact of training duration.

RESULTS

Analyses of four studies involving 78 children showed magic-themed training significantly improved bimanual task performance (Hedges' g = 0.327, 95% confidence interval [CI] = 0.107-0.547, p = 0.004), especially in group settings (Hedges' g = 0.435, 95% CI = 0.176-0.693, p = 0.001), compared with non-significant gains from video interventions (Hedges' g = 0.041, 95% CI = -0.380 to 0.462, p = 0.850). Additionally, training duration positively correlated with performance gains (coefficient = 0.0076 per hour, p = 0.001).

INTERPRETATION

Magic-themed training, especially through group sessions and extended durations, enhances bimanual skills in children with unilateral spastic CP.

Cross-cultural adaptation, validity and reliability of the Japanese version of ABILHAND-kids for children with cerebral palsy using Rasch measurement model

PURPOSE

The aim of this study was to develop the Japanese version of the ABILHAND-Kids and to examine its psychometric properties for Japanese children with cerebral palsy (CP).

METHODS

The experimental version of 75 items was developed using forward-backward translation method. Parents of 137 children with CP answered it. Their responses were analyzed to successive items, and psychometric properties of the final version were investigated through the Rasch measurement model.

RESULTS

The Japanese version of the ABILHAND-Kids contained 22 items. It showed valid item-patient targeting, no significant floor and ceiling effects, and no differential item functioning for demographic and clinical subgroups. All items contributed to the definition of one-dimensional measure. For internal consistency, the person separation index was 0.94. For test-retest reliability, the intraclass correlation coefficients were 0.96 (95% CI: 0.92-0.98). The minimal detectable difference was calculated with a logit score of 0.79 and a total raw score of 4.50. The logit score showed a strong correlation with the Manual Ability Classification System level (ρ= -0.70) and the Gross Motor Function Classification System level (ρ= -0.62).

CONCLUSIONS

The Japanese version of the ABILHAND-Kids was found to be valid and reliable. It appears to be a good tool for assessing manual abilities in daily activities in children with CP.

The Use of TheraBracelet Upper Extremity Vibrotactile Stimulation in a Child with Cerebral Palsy-A Case Report

Background

TheraBracelet is peripheral vibrotactile stimulation applied to the affected upper extremity via a wristwatch-like wearable device during daily activities and therapy to improve upper limb function. The objective of this study was to examine feasibility of using TheraBracelet for a child with hemiplegic cerebral palsy.

Methods

A nine-year-old male with cerebral palsy was provided with TheraBracelet to use during daily activities in the home and community settings for 1.5 years while receiving standard care physical/occupational therapy.

Results

The child used TheraBracelet independently and consistently except during summer vacations and elbow-to-wrist orthotic use from growth spurt-related contracture. The use of TheraBracelet did not impede or prevent participation in daily activities. No study-related adverse events were reported by the therapist, child, or parent.

Conclusion

Future research is warranted to investigate TheraBracelet as a propitious therapeutic device with focus on potential impact of use to improve the affected upper limb function in daily activities in children with hemiplegic cerebral palsy.

A Comparison of the Functioning and Disability Levels of Children With Hemiplegic and Diplegic Cerebral Palsy Based on ICF-CY Components

We compared children with hemiplegic and diplegic cerebral palsy (CP) using the conceptual framework of the International Classification of Functioning, Disability and Health: Child and Youth version (ICF-CY). We enrolled 42 children with CP aged 5 - 13 years old (M age = 9.57, SD = 2.8 years). We assessed their trunk control and dynamic balance with the Trunk Control Measurement Scale (TCMS) and the Timed Up and Go test (TUG), and we used ABILHAND-Kids and Assessment of Life Habits (Life-H) to assess their manual ability and participation with activities of daily living. We administered the European Child Environment Questionnaire (ECEQ) to identify relevant environmental factors. We employed structural equation modeling (SEM) to identify specific factors contributing to potential differences between these CP groups. Children with hemiplegic CP demonstrated significantly better outcomes in terms of trunk control, dynamic balance, and environmental factors compared to those with diplegic CP (p < .05). In contrast, children with diplegic CP demonstrated superior outcomes regarding manual ability, compared to those with hemiplegic CP (p < .001). In our structural equation models, trunk control strongly predicted both dynamic balance (0.75) and environmental factors (0.74). Moreover, the relationships between trunk control and participation in daily and social activities were 0.54 and 0.47, respectively. Impaired trunk control and dynamic balance were significant contributors to increased activity restrictions and environmental barriers in children with diplegic CP. This suggests that improving disability and functioning in children with diplegic CP requires a focus on trunk control training and dynamic balance exercises.

Fast and Fun: A Pilot Feasibility Study Using Dual Joystick-Operated Ride-on Toys for Upper Extremity Rehabilitation in Children with Hemiplegia

AIM

Our study investigates the feasibility and utility of implementing a dual joystick-operated ride-on-toy navigation training (RNT) program within a 3-week intensive camp based on principles of modified constraint-induced movement therapy and bimanual training, to improve upper extremity (UE) function in children with unilateral cerebral palsy (UCP).

METHODS

We employed a single-group pretest posttest, mixed methods study design. Eleven 4-to-10-year-old children with UCP received RNT as part of camp activities. Sessions required children to use both arms together for navigation and completing gross and fine motor UE challenges. We collected exit questionnaires from children, caregivers, and clinicians to assess the feasibility, acceptance, enjoyment, and perceived efficacy of RNT. Videos of training sessions were coded using Datavyu behavioral coding software to assess children's facial expressions and affective states, indicative of their level of engagement during intervention sessions.

RESULTS

We found high levels of child engagement during RNT sessions based on video data and stakeholder feedback. The RNT program was smoothly integrated into the camp. Stakeholders acknowledged the highly motivating nature of RNT. When combined with other camp activities, the program led to stakeholder-reported improvements in bimanual skills and spontaneous daily use of the affected UE.

CONCLUSIONS

Our pilot study provides promising evidence for using joystick-operated ride-on toys as engaging therapy adjuncts. Our findings call for future studies to systematically assess the efficacy of these devices in improving UE function among children with UCP.

Measuring global activity performance in children with cerebral palsy in West Africa: validation of an adapted version of the ACTIVLIM-CP questionnaire

PURPOSE

To calibrate a West-African version of the ACTIVLIM-CP questionnaire (ACTIVLIM-CP-WA) for children with cerebral palsy (CP).

MATERIALS AND METHODS

We recruited 287 children with CP of various age range: 2-6 years (n = 117, preschoolers), 6-12 years (n = 96, children) and 12-19 years (n = 74, adolescents). Caregivers of children of each age range completed the experimental version of the ACTIVLIM-CP-WA including 76 (preschoolers), 78 (children) and 76 (adolescents) global daily life activities. Responses were analyzed using the Rasch RUMM2030 software.

RESULTS

The final West-African version of ACTIVLIM-CP including 31 items (both common and age-specific items) defined a unidimensional, linear scale with well-discriminated response categories. It presented a high internal consistency (R = 0.94). Moreover, all items were locally independent and the item difficulty hierarchy was invariant regarding caregivers' education, children's age and gender, MACS and GMFCS levels. The ACTIVLIM-CP-WA measures were significantly correlated (p < 0.05) with Gross Motor Function Classification System (ρ = -0.77), Manual Ability Classification System (ρ = -0.75), Box and Block test (dominant hand r = 0.51; non-dominant hand r = 0.49), One-minute walking test (r = 0.28), and Timed up and Go test (r = -0.40).

CONCLUSIONS

The ACTIVLIM-CP-WA questionnaire provides a valid and reliable tool that has the potential to follow children's evolution and quantify changes consecutive to neurorehabilitation in Sub-Saharan Africa.IMPLICATIONS FOR REHABILITATIONThe West-African version of the ACTIVLIM-CP questionnaire (ACTIVLIM-CP-WA) measures global activities requiring a combination of lower and upper extremities in children with cerebral palsy.As a Rasch-built scale, measures are unidimensional and linear to document changes in children with cerebral palsy from 2 to 19 years in Sub-Saharan Africa.Rehabilitation professionals are encouraged to use the ACTIVLIM-CP-WA questionnaire as a psychometrically robust assessment tool measuring the global performance in daily life activities in children with cerebral palsy in Sub-Saharan Africa.

Efficacy of integrating a semi-immersive virtual device in the HABIT-ILE intervention for children with unilateral cerebral palsy: a non-inferiority randomized controlled trial

BACKGROUND

The implementation of virtual devices can facilitate the role of therapists (e.g., patient motivation, intensity of practice) to improve the effectiveness of treatment for children with cerebral palsy. Among existing therapeutic devices, none has been specifically designed to promote the application of principles underlying evidence-based motor skill learning interventions. Consequently, evidence is lacking regarding the effectiveness of virtual-based sessions in motor function rehabilitation with respect to promoting the transfer of motor improvements into daily life activities. We tested the effectiveness of implementing a recently developed virtual device (REAtouch®), specifically designed to enable the application of therapeutic motor skill learning principles, during a Hand Arm Bimanual Intensive Therapy Including Lower Extremities (HABIT-ILE) intervention.

METHODS

Forty children with unilateral cerebral palsy (5-18 years; MACS I-III; GMFCS I-II) were randomly assigned to a control group or a "REAtouch®" experimental group for a 90-h HABIT-ILE day-camp intervention (two weeks). Children in the REAtouch® group spent nearly half of their one-on-one therapeutic time using the REAtouch®. Participants underwent three testing sessions: the week before (T1), after intervention (T2), and at three months follow-up (T3). The primary outcome was the Assisting Hand Assessment (T3-T1; blinded). Secondary outcomes measured uni-bimanual hand function, stereognosis, gait endurance, daily life abilities, and functional goals. Accelerometers and a manual report of daily activities served to document therapeutic dosage and treatment characteristics. We used one-way RMANOVA to compare the efficacies of the two interventions, and non-inferiority analyses to contrast changes in the "REAtouch®" group versus the "HABIT-ILE" control group.

RESULTS

We found significant improvements in both groups for most of the outcome measures (p < 0.05). There was significant non-inferiority of changes in the REAtouch® group for upper extremities motor function, functional goals attainment, and abilities in daily life activities (p < 0.05).

CONCLUSIONS

Use of the REAtouch® device during HABIT-ILE showed non-inferior efficacy compared to the conventional evidence-based HABIT-ILE intervention in children with unilateral cerebral palsy. This study demonstrates the feasibility of using this virtual device in a high dosage camp model, and establishes the possibility of applying the therapeutic principles of motor skill learning during specifically designed virtual-based sessions.

TRIAL REGISTRATION

Trial registration number: NCT03930836-Registration date on the International Clinical Trials Registry Platform (ICTRP): June 21th, 2018; Registration date on NIH Clinical Trials Registry: April 29th, 2019. First patient enrollment: July 3rd, 2018.

Mirror movements and brain pathology in children with unilateral cerebral palsy

AIM

We systematically examined the relationship between mirror movements and brain lesion type, corticospinal tract (CST) organization, and hand function to determine the relevance between mirror movements, brain lesion, the CST pattern, and hand function in children with unilateral cerebral palsy (CP).

METHOD

Forty-eight children (mean age 9y 9mo [SD 3y 3mo], range 6-18y; 30 males, 18 females) with unilateral CP participated. Mirror movements, brain lesion type, CST pattern identified by transcranial magnetic stimulation, and clinical outcomes were evaluated. Children performed four unilateral tasks: hand opening/closing, finger opposition, individuation, and finger 'walking'. Mirror movements induced in the contralateral hand were scored using standardized criteria (scores 0-4 using the Woods and Teuber scale).

RESULTS

We found that children with periventricular lesion may have stronger mirror movement scores induced in either hand than those with middle cerebral artery lesion (more affected hand: p=0.02; less affected hand: p<0.01). The highest mirror movement score a child exhibits across the tested tasks (i.e. scores of 3-4 using the Woods and Teuber scoring criteria) may potentially be an indicator of an ipsilateral CST connectivity pattern (p=0.03). Significant correlations were observed between higher mirror movement scores when performing hand opening/closing as well as finger walking and better unimanual dexterity (Spearman's rank correlation coefficient r_s =0.44, p=0.002; r_s =0.46, p=0.002 respectively).

INTERPRETATION

Brain lesions may be predictive of the strength of mirror movements in either hand in children with unilateral CP. Our findings warrant further studies to extensively investigate the relationship between mirror movements and the underlying brain pathology.

WHAT THIS PAPER ADDS

Brain lesion type may be predictive of mirror movement scores induced in either hand in children with unilateral cerebral palsy. The highest mirror movement score a child exhibits across the tested tasks may indicate corticospinal tract connectivity pattern in children with unilateral cerebral palsy.

Cannabidiol Treatment for Neurological, Cognitive, and Psychiatric Symptoms in Sturge-Weber Syndrome

BACKGROUND

A prior drug trial of cannabidiol for treatment-resistant epilepsy in patients with Sturge-Weber syndrome (SWS), a rare neurovascular condition, implicated improvements in neurological, quality of life (QOL), neuropsychologic, psychiatric, and motor outcomes.

METHODS

Ten subjects with SWS brain involvement, controlled seizures, and cognitive impairments received study drug in this Johns Hopkins institutional review board-approved, open-label, prospective drug trial. Oral cannabidiol was taken for six months (dose ranged from 5 to 20 mg/kg/day). SWS neuroscore, port-wine birthmark score, QOL, and adverse events were recorded every four to 12 weeks. Neuropsychologic, psychiatric, and motor assessments were administered at baseline and six months' follow-up. Most evaluations were conducted virtually due to the coronavirus disease 2019 pandemic.

RESULTS

Cannabidiol was generally well tolerated. Six subjects reported mild to moderate side effects related to study drug and continued on drug; one subject withdrew early due to moderate side effects. No seizures were reported. Significant improvements in SWS neuroscore, patient-reported QOL, anxiety and emotional regulation, and report of bimanual ability use were noted. Migraine QOL scores were high at baseline in these subjects, and remained high. Neuropsychologic and other QOL and motor outcomes remained stable, with some within-subject improvements noted.

CONCLUSIONS

Further studies are needed to determine whether Epidiolex can improve quality of life and be beneficial for neurological, anxiety, and motor impairments in SWS independent of seizure control. Large multicentered studies are needed to extend these preliminary findings.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

CONCLUSION

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

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.

Improvements in Upper Extremity Function Following Intensive Training Are Independent of Corticospinal Tract Organization in Children With Unilateral Spastic Cerebral Palsy: A Clinical Randomized Trial

Background/Objectives: Intensive training of the more affected upper extremity (UE) has been shown to be effective for children with unilateral spastic cerebral palsy (USCP). Two types of UE training have been particularly successful: Constraint-Induced Movement Therapy (CIMT) and Bimanual training. Reorganization of the corticospinal tract (CST) early during development often occurs in USCP. Prior studies have suggested that children with an ipsilateral CST controlling the affected UE may improve less following CIMT than children with a contralateral CST. We tested the hypothesis that improvements in UE function after intensive training depend on CST laterality.

Study Participants and Setting: Eighty-two children with USCP, age 5 years 10 months to 17 years, University laboratory setting.

Materials/Methods: Single-pulse transcranial magnetic stimulation (TMS) was used to determine each child's CST connectivity pattern. Children were stratified by age, sex, baseline hand function and CST connectivity pattern, and randomized to receive either CIMT or Bimanual training, each of which were provided in a day-camp setting (90 h). Hand function was tested before, immediately and 6 months after the intervention with the Jebsen-Taylor Test of Hand Function, the Assisting Hand Assessment, the Box and Block Test, and ABILHAND-Kids. The Canadian Occupational Performance Measure was used to track goal achievement and the Pediatric Evaluation of Disability Inventory was used to assess functioning in daily living activities at home.

Results: In contrast to our hypothesis, participants had statistically similar improvements for both CIMT and Bimanual training for all measures independent of their CST connectivity pattern (contralateral, ipsilateral, or bilateral) (p < 0.05 in all cases).

Conclusions/Significance: The efficacy of CIMT and Bimanual training is independent of CST connectivity pattern. Children with an ipsilateral CST, previously thought to be maladaptive, have the capacity to improve as well as children with a contralateral or bilateral CST following intensive CIMT or Bimanual training.

Clinical Trial Registration:www.ClinicalTrials.gov, identifier NCT02918890.

Validity and reliability of the Persian ABILHAND-Kids in a sample of Iranian children with cerebral palsy

Aim: To develop a Persian version of ABILHAND-Kids and to determine its reliability and validity in Persian-speaking children with cerebral palsy (CP).Method: The ABILHAND-Kids questionnaire was translated into Persian language and cross-culturally adapted following guidelines. The Persian ABILHAND-Kids was administered to 50 parents of CP children. Among the 50 parents of CP children, 30 of them participated in a test-retest reliability phase. Fifty parents of healthy children participated for discriminative validity.Results: The Rasch analysis indicated the unidimensionality, reliability, and global invariance of the Persian ABILHAND-Kids. The internal consistency reliability was high (Cronbach's alpha = 0.96). Floor and ceiling effects were insignificant (4%). The Intraclass Correlation Coefficients of test-retest reliability were 0.96 and 0.70 for item difficulties and children's measures, respectively. The standard error of measurement and smallest detectable change for CP measure were 11.21 and 31.07%, respectively. The discriminative validity of the Persian ABILHAND-Kids was demonstrated by statistically significant lower ABILHAND-Kids measures in CP children than in healthy children (p < 0.001). Cross-cultural validity between the Persian and original version was established for 19 out of the 21 ABILHAND-Kids items.Interpretation: The Persian ABILHAND-Kids questionnaire is reliable and valid for assessing manual ability in Persian speaking children with CP.Implications for rehabilitationThe Persian version of ABILHAND-Kids is developed and presented as a valid and reliable instrument for use by Persian-speaking clinicians and researchers.It is now possible for the Persian-speaking researchers to participate in international investigations and to compare Persian data with those from other countries.

Motor Skill Training May Restore Impaired Corticospinal Tract Fibers in Children With Cerebral Palsy

Background. In children with unilateral cerebral palsy (UCP), the fibers of the corticospinal tract (CST) emerging from the lesioned hemisphere are damaged following the initial brain injury. The extent to which the integrity of these fibers is restorable with training is unknown. Objective. To assess changes in CST integrity in children with UCP following Hand-and-Arm-Bimanual-Intensive-Therapy-Including-Lower-Extremity (HABIT-ILE) compared to a control group. Methods. Forty-four children with UCP participated in this study. Integrity of the CSTs was measured using diffusion tensor imaging before and after 2 weeks of HABIT-ILE (treatment group, n = 23) or 2 weeks apart without intensive treatment (control group, n = 18). Fractional anisotropy (FA) and mean diffusivity (MD) were the endpoints for assessing the integrity of CST. Results. As highlighted in our whole tract analysis, the FA of the CST originating from the nonlesioned and lesioned hemispheres increased significantly after therapy in the treatment group compared to the control group (group * test session interaction: P < .001 and P = .049, respectively). A decrease in MD was also observed in the CST emerging from the nonlesioned and lesioned hemispheres (group * time interaction: both P < .001). In addition, changes in manual ability correlated with changes in FA in both CSTs (r = 0.463, P = .024; r = 0.643, P < .001) and changes in MD in CST emerging from nonlesioned hemisphere (r = -0.662, P < .001). Conclusions. HABIT-ILE improves FA/MD in the CST and hand function of children with UCP, suggesting that CST fibers retain a capacity for functional restoration. This finding supports the application of intensive motor skill training in clinical practice for the benefit of numerous patients.

Protocol for a multisite randomised trial of Hand-Arm Bimanual Intensive Training Including Lower Extremity training for children with bilateral cerebral palsy: HABIT-ILE Australia

INTRODUCTION

Children with bilateral cerebral palsy often experience difficulties with posture, gross motor function and manual ability, impacting independence in daily life activities, participation and quality of life (QOL). Hand-Arm Bimanual Intensive Training Including Lower Extremity (HABIT-ILE) is a novel intensive motor intervention integrating upper and lower extremity training. This study aimed to compare HABIT-ILE to usual care in a large randomised controlled trial (RCT) in terms of gross motor function, manual ability, goal attainment, walking endurance, mobility, self-care and QOL. A within-trial cost-utility analysis will be conducted to synthesise costs and benefits of HABIT-ILE compared with usual care.

METHODS AND ANALYSIS

126 children with bilateral cerebral palsy aged 6-16 years will be recruited across three sites in Australia. Children will be stratified by site and Gross Motor Function Classification System and randomised using concealed allocation to either receiving HABIT-ILE immediately or being waitlisted for 26 weeks. HABIT-ILE will be delivered in groups of 8-12 children, for 6.5 hours per day for 10 days (total 65 hours, 2 weeks). Outcomes will be assessed at baseline, immediately following intervention, and then retention of effects will be tested at 26 weeks. Primary outcomes will be the Gross Motor Function Measure and ABILHAND-Kids. Secondary outcomes will be brain structural integrity, walking endurance, bimanual hand performance, self-care, mobility, performance and satisfaction with individualised goals, and QOL. Analyses will follow standard principles for RCTs using two-group comparisons on all participants on an intention-to-treat basis. Comparisons between groups for primary and secondary outcomes will be conducted using regression models.

ETHICS AND DISSEMINATION

Ethics approval has been granted by the Medical Research Ethics Committee of Children's Health Queensland Hospital and the Health Service Human Research Ethics Committee (HREC/17/QRCH/282) of The University of Queensland (2018000017/HREC/17/QRCH/2820), and The Cerebral Palsy Alliance Ethics Committee (2018_04_01/HREC/17/QRCH/282).

TRIAL REGISTRATION NUMBER

ACTRN12618000164291.

Cross-cultural adaptation and validation of the Ukrainian version of the ABILHAND-Kids questionnaire

PURPOSE

To develop and cross-culturally validate the Ukrainian version of the ABILHAND-Kids questionnaire by testing its psychometric properties in a sample of Ukrainian children with cerebral palsy.

METHODS

The ABILHAND-Kids questionnaire was translated into Ukrainian, cross-culturally adapted, and administered to 113 parents of children with cerebral palsy. The psychometric properties of the Ukrainian version and its cross-cultural validation were investigated through the Rasch rating scale model.

RESULTS

One major misfit has been found for the item "Rolling up a sleeve of a sweater" that further was removed. The item "Putting on a backpack/schoolbag" was split into gender-specific items, separately for girls and for boys, as it was systematically easier for Ukrainian girls. All remaining items contributed to the definition of a unidimensional measure of manual ability. The internal consistency reliability of the scale was high (R = 0.95). No significant floor (4%) and ceiling effects (5%) were observed. Three major differential item functioning items were found across Belgium and Ukraine, highlighting the need to use the Ukrainian calibration of ABILHAND-Kids in Ukraine.

CONCLUSION

The Ukrainian ABILHAND-Kids questionnaire has good psychometric properties for assessing manual ability in Ukrainian children with cerebral palsy, holding potential to be implemented in clinical practice nationwide.Implications for rehabilitationCerebral palsy impairs manual ability leading to decreased quality of life and participation.Professionals need valid and reliable tools to detect small changes of manual ability during rehabilitation.Metric properties and availability of the Ukrainian version of the ABILHAND-Kids questionnaire make it a useful tool in the assessment of children with cerebral palsy.

The Cerebral Palsy Profile of Health and Function: Upper-Extremity Domain's Sensitivity to Change Following Musculoskeletal Surgery

PURPOSE

The Cerebral Palsy Profile of Health and Function (CP-PRO) Computerized Adaptive Tests (CAT) are quality of life measures developed specifically for use in children with cerebral palsy. This study examined the ability of the upper-extremity (UE) CP-PRO CAT to detect change in function after UE surgery compared with the Pediatric Outcomes Data Collection Instrument (PODCI), ABILHAND-Kids, and Box and Blocks test.

METHODS

From 2009 to 2013, children with cerebral palsy who had UE musculoskeletal surgery completed the UE CP-PRO CAT, PODCI-UE, ABILHAND-Kids, and Box and Blocks tests before surgery (97 children) and at 3 postoperative intervals: 6 months (80 children), 12 months (73 children), and 24 months (52 children). Mean, SD, effect size (ES), and standardized response mean (SRM) values for each measure at each time interval and each level of the Manual Ability Classification System were calculated and compared. Finally, the minimal detectable change at the 90% confidence level was determined.

RESULTS

Values for the ES (0.40) and SRM (0.53) for the UE CP-PRO CAT at baseline to 6 months were moderate and significantly greater than the PODCI-UE (ES, 0.18; SRM, 0.25). The ES and SRM for the PODCI-UE, ABILHAND-Kids, and Box and Blocks tests were not significantly greater than for the UE CP-PRO CAT at any period. From baseline to 6 months, the UE CP-PRO CAT detected a large and significant improvement for Manual Ability Classification System level II (SRM, 0.70; ES, 0.70). The minimal detectable change for the UE CP-PRO CAT was 5.20.

CONCLUSIONS

The UE CP-PRO CAT is significantly better in detecting change in UE function in the first 6 months after surgery and is comparable to other measures at 12 and 24 months.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic II.

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.

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.

Responsiveness of the ACTIVLIM-CP questionnaire: measuring global activity performance in children with cerebral palsy

AIM

To investigate the responsiveness of the ACTIVLIM-CP questionnaire after two evidence-based interventions for children with cerebral palsy (CP).

METHOD

Seventy-five children with CP either participated in an intensive motor-skill learning intervention (hand-arm bimanual intensive therapy including lower extremities [HABIT-ILE], n=47) or received botulinum neurotoxin-A (BoNT-A) injection(s) into lower extremities combined with conventional physical therapy (n=28). All children were assessed three times: at baseline (T₀ ; before HABIT-ILE/the day of BoNT-A injection), at T₁ (last day of HABIT-ILE/6wks after BoNT-A injection), and at follow-up (T₂ ; 3-4mo after the beginning of intervention). Parents completed ACTIVLIM-CP and three other activity questionnaires. Responsiveness was analysed using group (based on intervention), subgroup (based on gross motor function level), and individual approaches.

RESULTS

For the HABIT-ILE group, significant improvements in ACTIVLIM-CP were observed for the T₀ -T₁ period (p<0.001) but not for the T₁ -T₂ period. No significant changes were found in the BoNT-A group during assessments (p=0.84). In the subgroup analysis for the HABIT-ILE group (T₀ -T₁ ), greater changes were demonstrated for children in Gross Motor Function Classification System levels III and IV (p<0.001, effect size=1.36). The individual approach was congruent with the group approach.

INTERPRETATION

ACTIVLIM-CP demonstrated high responsiveness after HABIT-ILE, showing that this scale may be used to investigate global activity performance in clinical trials focusing on improving daily life activities.

WHAT THIS PAPER ADDS

Good responsiveness of ACTIVLIM-CP questionnaire during intensive motor-skill learning intervention. Higher responsiveness for children in Gross Motor Function Classification System (GMFCS) levels III and IV versus I and II after intensive intervention. ACTIVLIM-CP is useful to identify children improving their performance after botulinum neurotoxin-A injection.

Effects of Upper-Extremity Surgery on Manual Performance of Children and Adolescents with Cerebral Palsy: A Multidisciplinary Approach Using Shared Decision-Making

BACKGROUND

Little is known about the effects of upper-extremity surgery on the manual performance of children and adolescents with cerebral palsy (CP). This clinical cohort study describes our experience with patient selection based on multidisciplinary assessment and shared decision-making and the effects of upper-extremity surgery on manual performance and patient-relevant outcomes.

METHODS

All patients (up to 20 years of age) with CP referred to our multidisciplinary team for evaluation for upper-extremity surgery between July 2011 and May 2017 were included. Suitability for upper-extremity surgery was assessed with comprehensive, multidisciplinary screening, and the decision to proceed with surgery was made together with the patient. Individual patient-relevant goals were identified with the Canadian Occupational Performance Measure (COPM); perceived independence in performing bimanual activities at home was assessed with the ABILHAND-Kids tool, and perceived quality of use of the affected hand during daily activities was assessed with a visual analog scale (VAS). The quality of use of the affected hand during bimanual performance was measured with the Assisting Hand Assessment (AHA), and gross manual dexterity was evaluated with the Box and Block Test (BBT). All baseline assessments were repeated at an average of 9 months after the surgery.

RESULTS

Of 66 patients assessed by the multidisciplinary upper-extremity-surgery team, 44 were considered eligible for upper-extremity surgery. Of these patients, 39 (mean age and standard deviation [SD], 14.9 ± 2.10 years, 87% with unilateral CP, and 72% at Manual Ability Classification System [MACS] level II) underwent upper-extremity surgery and were evaluated in the pre-post study. All outcomes improved significantly after upper-extremity surgery, with average improvements of 3.1 ± 1.6 points in the COPM-Performance (COPM-P) score (p < 0.001), 3.3 ± 2.1 points in the COPM-Satisfaction (COPM-S) score (p < 0.001), 1.5 ± 1.2 logits in the ABILHAND score (p < 0.001), 2.4 ± 1.9 cm in the VAS score (p < 0.001), 6.7 ± 4.2 units in the AHA score (p < 0.001), and 2.2 ± 5.0 blocks/minute on the BBT (p = 0.021). The improvement in the COPM-P, COPM-S, ABILHAND, VAS, AHA, and BBT scores was clinically meaningful in 80%, 77%, 55%, 62%, 71%, and 31% of the patients, respectively.

CONCLUSIONS

Careful assessment of eligibility for upper-extremity surgery, based on multidisciplinary screening and shared decision-making, resulted in a clinically relevant improvement in patient-specific functional and/or cosmetic goals and manual performance after upper-extremity surgery in most patients with CP.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Tele-UPCAT: study protocol of a randomised controlled trial of a home-based Tele-monitored UPper limb Children Action observation Training for participants with unilateral cerebral palsy

INTRODUCTION

A new rehabilitative approach, called UPper Limb Children Action Observation Training (UPCAT), based on the principles of action observation training (AOT), has provided promising results for upper limb rehabilitation in children with unilateral cerebral palsy (UCP). This study will investigate if a new information and communication technology platform, named Tele-UPCAT, is able to deliver AOT in a home setting and will test its efficacy on children and young people with UCP.

METHODS AND ANALYSIS

A randomised, allocation concealed (waitlist control) and evaluator-blinded clinical trial with two investigative arms will be carried out. The experimental group will perform AOT at home for 3 weeks using a customised Tele-UPCAT system where they will watch video sequences of goal-directed actions and then complete the motor training of the same actions. The control group will receive usual care for 3 weeks, which may include upper limb training. They will be offered AOT at home after 3 weeks. Twenty-four children with UCP will be recruited for 12 participants per group. The primary outcome will be measured using Assisting Hand Assessment. The Melbourne Assessment 2, ABILHAND, Participation and Environment Measure-Children and Youth and Cerebral Palsy Quality of Life Questionnaire will be included as secondary measures. Quantitative measures from sensorised objects and participants worn Actigraphs GXT3+ will be analysed. The assessment points will be the week before (T0) and after (T1) the period of AOT/standard care. Further assessments will be at T1 plus, the week after the AOT period for the waitlist group and at 8 weeks (T2) and 24 weeks (T3) after AOT training.

ETHICS AND DISSEMINATION

The trial has been approved by the Tuscany Paediatric Ethics Committee (169/2016). Publication of all outcomes will be in peer-reviewed journals and conference presentations.

TRIAL REGISTRATION

NCT03094455.