Efficacy of constraint-induced movement therapy and electrical stimulation on hand function of children with hemiplegic cerebral palsy: a controlled clinical trial

Effects of Low Intensity Focused Ultrasound Stimulation Combined With Functional Electrical Stimulation on Corticospinal Excitability and Upper Extremity Fine Motor Function

INTRODUCTION

Functional electrical stimulation (FES) is used to retrain motor function in neurological disorders but typically requires multiple sessions and shows limited benefits in chronic cases. Low-intensity transcranial focused ultrasound stimulation (TUS) is a noninvasive brain stimulation (NIBS) method offering greater focality and deeper penetration than current NIBS techniques. TUS delivered in a theta burst pattern (tbTUS) for 80 s produces neuroplastic changes with long-term potentiation-like effects lasting up to 60 min in healthy adults. Since tbTUS increases cortical excitability, combining it with FES may enhance neuroplasticity. We hypothesized that combining tbTUS with FES would result in increased corticospinal excitability compared to FES alone and lead to greater improvement in fine motor skills as assessed by Nine-Hole Peg Test (NHPT) scores.

METHODS

Fifteen healthy participants underwent two study visits consisting of real or sham tbTUS of the left motor cortex immediately followed by 30 min of FES of the first dorsal interosseous (FDI) and the opponens pollicis (OP) muscles for fine motor function training of the right hand. Motor-evoked potentials (MEPs) were recorded from the right FDI, OP, and abductor digiti minimi (ADM) muscles at baseline (BL), immediately after real or sham tbTUS (T0), immediately after 30 min of FES training (T45), and at 15 (T65) and 30 min (T80) post-FES. NHPT was delivered at BL and at T80.

RESULTS

Data from 14 participants were analyzed. It showed a significant decrease in MEP amplitudes of FDI and OP at T45 following only real tbTUS+FES with a return to BL at T80. No significant changes were seen in the NHPT scores in either condition.

CONCLUSION

Real tbTUS+FES combined with voluntary movement results in immediate corticospinal inhibition with a return to BL at ∼20 min post-stimulation suggestive of homeostatic metaplasticity. These findings highlight the potential of tbTUS+FES as a neuromodulatory intervention, warranting further exploration in neurological conditions for therapeutic applications.

Identificação de ingredientes de intervenções não invasivas para crianças deambuladoras com paralisia cerebral usando as minhas palavras favoritas: uma revisão de escopo

Objetivo

Mapear os ingredientes das intervenções não invasivas fornecidas às crianças deambuladoras com Paralisia Cerebral (PC).

Método

Os artigos foram selecionados e as características dos estudos extraídas. Os ingredientes das intervenções foram descritos em termos do Sistema de Especificação de Taxonomia de Reabilitação (RTSS) e vinculados às minhas palavras favoritas. Os resultados foram interpretados e validados por meio da abordagem de Envolvimento de pacientes e do Publico em Pesquisa (EPP).

Resultados

Sessenta e um artigos foram incluídos, dos quais 55,5% foram classificados como ensaios clínicos randomizados. Os estudos selecionados incluíram um total de 2187 crianças (a idade média variou de 3 meses a 5,9 anos), a maioria de países desenvolvidos. Os estudos incluídos investigaram um total de 27 intervenções, que juntas apresentaram ingredientes representando todas as minhas palavras favoritas, na seguinte ordem de frequência: “Saúde” (ex., treinamento de força e resistência), “Funcionalidade” (ex., prática ativa e repetitiva de uma tarefa), “Família” (ex., terapia focada no contexto), “Diversão” (ex., inclusão de atividades amistosas para crianças), “Amigos” (ex., atividades em grupo) e “Futuro” (ex., compartilhamento de informações didáticas). Assim, os ingredientes relacionados à palavra “Futuro” foram os relatados com menos frequência.

Interpretação

Terapeutas e famílias precisam estar cientes da correspondência mais apropriada entre as metas elencadas por meio das minhas palavras favoritas e os objetivos, ingredientes e alvos das intervenções. Finalmente, “Diversão”, “Amigos” e “Futuro” devem ser abordadas como desfechos potenciais em estudos futuros.

F-words ingredients of non-invasive interventions for young ambulant children with cerebral palsy: A scoping review

AIM

To map the ingredients of non-invasive interventions provided to young ambulant children with cerebral palsy.

METHOD

Articles were screened and each study's characteristics extracted. The intervention ingredients were described in terms of the Rehabilitation Treatment Specification System and linked to the 'F-words'. Results were interpreted and validated by a patient and public involvement group.

RESULTS

Sixty-one papers were included, of which 55.5% were classified as randomized controlled trial design studies. The selected studies included a total of 2187 children (mean age range 3 months to 5 years 11 months), most from high-income countries. The included studies investigated a total of 27 interventions, which together presented ingredients representing all F-words, in the following order of frequency: 'fitness' (e.g. strength and endurance training), 'functioning' (e.g. active and repetitive practice of a task), 'family' (e.g. context-focused therapy), 'fun' (e.g. inclusion of child-friendly activities), 'friends' (e.g. group activities), and 'future' (e.g. didactic information sharing). Thus, ingredients related to the F-word 'future' were the most infrequently reported.

INTERPRETATION

Therapists and families need to be aware of the most appropriate match between the F-word goals, ingredients, and targets. Finally, 'fun', 'friends', and 'future' should be addressed as potential outcomes in future studies.

Infant Modified Constraint-Induced Movement Therapy Paired With Neuromuscular Electrical Stimulation: A Feasibility Study

PURPOSE

To determine the feasibility of modified constraint-induced movement therapy (mCIMT) paired with neuromuscular electrical stimulation (NMES) for infants with asymmetrical hand function (AHF).

METHODS

Five infants received an experimental ABA design: (A1) 3 weeks of our Standard AHF Care, (B) 3 weeks mCIMT-NMES, and (A2) 3 weeks of our Standard AHF Care. Parents tracked key data in a daily log, and infants were assessed 4 times using the Hand Assessment for Infants and Peabody Developmental Motor Scale-2.

RESULTS

There was a high level of participant enrollment, visit frequency adherence, and compliance with the treatment protocol. No adverse events were reported. Mean Hand Assessment for Infants Both Hands measure scores changed more after mCIMT-NMES than after our Standard AHF Care.

CONCLUSIONS

mCIMT-NMES is a feasible early intervention for infants with AHF at risk for unilateral cerebral palsy. A future study in a larger sample should examine the efficacy of mCIMT-NMES in this population.

Association Between Prediabetes and Risk, Mortality of Hepatocellular Carcinoma: A Meta-Analysis

BACKGROUND

As the high-risk stage of diabetes, the role of prediabetes in the development of hepatocellular carcinoma (HCC) remains unclear. To address this knowledge gap, we undertook a meta-analysis to investigate the potential association between the prediabetic stage and HCC.

METHODS

In this study, two independent investigators conducted a comprehensive search for relevant articles published up until May 2023 in several databases, including PubMed, Web of Science, Medline, EMBASE, and Google Scholar. The results were then summarized using STATA 12.0 software.

RESULTS

Our analysis included a total of 6 cohort studies involving 1,490,752 participants, as well as 1 case-control study with 220 participants. The research aimed to examine the association between prediabetes and the risk of HCC. Our meta-analysis revealed that prediabetes was significantly associated with an elevated risk of HCC (odds ratio (OR)/relative risk (RR) = 1.25, 95% confidence interval (CI) 1.06 to 1.48, I2 = 57.2%, p = 0.012), using a random-effects model. Moreover, four cohort studies, encompassing 1,362,847 participants, explored the relationship between prediabetes and HCC mortality. The meta-analysis showed that prediabetes was associated with a higher mortality rate of HCC, also utilizing a random-effects model (hazard ratio (HR) = 1.36, 95% CI 1.02 to 1.81, I2 = 55.8%, p = 0.060).

CONCLUSIONS

Overall, our findings highlight a significant association between prediabetes and an increased risk of HCC and suggest that prediabetes may also contribute to higher mortality rates among HCC patients.

Electrical Stimulation for Children with Cerebral Palsy: A Meta-analysis for Randomized Controlled Trials

BACKGROUND

Different types of electrical stimulation (ES) showed diverse effects on children with cerebral palsy (CP). Previous studies reported inconsistent results for effects of ES on children with CP. The present study aimed to conduct a meta-analysis to summarize these diverse results.

METHODS

We searched for studies exploring effects of ES on children with CP in databases (PubMed and Web of Science) from their inception until December 2022. Standard mean differences (SMDs) and 95% confidence intervals (CIs) were computed using STATA 12.0 software.

RESULTS

The meta-analysis included 19 randomized controlled trials (including 265 CP patients in test group and 263 CP patients in corresponding control group). The study showed an increased improvement in gross motor function, walking speed, step length, and daily living activities in ES group compared with corresponding control group with random effects models (gross motor function: SMD = 2.04, 95% CI = 1.43-2.65; walking speed: SMD = 3.71, 95% CI = 1.49-5.92; step length: SMD = 1.89, 95% CI = 0.65-3.13; daily living activities: SMD = 5.18, 95% CI = 3.04-7.31), whereas the study showed no significant difference in change of muscle strength between ES group and the corresponding control group with a random effects model (SMD = 0.42, 95% CI = -0.12 to 0.97).

CONCLUSION

The study demonstrated that ES might be used as therapy to improve gross motor function, gait, and daily living activities in children with CP.

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

PURPOSE

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

MATERIAL AND METHOD

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

RESULTS

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

CONCLUSIONS

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

BCI-activated electrical stimulation in children with perinatal stroke and hemiparesis: A pilot study

Background

Perinatal stroke (PS) causes most hemiparetic cerebral palsy (CP) and results in lifelong disability. Children with severe hemiparesis have limited rehabilitation options. Brain computer interface- activated functional electrical stimulation (BCI-FES) of target muscles may enhance upper extremity function in hemiparetic adults. We conducted a pilot clinical trial to assess the safety and feasibility of BCI-FES in children with hemiparetic CP.

Methods

Thirteen participants (mean age = 12.2 years, 31% female) were recruited from a population-based cohort. Inclusion criteria were: (1) MRI-confirmed PS, (2) disabling hemiparetic CP, (3) age 6–18 years, (4) informed consent/assent. Those with neurological comorbidities or unstable epilepsy were excluded. Participants attended two BCI sessions: training and rehabilitation. They wore an EEG-BCI headset and two forearm extensor stimulation electrodes. Participants’ imagination of wrist extension was classified on EEG, after which muscle stimulation and visual feedback were provided when the correct visualization was detected.

Results

No serious adverse events or dropouts occurred. The most common complaints were mild headache, headset discomfort and muscle fatigue. Children ranked the experience as comparable to a long car ride and none reported as unpleasant. Sessions lasted a mean of 87 min with 33 min of stimulation delivered. Mean classification accuracies were (M = 78.78%, SD = 9.97) for training and (M = 73.48, SD = 12.41) for rehabilitation. Mean Cohen’s Kappa across rehabilitation trials was M = 0.43, SD = 0.29, range = 0.019–1.00, suggesting BCI competency.

Conclusion

Brain computer interface-FES was well -tolerated and feasible in children with hemiparesis. This paves the way for clinical trials to optimize approaches and test efficacy.

Neuromuscular Electrical Stimulation of Upper Limbs in Patients With Cerebral Palsy: A Systematic Review and Meta-analysis of Randomized Controlled Trials

OBJECTIVE

The aim of the study is to assess the effects of neuromuscular electrical stimulation on the upper limbs of patients with cerebral palsy.

DESIGN

We searched PubMed, Cochrane, Embase, and Scopus databases for randomized controlled trials examining the effects of neuromuscular electrical stimulation on the upper limbs of children with cerebral palsy.

RESULTS

Eight randomized controlled trials ( N = 294) were included in the meta-analysis. Compared with traditional physical therapy, sensorimotor training and task-oriented training, constraint-induced movement therapy, dynamic bracing, and conventional robot-assisted therapy, neuromuscular electrical stimulation in combination with these therapies resulted in significantly greater functional scale scores (standardized mean difference = 0.80; 95% confidence interval = 0.54 to 1.06), muscle strength of upper limbs (standardized mean difference = 0.57; 95% confidence interval = 0.25 to 0.88), and spasticity of upper limbs (relative risk = 2.53; 95% confidence interval = 1.46 to 4.39; standardized mean difference = -0.18; 95% confidence interval = -0.29 to -0.06) but did not improve the wrist range of motion (standardized mean difference = 0.43; 95% confidence interval = -0.04 to 0.91). In addition, the effect of neuromuscular electrical stimulation on functional scale scores remained after 3-mo follow-up (standardized mean difference = 0.68; 95% confidence interval = 0.16 to 1.2).

CONCLUSIONS

Neuromuscular electrical stimulation effectively improved hand function, muscle strength, and spasticity in patients with cerebral palsy.

Reliability and validity of the East Asian children's version of mini-MACS in children with cerebral palsy

Background

Mini-Manual Ability Classification System (Mini-MACS) was developed for children with cerebral palsy aged 1–4 years, but its validity and reliability in different cultures are unavailable yet. This study was to determine the reliability and validity of Mini-MACS in East Asian children with cerebral palsy and investigate the correlation between Mini-MACS and Gross Motor Function Classification System.

Methods

One hundred and four East Asian children with cerebral palsy aged 12–48 months were classified by one of their parents, an occupational therapist, and a physical therapist with Mini-MACS. The results were analyzed for inter-rater reliability by using intraclass correlation coefficient (ICC). The Nine-hole Peg Test was used for the criterion-related validity analysis, and parents retested their children after 2 weeks to evaluate test–retest reliability. Gross Motor Function Classification System levels were also collected to investigate the correlation with Mini-MACS.

Results

Good inter-rater reliability among the occupational therapist, physical therapist, and parents was found [ICC = 0.984 (95% confidence interval, CI, 0.976–0.989), 0.973 (95% CI 0.960–0.982), and 0.966 (95% CI 0.950–0.977), respectively; p < 0.01]. The test–retest reliability in parents was almost perfect [ICC = 0.985 (95% CI 0.977–0.990), p < 0.01]. Mini-MACS had consistency with the Nine-hole Peg Test (r = 0.582, 0.581, and 0.566, respectively; p < 0.01). A correlation was found between Gross Motor Function Classification System and Mini-MACS (r = 0.626, 0.596, and 0.598, respectively; p < 0.01).

Conclusion

The Mini-MACS demonstrates evidence that it is a valid and reliable tool to classify manual ability in East Asian children with cerebral palsy and is also positively related to the Gross Motor Function Classification System.

Aromatic L-amino acid decarboxylase deficiency: a systematic review

Aim: To gain greater knowledge regarding the natural history of aromatic L-amino acid decarboxylase (AADC) deficiency, a genetic disorder that causes severe deficits in motor and cognitive development. Materials & methods: A systematic literature review was performed of all case reports and clinical studies published through December 2019 of patients with AADC deficiency. The data were summarized descriptively. Results: The search identified 94 publications that described 237 unique patients. Mean (standard deviation) age at diagnosis was 3.2 (±5.7) years and 16 deaths were reported. Most patients (57%) received the standard of care therapies, which showed limited efficacy in this patient population. Conclusion: AADC deficiency is a devastating disease and prospectively defined natural history studies are warranted to further understand this disease.

The Effect of Constraint-Induced Movement Therapy Combined With Repetitive Transcranial Magnetic Stimulation on Hand Function in Preschool Children With Unilateral Cerebral Palsy: A Randomized Controlled Preliminary Study

Constraint-induced movement therapy (CIMT) combined with repetitive transcranial magnetic stimulation (rTMS) have shown great potential in improving function in schoolchildren with unilateral cerebral palsy attributed to perinatal stroke. However, the prospect of application in preschool children with unilateral cerebral palsy (UCP) attributed to various brain disorders remains unclear. In this prospective, assessor-blinded, randomized controlled study, 40 preschool children with UCP (aged 2.5–6 years) were randomized to receive 10 days of CIMT combined with active or sham rTMS. Assessments were performed at baseline, 2 weeks, and 6 months post-intervention to investigate upper limb extremity, social life ability, and perceived changes by parents and motor-evoked potentials. Overall, 35 participants completed the trial. The CIMT plus active stimulation group had greater gains in the affected hand function (range of motion, accuracy, and fluency) than the CIMT plus sham stimulation group (P < 0.05), but there was no significant difference in muscular tone, social life ability, and perceived changes by parents between the two groups (P > 0.05). In addition, there was no significant difference in hand function between children with and without motor-evoked potential (P > 0.05). No participants reported severe adverse events during the study session. In short, the treatment of CIMT combined with rTMS is safe and feasible for preschool children with UCP attributed to various brain disorders. Randomized controlled studies with large samples and long-term effects are warranted.

Hand function development of children with hemiplegic cerebral palsy: A scoping review

PURPOSE

Hemiplegic cerebral palsy (hCP) typically impacts sensorimotor control of the hand, but comprehensive assessments of the hands of children with hCP are relatively rare. This scoping review summarizes the development of hand function for children with hCP.

METHODS

This scoping review focused on the development of hand function in children with hCP. Electronic databases (PubMed, PEDro, Web of Science, CINAHL, and SpringerLink) were searched to identify studies assessing hand function in children with hCP. The search was performed using keywords (e.g., "hemiplegia"). An iterative approach verified by two authors was used to select the studies. Articles which reported quantitative data for children with hCP on any items of a specified set of hand evaluations were included. Measures were sorted into three categories: quantitative neuromechanics, clinical assessments, and clinical functional evaluations.

RESULTS

Initial searches returned 1536 articles, 131 of which were included in the final review. Trends between assessment scores and age were examined for both hands.

CONCLUSION

While several studies have evaluated hand function in children with hCP, the majority relied on clinical scales, assessments, or qualitative descriptions. Further assessments of kinematics, kinetics, and muscle activation patterns are needed to identify the underlying impairment mechanisms that should be targeted for treatment.

Perinatal stroke: mapping and modulating developmental plasticity

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

In-depth analysis reveals complex molecular aetiology in a cohort of idiopathic cerebral palsy

Cerebral palsy is the most prevalent physical disability in children; however, its inherent molecular mechanisms remain unclear. In the present study, we performed in-depth clinical and molecular analysis on 120 idiopathic cerebral palsy families, and identified underlying detrimental genetic variants in 45% of these patients. In addition to germline variants, we found disease-related postzygotic mutations in ∼6.7% of cerebral palsy patients. We found that patients with more severe motor impairments or a comorbidity of intellectual disability had a significantly higher chance of harbouring disease-related variants. By a compilation of 114 known cerebral-palsy-related genes, we identified characteristic features in terms of inheritance and function, from which we proposed a dichotomous classification system according to the expression patterns of these genes and associated cognitive impairments. In two patients with both cerebral palsy and intellectual disability, we revealed that the defective TYW1, a tRNA hypermodification enzyme, caused primary microcephaly and problems in motion and cognition by hindering neuronal proliferation and migration. Furthermore, we developed an algorithm and demonstrated in mouse brains that this malfunctioning hypermodification specifically perturbed the translation of a subset of proteins involved in cell cycling. This finding provided a novel and interesting mechanism for congenital microcephaly. In another cerebral palsy patient with normal intelligence, we identified a mitochondrial enzyme GPAM, the hypomorphic form of which led to hypomyelination of the corticospinal tract in both human and mouse models. In addition, we confirmed that the aberrant Gpam in mice perturbed the lipid metabolism in astrocytes, resulting in suppressed astrocytic proliferation and a shortage of lipid contents supplied for oligodendrocytic myelination. Taken together, our findings elucidate novel aspects of the aetiology of cerebral palsy and provide insights for future therapeutic strategies.

Can Children With Perinatal Stroke Use a Simple Brain Computer Interface?

[Figure: see text].

Constraint-Induced Movement Therapy Promotes Neural Remodeling and Functional Reorganization by Overcoming Nogo-A/NgR/RhoA/ROCK Signals in Hemiplegic Cerebral Palsy Mice

Background. Little is known about the induction of functional and brain structural reorganization in hemiplegic cerebral palsy (HCP) by constraint-induced movement therapy (CIMT). Objective. We aimed to explore the specific molecular mechanism of functional and structural plasticity related to CIMT in HCP. Methods. The mice were divided into a control group and HCP groups with different interventions (unconstraint-induced movement therapy [UNCIMT], CIMT or siRNA-Nogo-A [SN] treatment): the HCP, HCP+UNCIMT, HCP+CIMT, HCP+SN, and HCP+SN+CIMT groups. Rotarod and front-limb suspension tests, immunohistochemistry, Golgi-Cox staining, transmission electron microscopy, and Western blot analyses were applied to measure motor function, neurons and neurofilament density, dendrites/axon areas, myelin integrity, and Nogo-A/NgR/RhoA/ROCK expression in the motor cortex. Results. The mice in the HCP+CIMT group had better motor function, greater neurons and neurofilament density, dendrites/axon areas, myelin integrity, and lower Nogo-A/NgR/RhoA/ROCK expression in the motor cortex than the HCP and HCP+UNCIMT groups (P < .05). Moreover, the expression of Nogo-A/NgR/RhoA/ROCK, the improvement of neural remodeling and motor function of mice in the HCP+SN group were similar to those in the HCP+CIMT group (P > .05). The neural remodeling and motor function of the HCP+SN+CIMT group were significantly greater than those in the HCP+SN and HCP+CIMT groups (P < .05). Motor function were positively correlated with the density of neurons (r = 0.450 and 0.309, respectively; P < .05) and neurofilament (r = 0.717 and 0.567, respectively; P < .05). Conclusions. CIMT might promote the remodeling of neurons, neurofilament, dendrites/axon areas, and myelin in the motor cortex by partially inhibiting the Nogo-A/NgR/RhoA/ROCK pathway, thereby promoting the improvement of motor function in HCP mice.

[Effectiveness of constraint-induced movement therapy in upper extremity rehabilitation in patients with cerebral palsy: A systematic review]

BACKGROUND AND OBJECTIVE

In hemiplegic cerebral palsy, learned non-use may appear. This phenomenon can be reversed by constraint-induced movement therapy in the healthy side. The aim of this article was to review the evidence of the effectiveness of this therapy on upper extremity functioning, the performance of activities of daily living and quality of life.

PATIENTS AND METHODS

We performed a systematic review between January and April 2019 in the PubMed, COCHRANE, PEDro and TRIPDATABASE databases. We included 14 clinical studies describing their characteristics.

RESULTS

Most of the studies found significant improvements compared with control groups. Only one article investigated quality of life.

CONCLUSIONS

Constraint-induced movement therapy seems to have positive effects in the motor rehabilitation of the upper extremity in patients with hemiplegic cerebral palsy. Further studies are needed to assess the individual factors of greatest influence in rehabilitation.

Immersive Virtual Environments and Wearable Haptic Devices in rehabilitation of children with neuromotor impairments: a single-blind randomized controlled crossover pilot study

Background

The past decade has seen the emergence of rehabilitation treatments using virtual reality. One of the advantages in using this technology is the potential to create positive motivation, by means of engaging environments and tasks shaped in the form of serious games. The aim of this study is to determine the efficacy of immersive Virtual Environments and weaRable hAptic devices (VERA) for rehabilitation of upper limb in children with Cerebral Palsy (CP) and Developmental Dyspraxia (DD).

Methods

A two period cross-over design was adopted for determining the differences between the proposed therapy and a conventional treatment. Eight children were randomized into two groups: one group received the VERA treatment in the first period and the manual therapy in the second period, and viceversa for the other group. Children were assessed at the beginning and the end of each period through both the Nine Hole Peg Test (9-HPT, primary outcome) and Kinesiological Measurements obtained during the performing of similar tasks in a real setting scenario (secondary outcomes).

Results

All subjects, not depending from which group they come from, significantly improved in both the performance of the 9-HPT and in the parameters of the kinesiological measurements (movement error and smoothness). No statistically significant differences have been found between the two groups.

Conclusions

These findings suggest that immersive VE and wearable haptic devices is a viable alternative to conventional therapy for improving upper extremity function in children with neuromotor impairments.

Trial registration ClinicalTrials, NCT03353623. Registered 27 November 2017-Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03353623

Principles of Medical and Surgical Treatment of Cerebral Palsy

Cerebral palsy is the most common cause of childhood motor disability, affecting 2 to 3/1000 children worldwide. Clinical abnormalities in tone, posture, and movement are the result of brain dysgenesis or injury early in life, and impairment varies in type, distribution, and in severity. The underlying brain disorder may also lead to other associated neurologic and systemic impairments. Variability in functional impairments, which can change during development, necessitates an individualized treatment plan. Treatment options are primarily symptomatic and directed toward optimizing independence, function, and/or ease of care-while limiting side effects. New promising disease-preventing and modifying treatments are emerging.

Occupational Therapy Practice Guidelines for Early Childhood: Birth-5 Years

IMPORTANCE

This Practice Guideline provides stakeholders with a condensed summary of a large number of effectiveness studies. It is a valuable tool for facilitating decision making related to occupational therapy interventions for children ages birth-5 yr.

OBJECTIVE

Early childhood (birth-5 yr) is a critical period in which the foundation of key life occupations is developed (e.g., eating, dressing, play, learning, social participation, rest and sleep, and chores). The development of cognitive, motor, social-emotional, and self-care skills is important to support these occupations. This Practice Guideline synthesizes recent systematic reviews (SRs) on these areas of development to promote decision making for and high-quality interventions with this population.

METHOD

Four SRs related to cognition, mental health, motor function, and ADLs analyzed studies published from 2010 to 2017 retrieved from six electronic databases (MEDLINE, PsycINFO, CINAHL, ERIC, OTseeker, and Cochrane).

RESULTS

A total of 196 articles were included in the SRs, which served as a guide to final clinical recommendations. Case studies describe translation and application to practice.

CONCLUSION

and Recommendations: A variety of interventions within the domain of occupational therapy were found to support the development of cognitive, social-emotional, motor, and self-care skills. Although some of these interventions are typically implemented by occupational therapy practitioners, others can be implemented by parents after training or by teams working in preschool settings. These findings should be used to inform evidence-based practice provided by occupational therapy practitioners working in various early childhood settings.

WHAT THIS ARTICLE ADDS

This Practice Guideline gives occupational therapy practitioners clear information about which interventions will be effective for specific outcomes. Better intervention choices mean better outcomes for young children and their families.

Comparison of the effects of Kinesio tape and neuromuscular electrical stimulation on hand extensors in children with cerebral palsy

Background/aims

Cerebral palsy is a lifelong condition resulting in weakness in the muscles, difficulty moving and excessive tension in the muscles of the arms and legs. This study aimed to investigate the effects of adding Kinesio taping and neuromuscular electrical stimulation to neurodevelopmental treatment on joint range of motion, muscle tone and functional ability in children with cerebral palsy.

Methods

A total of 30 children were included in the study. They were allocated to one of two groups: Kinesio taping (n=15) or neuromuscular electrical stimulation (n=15). The children in both groups received 20 sessions of twice-weekly neurodevelopmental treatment. Range of motion, Modified Ashworth Scale, Duruoz Hand Index, Manual Ability Classification System, Gross Motor Function Classification System, Minnesota Hand Skill Test and Jebsen Hand Function Test were assessed before and after the treatment programme.

Results

Statistically significant improvements (P<0.05) were found in all measures except Gross Motor Function Classification System in both groups. Significant between-group differences in left shoulder flexion, left shoulder abduction and unilateral Minnesota Hand Skill Test were found in favour of neuromuscular electrical stimulation; whereas significant improvement in left elbow flexion was found in favour of Kinesio taping.

Conclusions

The addition of Kinesio taping and neuromuscular electrical stimulation to neurodevelopmental treatment improved the joint range of motion and functional ability of children with cerebral palsy.

A biofeedback-enhanced therapeutic exercise video game intervention for young people with cerebral palsy: A randomized single-case experimental design feasibility study

Importance/Background

Movement-controlled video games have potential to promote home-based practice of therapy activities. The success of therapy gaming interventions depends on the quality of the technology used and the presence of effective support structures.

Aim

This study assesses the feasibility of a novel intervention that combines a co-created gaming technology integrating evidence-based biofeedback and solution-focused coaching (SFC) strategies to support therapy engagement and efficacy at home.

Methods

Following feasibility and single-case reporting standards (CONSORT and SCRIBE), this was a non-blind, randomized, multiple-baseline, AB, design. Nineteen (19) young people with cerebral palsy (8–18 years old) completed the 4-week home-based intervention in France and Canada.

Participant motivations, personalized practice goals, and relevance of the intervention to daily activities were discussed in a Solution Focused Coaching-style conversation pre-, post-intervention and during weekly check-ins. Participants controlled a video game by completing therapeutic gestures (wrist extension, pinching) detected via electromyography and inertial sensors on the forearm (Myo Armband and custom software).

Process feasibility success criteria for recruitment response, completion and adherence rates, and frequency of technical issues were established a priori. Scientific feasibility, effect size estimates and variance were determined for Body Function outcome measures: active wrist extension, grip strength and Box and Blocks Test; and for Activities and Participation measures: Assisting Hand Assessment (AHA), Canadian Occupational Performance Measure (COPM) and Self-Reported Experiences of Activity Settings (SEAS).

Results

Recruitment response (31%) and assessment completion (84%) rates were good and 74% of participants reached self-identified practice goals. As 17% of technical issues required external support to resolve, the intervention was graded as feasible with modifications. No adverse events were reported.

Moderate effects were observed in Body Function measures (active wrist extension: SMD = 1.82, 95%CI = 0.85–2.78; Grip Strength: SMD = 0.63, 95%CI = 0.65–1.91; Box and Blocks: Hedge’s g = 0.58, 95%CI = -0.11–1.27) and small-moderate effects in Activities and Participation measures (AHA: Hedge’s g = 0.29, 95%CI = -0.39–0.97, COPM: r = 0.60, 95%CI = 0.13–0.82, SEAS: r = 0.24, 95%CI = -0.25–0.61).

Conclusion

A definitive RCT to investigate the effectiveness of this novel intervention is warranted. Combining SFC-style coaching with high-quality biofeedback may positively engage youth in home rehabilitation to complement traditional therapy.

Trial registration

ClinicalTrials.gov, U.S. National Library of Medicine: NCT03677193.

Interventions Within the Scope of Occupational Therapy Practice to Improve Motor Performance for Children Ages 0–5 Years: A Systematic Review

Importance: Occupational therapy practitioners need updated information about which interventions may improve motor skills for young children.

Objective: To identify the effectiveness of occupational therapy interventions to promote motor development and prevent delay for children ages 0–5 yr.

Data Sources: Six databases (CINAHL, MEDLINE, PsycINFO, ERIC, Cochrane, and OTseeker) were searched for articles published from January 2010 to March 2017.

Study Selection and Data Collection: The search yielded 4,488 articles that were reviewed for inclusion. Fifty-six studies were entered into both evidence and risk-of-bias tables. Included studies used Level I–III designs, were within occupational therapy’s scope of practice, included participants with a mean age younger than 6 yr, and addressed motor skills.

Findings: Three intervention themes emerged: early intervention for children younger than age 3 yr, interventions for preschool children ages 3–5 yr, and interventions for children with or at risk for cerebral palsy.

Conclusions and Relevance: Occupational therapy practitioners should consider use of interventions with moderate or strong evidence as described in this review. Limitations include high risk of bias and limited evidence for several interventions.

What This Article Adds: This article provides occupational therapy practitioners with updated information on evidence-based practices for children age 5 and younger who have motor delays.

Wearable Haptics and Immersive Virtual Reality Rehabilitation Training in Children With Neuromotor Impairments

The past decade has seen the emergence of rehabilitation treatments using virtual reality (VR) environments although translation into clinical practice has been limited so far. In this paper, an immersive VR rehabilitation training system endowed with wearable haptics is proposed for children with neuromotor impairments: it aims to enhance involvement and engagement of patients, to provide congruent multi-sensory afferent feedback during motor exercises and to benefit from the flexibility of VR in adapting exercises to the patient's need. An experimental rehabilitation session conducted with children with cerebral palsy (CP) and developmental dyspraxia (DD) has been performed to evaluate the usability of the system and proof of concept trial of the proposed approach. We compared CP/DD performance with both typically developing children and adult control group. Results show the system was compliant with different levels of motor skills and allowed patients to complete the experimental rehabilitation session, with performance varying according to the expected motor abilities of different groups. Moreover, a kinematic assessmentbased on the presented system has been designed. Obtained results reflected different motor abilities of patients and participants, suggesting suitability of the proposed kinematic assessment as a motor function outcome.

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.

The Feasibility of Functional Electrical Stimulation to Improve Upper Extremity Function in a Two-year-old Child with Perinatal Stroke: A Case Report

AIMS

To evaluate the effectiveness and feasibility (i.e. tolerability, adherence) of functional electrical stimulation (FES) for the upper extremity (UE) in a two-year-old child with perinatal stroke.

METHODS

Forty hours of FES over eight weeks was prescribed. FES to the hemiplegic triceps, extensor carpi radialis longus and brevis, extensor carpi ulnaris and extensor digitorum was timed with reaching during play. Assessments were performed before, during, and two months post-intervention. UE function (Melbourne Assessment 2 (MA2), Assisting Hand Assessment (AHA)) and spasticity (Modified Tardieu with electrogoniometry and electromyography) were measured. The mother completed a semi-structured interview post-intervention. Descriptive statistics were used for adherence and UE measures. A repeated-measures ANOVA compared Modified Tardieu parameters (e.g. catch angle) over time. Conventional content analysis was used for the interview data.

RESULTS

The child completed 39.2/40 hours. Immediately post-intervention, improvements were observed on MA2's Range of Motion subscale and catch angle (Modified Tardieu, p < 0.001). Two months post-intervention, improvements were observed on MA2's Accuracy and Fluency subscales. No change in AHA score occurred. Three themes emerged from the interview: (1) Ingredients for program success; (2) Information about the FES device; and (3) The child's response.

CONCLUSIONS

UE FES was feasible in a two-year-old child with hemiplegia.

Upper limb therapy in children with cerebral palsy (CP) – The Pirate Group

Introduction: Children with cerebral palsy (CP) in the form of spastic hemiplegia experience numerous difficulties concerning an affected upper limb such as reaching for objects, gripping or manipulating them. These limitations affect their everyday activity. Conducting an effective and simultaneously an interesting therapy aimed at meeting the child’s individual needs and improving upper limb function is a challenge for a physiotherapist. The aim of the study was to assess the effectiveness of upper limb therapy carried out within the project titled “The Pirate Group” based on Constraint-Induced Movement Therapy (CIMT) and Bimanual Training (BIT) conducted in a specially arranged environment. Material and methods: The research included 16 children with CP in the form of spastic hemiplegia. Mean age of the study participants was 4.23 years. The children underwent a two-week Constraint-Induced Movement Therapy (CIMT) combined with Bimanual Training (BIT). In order to evaluate the effects of the therapy, each child underwent the Assisting Hand Assessment (AHA) prior to the therapy and after its completion. Results: Statistical analysis revealed a significant difference (p<0.05) between the results of AHA prior to and after the therapy (t(14)=9.12, p<0.0001). An improvement in the affected upper limb function was noted in all the children participating in the research. Conclusions: The project titled “The Pirate Group”, based on CIMT and BIT is an effective therapeutic intervention which improves spontaneous activity of the affected upper limb in children with hemiplegia.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Effects of Robot-Assisted Training for the Unaffected Arm in Patients with Hemiparetic Cerebral Palsy: A Proof-of-Concept Pilot Study

On a voluntary basis, 10 adolescents with hemiparesis due to cerebral palsy and 11 neurologically healthy control subjects participated in this proof-of-concept pilot study. The aim was to examine the effects of robot-assisted training for the unaffected arm in patients with hemiparetic cerebral palsy. Baseline comparison between the unaffected arm of the hemiparetic patients with cerebral palsy and the dominant arm of healthy control subjects showed significant differences on the Jebsen-Taylor Hand Function test and action planning ability tests. Within-group comparison after ten 30-minute sessions (five days a week for two consecutive weeks) of robot-assisted training for the unaffected arm showed significant improvements in patients with cerebral palsy on the Jebsen-Taylor Hand Function test (performed at both hands) and action planning ability test (evaluated at the unaffected arm). Our findings are in line with previous evidences of action planning deficits at the unaffected arm in patients with hemiparetic cerebral palsy and support the hypothesis that robot-assisted training for the unaffected arm may be useful to improve manual dexterity and action planning in patients with hemiparesis due to cerebral palsy.

Constraint-induced movement therapy improves upper limb activity and participation in hemiplegic cerebral palsy: a systematic review

QUESTIONS

Does constraint-induced movement therapy improve activity and participation in children with hemiplegic cerebral palsy? Does it improve activity and participation more than the same dose of upper limb therapy without restraint? Is the effect of constraint-induced movement therapy related to the duration of intervention or the age of the children?

DESIGN

Systematic review of randomised trials with meta-analysis.

PARTICIPANTS

Children with hemiplegic cerebral palsy with any level of motor disability.

INTERVENTION

The experimental group received constraint-induced movement therapy (defined as restraint of the less affected upper limb during supervised activity practice of the more affected upper limb). The control group received no intervention, sham intervention, or the same dose of upper limb therapy.

OUTCOME MEASURES

Measures of upper limb activity and participation were used in the analysis.

RESULTS

Constraint-induced movement therapy was more effective than no/sham intervention in terms of upper limb activity (SMD 0.63, 95% CI 0.20 to 1.06) and participation (SMD 1.21, 95% CI 0.41 to 2.02). However, constraint-induced movement therapy was no better than the same dose of upper limb therapy without restraint either in terms of upper limb activity (SMD 0.05, 95% CI -0.21 to 0.32) or participation (SMD -0.02, 95% CI -0.34 to 0.31). The effect of constraint-induced movement therapy was not related to the duration of intervention or the age of the children.

CONCLUSIONS

This review suggests that constraint-induced movement therapy is more effective than no intervention, but no more effective than the same dose of upper limb practice without restraint.

REGISTRATION

PROSPERO CRD42015024665. [Chiu H-C, Ada L (2016) Constraint-induced movement therapy improves upper limb activity and participation in hemiplegic cerebral palsy: a systematic review.Journal of Physiotherapy62: 130-137].

Does therapeutic electrical stimulation improve function in children with disabilities? A comprehensive literature review

The use of therapeutic electrical stimulation for medical purposes is not new; it has been described in medical textbooks since the 18th century, but its use has been limited due to concerns for tolerance and lack of research showing efficacy. The purpose of this review is to discuss the potential clinical applicability, while clarifying the differences in electrical stimulation (ES) treatments and the theory behind potential benefits to remediate functional impairments in youth.The literature review was performed as follows: A total of 37 articles were reviewed and the evidence for use in pediatric diagnoses is reported.The synthesis of the literature suggests that improvements in various impairments may be possible with the integration of ES. Most studies were completed on children with cerebral palsy (CP). Electrical stimulation may improve muscle mass and strength, spasticity, passive range of motion (PROM), upper extremity function, walking speed, and positioning of the foot and ankle kinematics during walking. Sitting posture and static/dynamic sitting balance may be improved with ES to trunk musculature. Bone mineral density may be positively affected with the use of Functional Electrical Stimulation (FES) ergometry. ES may also be useful in the management of urinary tract dysfunction and chronic constipation. Among all reviewed studies, reports of direct adverse reactions to electrical stimulation were rare.In conclusion, NMES and FES appear to be safe and well tolerated in children with various disabilities. It is suggested that physiatrists and other healthcare providers better understand the indications and parameters in order to utilize these tools effectively in the pediatric population. MeSH terms: Electrical stimulation; child; review.

Tolerability of Repeated Application of Transcranial Electrical Stimulation with Limited Outputs to Healthy Subjects

BACKGROUND

The safety and tolerability of limited output transcranial electrical stimulation (tES) in clinical populations support a non-significant risk designation. The tolerability of long-term use in a healthy population had remained untested.

OBJECTIVE

We tested the tolerability and compliance of two tES waveforms, transcranial direct current stimulation (tDCS) and modulated high frequency transcranial pulsed current stimulation (MHF-tPCS) compared to sham-tDCS, applied to healthy subjects for three to five days (17-20 minutes per day) per week for up to six weeks in a communal setting. MHF-tPCS consisted of asymmetric high-frequency pulses (7-11 kHz) having a peak amplitude of 10-20 mA peak, adjusted by subject, resulting in an average current of 5-7 mA.

METHOD

A total of 100 treatment blind healthy subjects were randomly assigned to one of three treatment groups: tDCS (n = 33), MHF-tPCS (n = 30), or sham-tDCS (n = 37). In order to test the role of waveform, electrode type and montage were fixed across tES and sham-tDCS arms: high-capacity self-adhering electrodes on the right lateral forehead and back of the neck. We conducted 1905 sessions (636 sham-tDCS, 623 tDCS, and 646 MHF-tPCS sessions) on study volunteers over a period of six weeks.

RESULTS

Common adverse events were primarily restricted to influences upon the skin and included skin tingling, itching, and mild burning sensations. The incidence of these events in the active tES treatment arms (MHF-tPCS, tDCS) was equivalent or significantly lower than their incidence in the sham-tDCS treatment arm. Other adverse events had a rarity (<5% incidence) that could not be significantly distinguished across the treatment groups. Some subjects were withdrawn from the study due to atypical headache (sham-tDCS n = 2, tDCS n = 2, and MHF-tPCS n = 3), atypical discomfort (sham-tDCS n = 0, tDCS n = 1, and MHF-tPCS n = 1), or atypical skin irritation (sham-tDCS n = 2, tDCS n = 8, and MHF-tPCS n = 1). The rate of compliance, elected sessions completed, for the MHF-tPCS group was significantly greater than the sham-tDCS group's compliance (p = 0.007). There were no serious adverse events in any treatment condition.

CONCLUSION

We conclude that repeated application of limited output tES across extended periods, limited to the hardware, electrodes, and protocols tested here, is well tolerated in healthy subjects, as previously observed in clinical populations.

Muscle Recruitment and Coordination following Constraint-Induced Movement Therapy with Electrical Stimulation on Children with Hemiplegic Cerebral Palsy: A Randomized Controlled Trial

Objective

To investigate changes of muscle recruitment and coordination following constraint-induced movement therapy, constraint-induced movement therapy plus electrical stimulation, and traditional occupational therapy in treating hand dysfunction.

Methods

In a randomized, single-blind, controlled trial, children with hemiplegic cerebral palsy were randomly assigned to receive constraint-induced movement therapy (n = 22), constraint-induced movement therapy plus electrical stimulation (n = 23), or traditional occupational therapy (n = 23). Three groups received a 2-week hospital-based intervention and a 6-month home-based exercise program following hospital-based intervention. Constraint-induced movement therapy involved intensive functional training of the involved hand during which the uninvolved hand was constrained. Electrical stimulation was applied on wrist extensors of the involved hand. Traditional occupational therapy involved functional unimanual and bimanual training. All children underwent clinical assessments and surface electromyography (EMG) at baseline, 2 weeks, 3 and 6 months after treatment. Surface myoelectric signals were integrated EMG, root mean square and cocontraction ratio. Clinical measures were grip strength and upper extremity functional test.

Results

Constraint-induced movement therapy plus electrical stimulation group showed both a greater rate of improvement in integrated EMG of the involved wrist extensors and cocontraction ratio compared to the other two groups at 3 and 6 months, as well as improving in root mean square of the involved wrist extensors than traditional occupational therapy group (p<0.05). Positive correlations were found between both upper extremity functional test scores and integrated EMG of the involved wrist as well as grip strength and integrated EMG of the involved wrist extensors (p<0.05).

Conclusions

Constraint-induced movement therapy plus electrical stimulation is likely to produce the best outcome in improving muscle recruitment and coordination in children with hemiplegic cerebral palsy compared to constraint-induced movement therapy alone or traditional occupational therapy.

Trial registration

chictr.org ChiCTR-TRC-13004041

Improving arm function in chronic stroke: a pilot study of sensory amplitude electrical stimulation via glove electrode during task-specific training

OBJECTIVE

To investigate the effects of sensory amplitude electrical stimulation (SES) delivered by glove electrode during task-specific exercise on arm movement, function, and sensation in chronic stroke.

METHODS

The design was an intervention pilot study, pre-test, post-test, follow-up design. The settings used were a university research laboratory and home-based intervention. Participants comprised of 11 individuals with chronic stroke (7.2 ± 4.1 years post onset) and moderate arm paresis, 10.82/20 ± 2.27 on the Stroke Rehabilitation Assessment of Movement (STREAM) - Arm Subscale. Participants were seven males and four females (mean age: 59 years). Participants were recruited from university-based database. Intervention- Participants engaged in task-specific training at home for 30 min, twice daily, for 5 weeks, while receiving SES via glove electrode. Participants received supervised task practice at least twice during intervention period for 1 hour. Main outcome measures- Jebsen-Taylor Hand Function Test (JTHFT), STREAM - Arm Subscale, Motor Activity Log-14 (MAL-14) - Amount and Quality Subscales, and Nottingham Stereognosis Assessment (NSA).

RESULTS

Significant changes were found in group mean pre- and post-test comparisons on the NSA (P = 0.042), MAL amount subscale (P = 0.047), and JTHFT (with writing item 29 excluded) (P = 0.003) and in pre-test to follow-up comparisons on NSA (P = 0.027) and JTHFT (writing item excluded) (P = 0.009). There was no significant change on the STREAM (P = 1.0). Individuals with a greater baseline motor capacity determined by STREAM scores (P = 0.048) and more recent stroke (P = 0.014) had significantly greater improvements.

CONCLUSION

Combining task-specific training with glove-based SES in chronic stroke resulted in changes in arm sensation and function that were maintained at 3-month follow-up.

Upper limb function evaluation scales for individuals with cerebral palsy: a systematic review

[Purpose] The aim of the present study was to perform a systematic review of the literature on the scales and methods most often used for the evaluation of upper limb function in individuals with cerebral palsy. [Materials and Methods] Searches were conducted in the Medline, PEDro, Lilacs, Scielo, and PubMed databases. The following inclusion criteria were used for the selection of articles: randomized controlled study, evaluation of upper limb function in individuals with cerebral palsy, and publication between 2006 and 2014. The methodological quality of the articles was evaluated using the PEDro evidence scale. [Results] Five articles met the inclusion criteria and achieved 6 points or higher on the PEDro scale of methodological quality. [Conclusion] The studies analyzed used different evaluation scales, but no consensus has been reached thus far on which scale is the most appropriate. Thus, further studies are needed to establish an adequate method for the evaluation of upper limb function in individuals with cerebral palsy.

Effects of neuromuscular electrical stimulation on the wrist and finger flexor spasticity and hand functions in cerebral palsy

PURPOSE

To evaluate the effects of neuromuscular electrical stimulation on wrist range of motion, wrist and finger flexor spasticity, and hand functions in patients with unilateral cerebral palsy.

METHOD

Twenty-four children with unilateral spastic cerebral palsy (14 boys and 10 girls) between the ages of 5 and 14 years were randomized into neuromuscular electrical stimulation and control groups. Conventional exercises were applied, and static volar wrist-hand orthosis was administered to all patients 5 days a week for 6 weeks. Additionally, 30-minute neuromuscular electrical stimulation sessions were applied to the wrist extensor muscles in the neuromuscular electrical stimulation group. Patients were evaluated by Zancolli Classification System, Manual Ability Classification System, and Abilhand-Kids Test.

RESULTS

Compared with baseline, a significant increase was evident in active wrist extension angle at the fourth and sixth weeks in both groups (all P < 0.001), more prominent in the neuromuscular electrical stimulation group at the fourth and sixth weeks (P = 0.015 and P = 0.006, respectively). A decrease was observed in the spasticity values in the neuromuscular electrical stimulation group at the fourth and sixth weeks (P = 0.002 and P = 0.001, respectively) and in the control group only at the sixth week (P = 0.008). Abilhand-Kids values improved only in the neuromuscular electrical stimulation group (P < 0.001).

CONCLUSION

Neuromuscular electrical stimulation application in addition to conventional treatments is effective in improving active wrist range of motion, spasticity, and hand functions in cerebral palsy.

Effectiveness of constraint-induced movement therapy on upper-extremity function in children with cerebral palsy: a systematic review and meta-analysis of randomized controlled trials

Objective:

To systematically examine the research literature on the effectiveness of constraint-induced movement therapy on improving arm function in children with cerebral palsy, and to assess the association between the study effect size and the characteristics of the patients and intervention protocol.

Data sources:

A systematic literature search was conducted in PubMed, PsycINFO, Cochrane, CINAHL, Web of Science, and TRIP Database up to May 2014.

Review methods:

Studies employing randomized controlled trial design, children with cerebral palsy, comparing constraint-induced movement therapy with another intervention with a focus on arm function, and upper-extremity measures were included in this review. Methodological quality was evaluated using the Physiotherapy Evidence-based Database (PEDro) scale.

Results:

The literature search resulted in 27 randomized controlled trial studies with good methodological quality that compared constraint-induced movement therapy with other intervention therapy. Overall, constraint-induced movement therapy provided a medium beneficial effect ( d = 0.546; p < 0.001) when compared with conventional therapy. For the subgroup analyses, presence of a dose-equivalent comparison group, intervention location, and time of follow-up were significant factors. Studies examining constraint-induced movement therapy effect without a dose-equivalent comparison group showed a large effect in children with cerebral palsy, but studies with a dose-equivalent group only showed a small effect. Children who received home-based constraint-induced movement therapy had a better improvement in arm function than those who received constraint-induced movement therapy elsewhere.

Conclusion:

The research literature supports constraint-induced movement therapy as an effective intervention to improve arm function in children with cerebral palsy.

The state of the evidence for intensive upper limb therapy approaches for children with unilateral cerebral palsy

Children with unilateral cerebral palsy experience difficulties with unimanual and bimanual upper limb function, impacting independence in daily life. Targeted upper limb therapies such as constraint-induced movement therapy, bimanual training, and combined approaches have emerged in the last decade. This article reviews the scientific rationale underpinning these treatments and current evidence to improve upper limb outcomes and goal attainment. Intensive models of therapy achieved modest to strong effects to improve upper limb function compared to usual care. Dose-matched comparisons of bimanual and unimanual training demonstrated similar gains in upper limb outcomes. The optimum timing, dose and impact of repeat episodes of intensive upper limb therapies require further investigation. Characteristics of children who achieve clinically meaningful outcomes remain unclear. Key components of intervention include collaborative goal setting with families and intensive repetitive, incrementally challenging, task practice. Choice of treatment approach should be governed by child/family goals and preferences, individual, and contextual factors.

Upper extremity strength measurement for children with cerebral palsy: a systematic review of available instruments

BACKGROUND

In order to make inferences about strength related to development or treatment interventions, it is important to use measurement instruments that have sound clinimetric properties.

PURPOSE

The objective of this review is to systematically evaluate the level of evidence of the clinimetric properties of instruments for measuring upper extremity muscle strength at the "body functions & structures" level of the International Classification of Functioning, Disability and Health for Children and Youth (ICF-CY) for children with cerebral palsy (CP).

DATA SOURCES

A systematic search of the PubMed, EMBASE, OTseeker, CINAHL, PEDro, and MEDLINE databases up to November 2012 was performed.

STUDY SELECTION

Two independent raters identified and examined studies that reported the use of upper extremity strength measurement instruments and methods for children and adolescents with CP aged 0 to 18 years.

DATA EXTRACTION

The COSMIN (COnsensus-based Standards for the selection of health status Measurement INstruments) checklist with 4-point rating scale was used by 2 independent raters to evaluate the methodological quality of the included studies. Best evidence synthesis was performed using COSMIN outcomes and the quality of the clinimetric properties.

DATA SYNTHESIS

Six different measurement instruments or methods were identified. Test-retest, interrater, and intrarater reliability were investigated. Two test-retest reliability studies were rated as "fair" for the level of evidence. All other studies were rated as "unknown" for the level of evidence.

LIMITATIONS

The paucity of literature describing clinimetric properties, especially other than reliability, of upper limb strength measurement instruments for children with CP was a limitation of the study.

CONCLUSIONS

For measuring grip strength, the Jamar dynamometer is recommended. For other muscle groups, handheld dynamometry is recommended. Manual muscle testing (MMT) can be used in case of limited (below MMT grade 4) wrist strength or for total upper limb muscle strength. Based on lacking information regarding other clinimetric properties, caution is advised regarding interpretation of the results.

Treatment taxonomy for rehabilitation: past, present, and prospects

The idea of constructing a taxonomy of rehabilitation interventions has been around for quite some time, but other than small and mostly ad hoc efforts, not much progress has been made, in spite of articulate pleas by some well-respected clinician scholars. In this article, treatment taxonomies used in health care, and in rehabilitation specifically, are selectively reviewed, with a focus on the need to base a rehabilitation treatment taxonomy (RTT) on the "active ingredients" of treatments and their link to patient/client deficits/problems that are targeted in therapy. This is followed by a description of what we see as a fruitful approach to the development of an RTT that crosses disciplines, settings, and patient diagnoses, and a discussion of the potential uses in and benefits of a well-developed RTT for clinical service, research, education, and service administration.

Guidelines for future research in constraint-induced movement therapy for children with unilateral cerebral palsy: an expert consensus

AIM

The aim of this study was to provide an overview of what is known about constraintinduced movement therapy (CIMT) in children with unilateral cerebral palsy (CP), to identify current knowledge gaps, and to provide suggestions for future research.

METHOD

Nine experts participated in a consensus meeting. A comprehensive literature search was conducted and data were summarized before the meeting. The core model produced by the European network for Health Technology Assessment was used as a framework for discussion and to identify critical issues for future research.

RESULTS

All models of CIMT have demonstrated improvements in the upper limb abilities of children with unilateral CP. A consensus was reached on 11 important questions to be further explored in future studies. The areas of highest priority included the effect of dosage, the effect of repeated CIMT, and the impact of predictive factors, such as age, on the response to CIMT. Consensus suggestions for future study designs and the use of validated outcome measures were also provided.

INTERPRETATION

The CIMT construct is complex, and much remains unknown. It is unclear whether a specific model of CIMT demonstrates superiority over others and whether dosage of training matters. Future research should build upon existing knowledge and aim to provide information that will help implement CIMT in various countries with different healthcare resources and organizational structures.

Efficacy of upper limb therapies for unilateral cerebral palsy: a meta-analysis

BACKGROUND AND OBJECTIVE

Children with unilateral cerebral palsy present with impaired upper limb (UL) function affecting independence, participation, and quality of life and require effective rehabilitation. This study aims to systematically review the efficacy of nonsurgical upper limb therapies for children with unilateral cerebral palsy.

METHODS

Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Embase, the Cochrane Central Register of Controlled Trials, and PubMed were searched to December 2012. Randomized controlled or comparison trials were included.

RESULTS

Forty-two studies evaluating 113 UL therapy approaches (N = 1454 subjects) met the inclusion criteria. Moderate to strong effects favoring intramuscular injections of botulinum toxin A and occupational therapy (OT) to improve UL and individualized outcomes compared with OT alone were identified. Constraint-induced movement therapy achieved modest to strong treatment effects on improving movement quality and efficiency of the impaired UL compared with usual care. There were weak treatment effects for most outcomes when constraint therapy was compared with an equal dose (amount) of bimanual OT; both yielded similar improved outcomes. Newer interventions such as action observation training and mirror therapy should be viewed as experimental.

CONCLUSIONS

There is modest evidence that intensive activity-based, goal-directed interventions (eg, constraint-induced movement therapy, bimanual training) are more effective than standard care in improving UL and individualized outcomes. There is little evidence to support block therapy alone as the dose of intervention is unlikely to be sufficient to lead to sustained changes in UL outcomes. There is strong evidence that goal-directed OT home programs are effective and could supplement hands-on direct therapy to achieve increased dose of intervention.

COMBIT: protocol of a randomised comparison trial of COMbined modified constraint induced movement therapy and bimanual intensive training with distributed model of standard upper limb rehabilitation in children with congenital hemiplegia

INTRODUCTION

Children with congenital hemiplegia often present with limitations in using their impaired upper limb which impacts on independence in activities of daily living, societal participation and quality of life. Traditional therapy has adopted a bimanual training approach (BIM) and more recently, modified constraint induced movement therapy (mCIMT) has emerged as a promising unimanual approach. Evidence of enhanced neuroplasticity following mCIMT suggests that the sequential application of mCIMT followed by bimanual training may optimise outcomes (Hybrid CIMT). It remains unclear whether more intensely delivered group based interventions (hCIMT) are superior to distributed models of individualised therapy. This study aims to determine the optimal density of upper limb training for children with congenital hemiplegia.

METHODS AND ANALYSES

A total of 50 children (25 in each group) with congenital hemiplegia will be recruited to participate in this randomized comparison trial. Children will be matched in pairs at baseline and randomly allocated to receive an intensive block group hybrid model of combined mCIMT followed by intensive bimanual training delivered in a day camp model (COMBiT; total dose 45 hours direct, 10 hours of indirect therapy), or a distributed model of standard occupational therapy and physiotherapy care (SC) over 12 weeks (total 45 hours direct and indirect therapy). Outcomes will be assessed at 13 weeks after commencement, and retention of effects tested at 26 weeks. The primary outcomes will be bimanual coordination and unimanual upper-limb capacity. Secondary outcomes will be participation and quality of life. Advanced brain imaging will assess neurovascular changes in response to treatment. Analysis will follow standard principles for RCTs, using two-group comparisons on all participants on an intention-to-treat basis. Comparisons will be between treatment groups using generalized linear models.

TRIAL REGISTRATION

ACTRN12613000181707.

Six years after a modified constraint induced movement therapy (CIMT) program--what happens when the children have become young adults?

The aim is to describe the development of hand function in young adults with unilateral cerebral palsy (CP), who participated in a 2-week Constraint Induced Movement Therapy (CIMT) camp 6 years earlier. Eleven participants, 16-21 years at follow-up, were assessed at three occasions during 2005 and once in 2011. At the 6-year follow-up, performance on the Assisting Hand Assessment and the Jebsen-Taylor Hand Function test remained unchanged (P > 0.05) from the first assessment before the camp. Grip strength (Grippit®) increased in both the involved (+80.9%) and non-involved hand (+94.4%) (P < 0.05), while performance on the Melbourne Assessment tended to decrease (-7%). In conclusion, it seems that young adults with unilateral CP maintain their hand function performance at the same level as in the early adolescent period. Interestingly, the grip strength increased over time also for the involved hand.