Jeanne Charles

Efficacy of a child‐friendly form of constraint‐induced movement therapy in hemiplegic cerebral palsy: a randomized control trial

Constraint-induced (CI) movement therapy is a promising therapy for improving upper limb function in adults after stroke. It involves restraint of the non-involved limb and extensive movement practice with the involved limb. In this study, a single-blinded, randomized, control study was performed to examine the efficacy of CI therapy, modified to be child friendly, in children with hemiplegic cerebral palsy (CP). Twenty-two children (8 females, 14 males; mean age 6 y 8 mo [SD 1 y 4 mo]; range 4-8 y) were randomized to either an intervention group (n=11) or a delayed treatment control group (n=11). Children wore a sling on their non-involved upper limb for 6 hours per day for 10 out of 12 consecutive days and were engaged in play and functional activities. Children in the treatment group demonstrated improved movement efficiency and dexterity of the involved upper extremity, which were sustained through the 6-month evaluation period, as measured by the Jebsen-Taylor Test of Hand Function and fine motor-subtests of the Bruininks-Oseretsky Test of Motor Proficiency (p<0.05 in both cases). Initial severity of hand impairment and testing compliance were strong predictors of improvement. Caregivers reported significant increases in involved limb frequency of use and quality of movement. However, there was no change in strength, sensibility, or muscle tone (p>0.05 in all cases). Results suggest that for a carefully selected subgroup of children with hemiplegic CP, CI therapy modified to be child-friendly, appears to be efficacious in improving movement efficiency of the involved upper extremity.

Efficacy of a hand–arm bimanual intensive therapy (HABIT) in children with hemiplegic cerebral palsy: a randomized control trial

Children with hemiplegic cerebral palsy (CP) have impairments in bimanual coordination above and beyond their unilateral impairments. Recently we developed hand‐arm bimanual intensive therapy (HABIT), using the principles of motor learning, and neuroplasticity, to address these bimanual impairments. A single‐blinded randomized control study of HABIT was performed to examine its efficacy in children with hemiplegic CP with mild to moderate hand involvement. Twenty children (age range 3y 6mo‐15y 6mo) were randomized to either an intervention (n=10: seven males, three females; mean age 8y 7mo, SD 4y) or a delayed treatment control group (n=10: seven males, three females; mean age 6y 10mo, SD 2y 4mo). Children were engaged in play and functional activities that provided structured bimanual practice 6 hours per day for 10 days. Each child was evaluated immediately before and after the intervention, and again at 1‐month post‐intervention. Children in the intervention group demonstrated improved scores on the Assisting Hand Assessment, increased involved extremity use measured using accelerometry and a caregiver survey, bimanual items of the Bruininks–Oseretsky Test of Motor Proficiency, and the simultaneity of completing a draw‐opening task with two hands (p<0.05 in all cases). The results suggest that for this carefully selected subgroup of children with hemiplegic CP, HABIT appears to be efficacious in improving bimanual hand use.

Bimanual Training and Constraint-Induced Movement Therapy in Children With Hemiplegic Cerebral Palsy: A Randomized Trial

Background. Constraint-induced movement therapy (CIMT) promotes hand function using intensive unimanual practice along with restraint of the less-affected hand. CIMT has not been compared with a treatment with equivalent dosing frequency and intensity in children with cerebral palsy (CP). Objectives. The authors report a randomized trial comparing CIMT and a bimanual intervention (hand-arm intensive bimanual therapy; HABIT) that maintains the intensity of practice associated with CIMT but where children are engaged in functional bimanual tasks. Methods. A total of 42 participants with hemiplegic CP between the ages of 3.5 and 10 years (matched for age and hand function) were randomized to receive 90 hours of CIMT or an equivalent dosage of functional bimanual training (HABIT) conducted in day-camp environments. A physical therapist blinded to treatment allocation tested hand function before and after treatment. The primary outcomes were changes in Jebsen-Taylor Test of Hand Function (JTTHF) and Assisting Hand Assessment (AHA) scores. Secondary measures included the Goal Attainment Scale (GAS). Results. Both the CIMT and HABIT groups demonstrated comparable improvement from the pretest to immediate posttest in the JTTHF and AHA (P < .0001), which were maintained at 6 months. GAS, however, revealed greater progress toward goals for the HABIT group (P < .0001), with continued improvement across test sessions for both groups (P < .0001). Conclusions. Both CIMT and bimanual training lead to similar improvements in hand function. A potential benefit of bimanual training is that participants may improve more on self-determined goals.

Development of hand-arm bimanual intensive training (HABIT) for improving bimanual coordination in children with hemiplegic cerebral palsy.

Constraint-induced (CI) movement therapy is a physical intervention that has been receiving increasing attention in pediatric rehabilitation. So far, the evidence suggests that practice associated with CI therapy may improve impaired unimanual hand function in some children with hemiplegic cerebral palsy (CP). However, CI therapy has several important limitations. Most importantly, children with hemiplegia have impairments in bimanual coordination beyond their unilateral impairments. Thus, an intervention approach to increase functional independence during activities of daily living by using both hands in cooperation is needed. Here we briefly review the etiology of hemiplegic CP, describe studies of pediatric CI therapy efficacy in relation to the etiology, discuss the conceptual and practical limitations of CI therapy for this population, and describe bimanual coordination impairments in children with hemiplegia. Finally, we introduce a new intervention for children with hemiplegia, hand-arm bimanual intensive training (HABIT), to address the limitations of CI therapy and to improve bimanual coordination. HABIT retains the two major elements of pediatric CI therapy (intensive structured practice and child-friendliness). The proposed methodology demonstrates that extensive targeted practice can be provided in a child-friendly manner without using a physical restraint, although the efficacy of such an approach remains to be determined.

Efficacy of Constraint-Induced Movement Therapy on Involved Upper-Extremity Use in Children With Hemiplegic Cerebral Palsy Is Not Age-Dependent

OBJECTIVES. Constraint-induced (CI) movement therapy has been shown recently to be promising for improving upper-limb function in children with cerebral palsy (CP). Because little is known about patient characteristics predicting treatment efficacy, not all children may benefit from this intervention. Here we examine the relationship between efficacy of a child-friendly form of CI therapy and age on involved upper-extremity function. DESIGN. Twenty children with hemiplegic CP age 4 to 13 years received CI therapy and completed evaluations. Based on established functional and neuromaturational changes in hand skill development, the children were divided into a “younger group” (age 4–8 years, n = 12) and “older group” (age 9–13 years, n = 8). Children wore a sling on their noninvolved upper extremity for 6 hours per day for 10 of 12 consecutive days, during which time they were engaged in play and functional activities. Each child was evaluated by trained evaluators who were blinded to the fact that the children received treatment. The evaluations took place once before the intervention and at 1 week, 1 month, and 6 months after the intervention. Efficacy was examined at the movement efficiency (Jebsen-Taylor Test of Hand Function, subtest 8 of the Bruininks-Oseretsky Test of Motor Proficiency), environmental (caregiver frequency and quality of involved upper-limb use), and impairment (strength, tactile sensitivity, and muscle tone) levels. RESULTS. Children in both age groups had significant improvements in involved hand-movement efficiency and environmental functional limitations, which were retained through the 6-month posttest. However, there were no differences in efficacy between younger and older children. Both hand severity and the childrens behavior during testing (number of redirections), with the latter serving as a reasonable correlate for attention during the intervention, were related to changes in performance in the younger group but not in the older group. CONCLUSIONS. The results suggest that the intensive practice associated with CI therapy can improve movement efficiency and environmental functional limitations among a carefully selected subgroup of children with hemiplegic CP of varying ages and that this efficacy is not age-dependent.

A Critical Review of Constraint-Induced Movement Therapy and Forced Use in Children with Hemiplegia

Hemiplegia is a physical impairment that can occur in childhood following head trauma, cerebral vascular accident or transient ischemic attack (stroke), brain tumor, or congenital or perinatal injury. One of the most disabling symptoms of hemiplegia is unilaterally impaired hand and arm function. Sensory and motor impairments in children with hemiplegia compromise movement efficiency. Such children often tend not to use the affected extremity, which may further exacerbate the impairments, resulting in a developmentally learned non-use of the involved upper extremity, termed ‘developmental disuse’. Recent studies suggest that children with hemiplegia benefit from intensive practice. Forced use and Constraint-lnduced Movement Therapy (CI therapy) are recent therapeutic interventions involving the restraint of the non-involved upper extremity and intensive practice with the involved upper extremity. These approaches were designed for adults with hemiplegia, and increasing evidence suggests that they are efficacious in this population. Recently, forced use and constraint-induced therapy have been applied to children with hemiplegia. In this review, we provide a brief description of forced use and CI therapy and their historical basis, provide a summary of studies of these interventions in children, and discuss a number of important theoretical considerations, as well as implications for postural control. We will show that whereas the studies to date suggest that both forced use and CI therapy appear to be promising for improving hand function in children with hemiplegia, the data are limited. Substantially more work must be performed before this approach can be advocated for general clinical use.

Fingertip forces during object manipulation in children with hemiplegic cerebral palsy. II: Bilateral coordination

The present study examines the coordination of fingertip forces during object manipulation in both the involved and non‐involved hand of 14 children with hemiplegic cerebral palsy (CP) aged between 8 and 14 years. While no impairment could be observed in the non‐involved hand, subtle deficits in the sequencing of the grip–lift movement were observed in all children tested in this hand. However, they were able to scale the fingertip force output of the non‐involved hand in advance (use anticipatory control) based on the objects weight. In the second experiment in this paper, we tested whether the anticipatory control can be generalized across hands. The results indicate that sensory information from the non‐involved hand can be used for anticipatory scaling of isometric force increase during subsequent lifts with the contralateral involved hand. These findings suggest that the initial lack of anticipatory control usually observed in the involved hand of children with hemiplegic CP is likely to be based on disturbed sensory input.

Effects of constraint-induced therapy on hand function in children with hemiplegic cerebral palsy.

Purpose: The effects of constraint‐induced therapy on hand function of the involved upper extremity were examined in three children with hemiplegic cerebral palsy. Methods: In these case reports, the noninvolved upper extremities of the children were constrained six hours daily for 14 consecutive days. Hand function, strength, sensation, and fingertip force coordination were examined pre‐ and postintervention. Results: The results indicated that there was an improvement in hand function for two of the three children and an improvement in two‐point discrimination threshold values for all children. While there was no consistent change in fingertip force coordination during precision grip across children, one child demonstrated a consistent decrease in duration of temporal phases of fingertip force coordination and two children demonstrated a reorganization of the grip‐lift synergy of the involved hand. Conclusion and Clinical Implications: Improvement in hand function is not captured by any one measure. The effectiveness of this intervention is promising but may be dependent on the severity of the impairment.

Bimanual coordination during a goal-directed task in children with hemiplegic cerebral palsy

Most studies of impaired hand function in children with hemiplegic cerebral palsy (CP) have focused on either the involved or the non‐involved extremity in isolation. Coordination of the involved and non‐involved hand during bimanual tasks in these children is not well understood. The present study examined bimanual coordination using a drawer‐opening task under speed and hand constraints in 10 children with hemiplegic CP (5 males and 5 females, mean age 13y 5mo, range 8y to 16y) and 10 age‐matched right‐handed developing typically children (6 males and 4 females, mean age 13y 1mo). Children were asked to reach forward and open a drawer with one hand and then activate a light switch inside the drawer with the contralateral hand. The role of the two hands (open drawer and activate switch) and speed (self‐paced vs fast‐as‐possible) were varied. The children with hemiplegic CP were slower (p<0.001) and less coordinated in this task, with reduced movement overlap of the two hands (p<0.001) and sequential completion of the two movement objectives (p<0.001). Moreover, the hand used for each task subcomponent affected task performance for the children with hemiplegic CP (p<0.05). Interestingly, faster speed facilitated better bimanual coordination for the children with hemiplegic CP (p<0.001). Results highlight the importance of movement constraints on task performance and suggest that movement speed might facilitate better bimanual coordination.

Fingertip Force Planning During Grasp Is Disrupted by Impaired Sensorimotor Integration in Children With Hemiplegic Cerebral Palsy

In the present study we examine the ability of children with hemiplegic cerebral palsy (CP) to use anticipatory control of fingertip forces during grasping, and whether anticipatory control is facilitated by lifts with the contralateral hand. Eight children with CP (age 4–13) were asked to perform several lifts of either a 250-g or 500-g object instrumented with force transducers with one hand, followed immediately by several lifts with the contralateral hand. This was repeated for each combination of weight and starting (involved or non-involved) hand. Similar to previous studies, the rate of load force development showed impaired anticipatory control during lifts with the involved hand, intact anticipatory control in the non-involved hand, and transfer of anticipatory control from the non-involved to the involved hand. Surprisingly, however, we also found a transfer from the involved hand to the non-involved hand. The results suggest that the impaired anticipatory control in the involved hand is not purely a sensory or motor problem, and instead is due to an inability to appropriately integrate sensory information with subsequent motor output of the same hand. These results provide important information about the mechanisms underlying impaired anticipatory control, and may have important clinical implications.