Yvonne Janssen-Potten

Botulinum toxin A and upper limb functional skills in hemiparetic cerebral palsy: a randomized trial in children receiving intensive therapy

The objective of this study was to determine whether the use of intramuscular botulinum toxin A (BTX‐A) increases upper limb function and skills in the context of a specific therapy programme in children with hemiparetic cerebral palsy. Twenty children (nine females, 11 males) aged 4 to 16 years who were thought likely to benefit from BTX‐A treatment were included. After matched pairs were made, on the basis of Zancolli grade and age, randomization took place. All patients were given structured rehabilitation (physiotherapy and occupational therapy three times a week for 6 months), and half of the patients received intramuscular BTX‐A. No placebo injections were given in the control group. Participants were assessed at baseline, at 2 and 6 weeks, and at 3, 6, and 9 months after injection. The Ash worth scale, active range of motion of arm joints, the Melbourne assessment of upper limb function, the Pediatric Evaluation of Disability Inventory, and the nine‐hole peg test were used for outcome measurement. Observers were blinded for treatment allocation only for scoring the Melbourne test. The children in the treatment group showed a clinically relevant increase in active dorsal flexion, and tone reduction of the wrist. For the functional outcome measures, no statistically significant differences between the groups could be demonstrated. Intramuscular BTX‐A added to an intensive therapy programme reduces impairment for at least 9 months; the effect on activity level is still uncertain.

Valid and reliable instruments for arm-hand assessment at ICF activity level in persons with hemiplegia: a systematic review

BackgroundLoss of arm-hand performance due to a hemiparesis as a result of stroke or cerebral palsy (CP), leads to large problems in daily life of these patients. Assessment of arm-hand performance is important in both clinical practice and research. To gain more insight in e.g. effectiveness of common therapies for different patient populations with similar clinical characteristics, consensus regarding the choice and use of outcome measures is paramount. To guide this choice, an overview of available instruments is necessary. The aim of this systematic review is to identify, evaluate and categorize instruments, reported to be valid and reliable, assessing arm-hand performance at the ICF activity level in patients with stroke or cerebral palsy.MethodsA systematic literature search was performed to identify articles containing instruments assessing arm-hand skilled performance in patients with stroke or cerebral palsy. Instruments were identified and divided into the categories capacity, perceived performance and actual performance. A second search was performed to obtain information on their content and psychometrics.ResultsRegarding capacity, perceived performance and actual performance, 18, 9 and 3 instruments were included respectively. Only 3 of all included instruments were used and tested in both patient populations. The content of the instruments differed widely regarding the ICF levels measured, assessment of the amount of use versus the quality of use, the inclusion of unimanual and/or bimanual tasks and the inclusion of basic and/or extended tasks.ConclusionsAlthough many instruments assess capacity and perceived performance, a dearth exists of instruments assessing actual performance. In addition, instruments appropriate for more than one patient population are sparse. For actual performance, new instruments have to be developed, with specific focus on the usability in different patient populations and the assessment of quality of use as well as amount of use. Also, consensus about the choice and use of instruments within and across populations is needed.

Effectiveness of functional progressive resistance exercise training on walking ability in children with cerebral palsy: A randomized controlled trial

The objective of the study was to evaluate the effectiveness of functional progressive resistance exercise (PRE) training on walking ability in children with cerebral palsy (CP). Fifty-one ambulant children with spastic CP (mean age 10 years 5 months, 29 boys) were randomized to an intervention (n=26) or control group (n=25, receiving usual care). The intervention consisted of 12 weeks functional PRE circuit training, for 3 times a week. Main outcome measures were walking ability and participation. Secondary outcomes were muscle strength and anaerobic muscle power. Possible adverse outcomes were spasticity and passive range of motion (ROM). Muscle strength increased significantly in the training group compared to the control group, but walking ability, participation and anaerobic muscle power did not change. Spasticity and ROM remained unchanged, except for a significant decrease in rectus femoris length in the intervention group. It is concluded that twelve weeks of functional PRE-training does not improve walking ability, despite improved muscle strength.

Outcome of motor training programmes on arm and hand functioning in patients with cervical spinal cord injury according to different levels of the ICF: a systematic review.

OBJECTIVE To investigate the outcome of motor training programmes on arm and hand functioning in patients with cervical spinal cord injury according to different levels of the International Classification of Functioning, Disability and Health (ICF). DESIGN Systematic review. METHODS A search of the following databases: Medline, Cochrane, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, Physiotherapy Evidence Database (PEDro) and Database of Abstracts of Reviews of Effects (DARE) from 1976 to August 2008 was performed using the following MeSH terms: Spinal Cord Injuries, Quadriplegia, Rehabilitation, Physical Education and Training, Exercise, Patient-Centered Care, Upper Extremity, Activities of Daily Living, Motor Skills, Motor Activity, Intervention Studies, Clinical Trial. The methodological quality of the selected articles was scored with the Van Tulder Checklist. Descriptive analyses were performed using the PICO principle (Patient characteristics, Intervention, Comparison, Outcome & results) along the ICF function and activity level. RESULTS Twelve studies were included in the analyses. Overall, the methodological quality of the studies was acceptable, with a mean Van Tulder score of 9.58. Interventions included motor training programmes at the level of function, activity or a combined programme. Most studies reported improvements in arm and hand functioning at the level that was trained for. CONCLUSION Motor training programmes may improve arm and hand functioning at function and/or activity level in cervical spinal cord injured patients. However, no general conclusion based on a meta-analysis can be drawn due to the wide variety of approaches.

Measuring change in arm hand skilled performance in persons with a cervical spinal cord injury: responsiveness of the Van Lieshout Test

Objectives:To asses whether the Van Lieshout Test (VLT) is responsive to measure changes in arm hand skilled performance (AHSP) over time during active rehabilitation in persons with cervical spinal cord injury (C-SCI) and in different subgroups of persons with C-SCI according to lesion completeness and to lesion level.Study design:Longitudinal cohort study.Setting:Spinal Cord Injury Units in eight rehabilitation centres across the Netherlands.Methods:In the present study, data from a national SCI cohort study are used. Data from the VLT, the Grasp Release Test (GRT), the Functional Independence Measure (FIM) and the Quadriplegia Index of Function (QIF) were recorded at three moments during active rehabilitation: at the start of active rehabilitation (t1), 3 months after t1 (t2) and at discharge (t3). Data have been analysed using three responsiveness measures, that is, the standardized response mean, the effect size and comparison of test scores measured at different times.Results:The VLT is responsive for the intervals t1–3, t1–2 and t2–3. The VLT can be used to measure changes in AHSP in persons with a C-SCI with an American Spinal Injury Association Impairment Scale (AIS) A or B score or an AIS C or D score, as well as in persons with a C3–C6 lesion or a C7–T1 lesion. The responsiveness of the VLT is significantly correlated to the GRT, but not to the FIM and the QIF.Conclusion:The VLT is responsive in measuring changes in AHSP during rehabilitation in persons with C-SCI.

Evaluation of a task-oriented client-centered upper extremity skilled performance training module in persons with tetraplegia

Study design:Clinical intervention study.Objective:Arm hand skilled performance (AHSP) has a major role in the rehabilitation of persons with cervical spinal cord injury (C-SCI). A task-oriented client-centered upper extremity skilled performance-training (ToCUEST) module was developed. The present study aims to evaluate effects of ToCUEST on specific and general AHSP in C-SCI, during and after rehabilitation.Setting:Adelante Rehabilitation Centre (The Netherlands).Methods:C-SCI persons, either during or after rehabilitation, completed the ToCUEST training; a control group of patients during rehabilitation received standard rehabilitation. The training module was focused on patients individual needs, combining principles of motor learning and training physiology. Three self-selected goals were trained 3 days per week, in three sessions of 30 min per day for 8 weeks. Measures were taken at 3 months after the start of the active rehabilitation (T0), before training (T1), after training (T2), at follow-up (3 months post-training; T3) and at discharge.Results:For both ToCUEST groups during (n=11) and after (n=12) rehabilitation, an improvement (P<0.001) on specific AHSP (using the Goal Attainment Scale and the Canadian Occupational Performance Measure (satisfaction and performance)) was found between T1–T2 and T1–T3. Also an improvement (P<0.02) in general AHSP (using the Van Lieshout Test, the QIF and the motor FIM) was found in the total ToCUEST group between T1–T2 and T1–T3. No significant difference in improvement of general AHSP was found between the ToCUEST rehab and control group.Conclusion:The ToCUEST module leads to improvement in AHSP, not only persons with C-SCI during rehabilitation, but also after finishing rehabilitation. These effects remain at follow-up.

Rehabilitation outcome of upper extremity skilled performance in persons with cervical spinal cord injuries

OBJECTIVE To investigate changes in arm hand skilled performance during and after active rehabilitation in (sub)groups of subjects with cervical spinal cord injuries. DESIGN Longitudinal multi-centre cohort study. PATIENTS Persons with cervical spinal cord injuries during (n?=?57) and after (n?=?35) rehabilitation. METHODS Patients from 8 Dutch rehabilitation centres received therapy as usual. At 3 time-points during active rehabilitation and one year after discharge arm hand skilled performance was measured using the Van Lieshout hand function test, the Grasp Release Test (for basic activities) and the Functional Independence Measure and the Quadriplegia Index of Function (for complex activities). RESULTS Arm hand skilled performance continues to improve over the entire rehabilitation period, mostly in the first stage of active rehabilitation, and especially in persons with a motor incomplete lesion. Persons with a motor incomplete lesion achieve higher arm hand skilled performance outcome than those with a motor complete lesion. After rehabilitation arm hand skilled performance does not decline. CONCLUSION Monitoring the outcome of arm hand skilled performance at the level of basic and complex activities during the whole rehabilitation phase may guide therapists in further optimizing therapy.

ToCUEST: a task-oriented client-centered training module to improve upper extremity skilled performance in cervical spinal cord-injured persons

Objectives:Given (a) the importance of upper extremity skill performance in persons with cervical spinal cord injury (C-SCI), (b) the limited number of studies on arm hand functioning in C-SCI and (c) the discrepancy between the importance of client centeredness and the lack of a theoretical framework and practical guidelines on how to apply client centeredness into practice, the aim of the present study is to (1) develop a training concept in which rehabilitation of the upper extremity focuses on patients needs and wishes and (2) to put this concept into practice for tetraplegic persons.Methods:The training concept contains two main components. The client-centered component includes both extracting individual goals and defining and objectifying these goals. The task-oriented component incorporates a task analysis and the composition of an individual training program.Results:A task-oriented client-centered training aimed at improving upper extremity skilled performance in tetraplegic persons is described step by step. The Canadian Occupational Performance Measure is used to identify patients specific needs. The Goal Attainment Scale is applied to define and objectify individual goals. A task analysis is essential to map limiting and facilitating factors of the person, the task and the environment and to identify which aspects should be trained. An individual task-oriented training program is composed, based on principles of motor learning and training physiology and the use of assistive devices. Each step is explained and illustrated using a case example.

Recognizing Complex Upper Extremity Activities Using Body Worn Sensors

To evaluate arm-hand therapies for neurological patients it is important to be able to assess actual arm-hand performance objectively. Because instruments that measure the actual quality and quantity of specific activities in daily life are lacking, a new measure needs to be developed. The aims of this study are to a) elucidate the techniques used to identify upper extremity activities, b) provide a proof-of-principle of this method using a set of activities tested in a healthy adult and in a stroke patient, and c) provide an example of the method’s applicability in daily life based on readings taken from a healthy adult. Multiple devices, each of which contains a tri-axial accelerometer, a tri-axial gyroscope and a tri-axial magnetometer were attached to the dominant hand, wrist, upper arm and chest of 30 healthy participants and one stroke patient, who all performed the tasks ‘drinking’, ‘eating’ and ‘brushing hair’ in a standardized environment. To establish proof-of-principle, a prolonged daily life recording of 1 participant was used to identify the task ‘drinking’. The activities were identified using multi-array signal feature extraction and pattern recognition algorithms and 2D-convolution. The activities ‘drinking’, ‘eating’ and ‘brushing hair’ were unambiguously recognized in a sequence of recordings of multiple standardized daily activities in a healthy participant and in a stroke patient. It was also possible to identify a specific activity in a daily life recording. The long term aim is to use this method to a) identify arm-hand activities that someone performs during daily life, b) determine the quantity of activity execution, i.e. amount of use, and c) determine the quality of arm-hand skill performance.

Accelerometry Measuring the Outcome of Robot-Supported Upper Limb Training in Chronic Stroke: A Randomized Controlled Trial

Purpose This study aims to assess the extent to which accelerometers can be used to determine the effect of robot-supported task-oriented arm-hand training, relative to task-oriented arm-hand training alone, on the actual amount of arm-hand use of chronic stroke patients in their home situation. Methods This single-blind randomized controlled trial included 16 chronic stroke patients, randomly allocated using blocked randomization (n = 2) to receive task-oriented robot-supported arm-hand training or task-oriented (unsupported) arm-hand training. Training lasted 8 weeks, 4 times/week, 2×30 min/day using the (T-)TOAT ((Technology-supported)-Task-Oriented-Arm-Training) method. The actual amount of arm-hand use, was assessed at baseline, after 8 weeks training and 6 months after training cessation. Duration of use and intensity of use of the affected arm-hand during unimanual and bimanual activities were calculated. Results Duration and intensity of use of the affected arm-hand did not change significantly during and after training, with or without robot-support (i.e. duration of use of unimanual use of the affected arm-hand: median difference of −0.17% in the robot-group and −0.08% in the control group between baseline and after training cessation; intensity of the affected arm-hand: median difference of 3.95% in the robot-group and 3.32% in the control group between baseline and after training cessation). No significant between-group differences were found. Conclusions Accelerometer data did not show significant changes in actual amount of arm-hand use after task-oriented training, with or without robot-support. Next to the amount of use, discrimination between activities performed and information about quality of use of the affected arm-hand are essential to determine actual arm-hand performance. Trial Registration Controlled-trials.com ISRCTN82787126