Upper limb strength training and somatosensory stimulation: optimizing self‐care independence for children with unilateral cerebral palsy

Abstract

The ability to live independently is a major concern in children and adolescents with unilateral cerebral palsy (CP), and in particular during their transition to adulthood. CP results in a lifelong disability. Yet children with unilateral CP are generally expected to achieve a similar level of functioning to their typically developing peers. Most children with unilateral CP walk independently and many have average cognitive abilities. However, impairments in the upper limb can be more severe, hampering the independent execution of daily life activities. Most daily life activities require the skilled use of both hands to complete such tasks. Higher levels of self-care independence are indeed reported in children with better manual abilities. Mastering self-care further enables the child to participate in home, school, and leisure activities. Therefore, the ultimate goal of the clinician is to optimize the child’s functional potential to improve performance in daily life. Yet there is still a lack of understanding of factors determining self-care independence in children with unilateral CP. Russo et al. contribute to this knowledge by investigating to what extent self-care independence is determined by upper limb impairments in unilateral CP. The authors concluded that muscle strength at the elbow and wrist along with somatosensory function determines self-care independence to a greater extent than spasticity and should therefore be prioritized in therapy. Interestingly, motor planning skills also significantly affected self-care independence. Unfortunately, other disease-specific factors (e.g. mirror movements, developmental disregard, visual deficits) as well as environmental factors (e.g. social status, access to health services) were not incorporated in the model, although they might provide additional insights into self-care independence. Previous research also identified distal muscle strength and somatosensory function as the strongest determinants for upper limb activity performance. Together, these findings support that muscle strength and somatosensory stimulation are important components of upper limb treatment paradigms for children with unilateral CP. Moreover, decreased muscle performance and impaired somatosensory function may result in reduced hand use in daily life, and consequently further decline muscle strength and limit somatosensory input. This vicious circle underlines the importance of intervention at an early age, not only in a therapy setting, but also at home. Upper limb strength training has been shown to improve muscle strength in unilateral CP, though its impact on activity and participation remains unclear. The effect of somatosensory stimulation also seems promising, yet only preliminary results are available. Nevertheless, somatosensory information is crucial for motor planning and for fine-tuning bimanual coordination, explaining its importance for self-care independence. Yet we cannot assume that impairment-based interventions alone will be effective for the level of activity and participation. The training principle of specificity should also be acknowledged. However, it is of clinical interest to examine whether adding upper limb strength training or somatosensory stimulation to activity or participation-based interventions would augment the treatment effects. In conclusion, the findings of Russo et al. provide an important step in developing a framework aimed at optimizing self-care independence in children with unilateral CP. Disentangling the multiple relevant factors, including disease-specific and environmental aspects will be challenging, but should be a focus of future research. In addition, systematic evaluation of treatment paradigms addressing these determinants will help clinicians to implement individually tailored therapy programs to achieve the highest possible level of functioning in daily life in each child with unilateral CP.