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 Ashworth 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.     

A magic-themed upper limb intervention for children with unilateral cerebral palsy: The perspectives of parents

ABSTRACT

Aim: To explore parent’s perspective of their child’s participation in a magic-themed intervention called Amazing Magic Club (AMC), and to further our understanding of motivated engagement and the impact of themed group-based interventions for children with unilateral cerebral palsy (CP).

Methods: Twenty-nine parents of children with unilateral CP completed semi-structured interviews. The child participants (n = 28) attended one of three AMCs; average age of the children was 10y 6mo (SD 2y 2mo). The parent interviews were analysed using thematic analysis.

Results: The three themes are: “It’s okay to be me”, the magic effect and “I can do it”. Parents observed their children to belong and learn about their abilities. The importance of the magicians and the performance is described. Parents observed their children to have increased self-belief and a new willingness to attempt difficult tasks.

Discussion: AMC appears to capture intrinsic motivation for children with unilateral CP to complete challenging tasks.     

The PEDALS stationary cycling intervention and health-related quality of life in children with cerebral palsy: a randomized controlled trial

Aim The aim of this study was to assess health‐related quality of life (HRQOL) following a stationary cycling intervention in children with cerebral palsy (CP). Method This was a phase I multisite randomized controlled trial with single blinding. HRQOL was evaluated using the Pediatric Quality of Life Inventory SF15 (PedsQL; children) and Pediatric Outcomes Data Collection Instrument (PODCI; parent proxy) before and after a 3‐month stationary cycling intervention. Sixty‐two children (29 male, 33 female; mean age 11y; range 7–18y) with spastic diplegic CP, classified as levels I to III on the Gross Motor Function Classification System, were enrolled. Paired and independent t‐tests were used to evaluate within‐ and between‐group differences respectively. Results Between‐group differences, favoring the cycling group, were found for PedsQL emotional functioning (p=0.046) and Parental PODCI treatment expectations scores (p=0.006). Between‐group differences were not found for other scales. Within‐group improvements were found in the cycling group: PedsQL total score (+5.8; p=0.006), psychosocial health summary (+6.9; p=0.008), and school functioning (+8.0; p=0.038). PODCI satisfaction with symptoms decreased significantly only in the control group (–12.0; p=0.046). Interpretation A beneficial influence of exercise on pediatric emotional well‐being and parental treatment expectations was found. The evidence was not strong for other aspects of HRQOL. Results support the positive relationship between physical fitness and emotional well‐being in the general population. A child’s perception is important when examining change in his or her emotional well‐being due to intervention.     

Management of upper limb dysfunction in children with cerebral palsy: a systematic review

Effective use of the upper limb can impact on educational outcomes, participation in activities of daily living and vocational options for many children with cerebral palsy (CP). This article presents the results of a systematic review of the literature on the management of upper limb dysfunction in children with CP. The range of management options includes therapies such as physiotherapy, occupational therapy, neurodevelopmental therapy and conductive education; peripheral splinting and casting; focal or generalized pharmacotherapy; and surgery to improve upper limb function or correct deformity. A literature search identified 60 papers, of which four were randomized controlled trials and 44 were prospective studies with objective outcome measures. Principal studies undertaken for each type of treatment and the efficacy of the different types of treatment were critically evaluated. In addition, the current level of evidence for each study was evaluated according to Sackett's (1989) model and ICIDH-2 classification. A close examination of two relatively new treatments for upper limb spasticity, constraint induced movement therapy and botulinum toxin type A (BTX-A) was conducted with reference to more extensive data on the efficacy of BTX-A in the lower limb.     

Efficacy of constraint-induced therapy on functional performance and health-related quality of life for children with cerebral palsy: a randomized controlled trial

To better generalize training effects to the context of daily living, home-based constraint-induced therapy has been proposed. Therapeutic success of constraint-induced therapy is limited as to whether the improvements in functional performance can be transferred to quality of life. This randomized controlled trial aimed to investigate the efficacy of home-based constraint-induced therapy on functional performance and health-related quality of life. Twenty-two children with spastic unilateral cerebral palsy (6-8 years, 10 boys) were randomly assigned to receive constraint-induced therapy or traditional rehabilitation. Home-based constraint-induced therapy had immediate and maintaining effects on motor efficacy and functional performance and induced greater gains in health-related quality of life in the long run than in the short term. The home-based constraint-induced therapy protocol (relatively moderate intensity and shortened constraint time), which might balance the effectiveness and compliance of participants and caregivers, may be an effective alternative to conventional constraint-induced therapy.     

Efficacy of modified constraint induced movement therapy in improving upper limb function in children with hemiplegic cerebral palsy: A randomized controlled trial

Purpose: The objective of this randomized single blind (outcome assessor) controlled trial was to evaluate the efficacy of 4 weeks of modified constraint induced movement therapy (mCIMT) in improving upper limb function in 3–8 years old children with hemiplegic cerebral palsy. Methods: Thirty-one children were randomly assigned to receive the mCIMT (N = 16) with conventional therapy or conventional therapy alone (N = 15). Children were evaluated three times (at enrollment, follow up at 4 weeks and 12 weeks). The primary outcome measure was difference in “change in mean total QUEST scores” at 4 weeks of intervention between the intervention and the control arm. Results: After 4 weeks of intervention, mCIMT group showed significant change in the affected upper limb in QUEST scores (10.7 ± 5.2 vs 1.4 ± 1.7, p < 0.001) and time (s) to complete nine-hole-pegboard test compared with control group [60(0–130) vs 5(−12 to 30), p < 0.001]. The improvement observed in upper limb function after 4 weeks of intervention persisted 8 weeks after discontinuation of intervention in mCIMT group. Conclusion: The modified constraint induced movement therapy appears to be effective in improving upper limb function in 3–8 years old hemiplegic cerebral palsy children.     

A Kinect-based upper limb rehabilitation system to assist people with cerebral palsy

This study assessed the possibility of rehabilitating two adolescents with cerebral palsy (CP) using a Kinect-based system in a public school setting. The system provided 3 degrees of freedom for prescribing a rehabilitation program to achieve customized treatment. This study was carried out according to an ABAB reversal replication design in which A represented the baseline and B represented intervention phases. Data showed that the two participants significantly increased their motivation for upper limb rehabilitation, thus improving exercise performance during the intervention phases. Practical and developmental implications of the findings are discussed.     

Effect of upper limb deformities on gross motor and upper limb functions in children with spastic cerebral palsy

The aims of this study were to investigate the nature and extent of upper limb deformities via the use of various classifications, and to analyze the relationship between upper limb deformities and gross motor or upper limb functionality levels. Upper extremity data were collected from 234 children with spastic cerebral palsy (CP) who were admitted to the university hospital for intensive rehabilitation. Upper limb deformities were classified according to the Zancolli classification for finger and wrist extension ability, the Gshwind and Tonkin classification for supination ability, and the House classification for thumb-in-palm deformity. Digital deformity was also classified. Upper limb function was assessed using the Upper Extremity Rating Scale (UERS) and the Upper Limb Physician's Rating Scale (ULPRS). Gross motor function was assessed using the Gross Motor Functional Classification System (GMFCS). Among the 234 children observed, 70.5% had a limitation in forearm supination, and 62.8% had problems with wrist and finger extension in at least one limb. Thumb-in-palm deformity of at least one hand was found in 47.0% of patients. Swan neck deformity was the most common finger deformity. Upper limb functional measures, the ULPRS and the UERS, significantly correlated with the degree of upper limb deformity, as assessed by the Gschwind and Tonkin, Zancolli, and House classifications. Further, the degree of upper limb deformity was significantly related to the GMFCS level in children with bilateral CP, but not in children with unilateral CP. Limitation of forearm supination was the most common upper limb deformity in children with spastic CP. The degree of upper limb deformity significantly affected upper limb function in these children.     

假期集中康复治疗对社区大龄脑瘫患儿综合功能的影响

目的 探索适合社区中大龄脑瘫患儿有益的康复治疗新方式.方法 将上海市闸北区9个社区内的31例年龄＞7周岁的脑瘫患儿根据区域随机分为假期康复组和常规康复组.假期康复组在假期中开展集中康复训练,常规康复组仅给予平时康复治疗指导.两组分别在治疗前,治疗6个月后,治疗15个月后采用功能综合评定量表(FCA)进行综合功能的评定.结果 治疗15个月后,两组患儿的综合评分均有提高,但假期组与常规组在治疗前后的评分差值相比有统计学意义(P＜0.05).结论 假期集中康复训练治疗方式能有效改进大龄脑瘫患儿的综合功能.     

Modified constraint-induced therapy for children with hemiplegic cerebral palsy: a randomized trial

Aim Conventional constraint‐based therapies are intensive and demanding to implement, particularly for children. Modified forms of constraint‐based therapies that are family‐centred may be more acceptable and feasible for families of children with cerebral palsy (CP)‐but require rigorous evaluation using randomized trials. The aim of this study was to determine the effects of modified constraint‐induced therapy compared with intensive occupational therapy on activities of daily living and upper limb outcomes in children with hemiplegic CP. Method In this assessor‐blinded pragmatic randomized trial, 50 children (27 males, 23 females; age range 19mo–7y 10mo) with hemiplegic CP were randomized using a concealed allocation procedure to one of two 8‐week interventions: intensive occupational therapy (n=25), or modified constraint‐induced therapy (n=25). Manual Ability Classification System (MACS) levels of the participants were, level I n=2, II n=37, III n=8, and level IV n=1; Gross Motor Function Classification System (GMFCS) levels were, level I n=33, level II n=15, and level III n=1. Participants were recruited through three specialist CP centres in Australia and randomized between January 2008 and April 2010. Children randomized to modified constraint‐induced therapy wore a mitt on the unaffected hand for 2 hours each day, during which time the children participated in targeted therapy. The primary outcome was the Canadian Occupational Performance Measure (COPM – measured on a 10‐point scale) at completion of therapy. Other outcome measures were Goal Attainment Scaling, Assisting Hand Assessment, Pediatric Motor Activity Log, Modified Ashworth Scale, Modified Tardieu Scale, and a parent questionnaire. Assessments were carried out at 10 weeks and 6 months following randomization. Results All participants were included in the analysis. Between‐group differences for all outcomes were neither clinically important nor statistically significant. The mean difference in COPM was 0.3 (95% confidence interval [CI] −0.8 to 1.4; p=0.61) and mean difference in COPM satisfaction was 0.1 (95% CI −1.1 to 1.2; p=0.90). Minor adverse events were reported by five of the 25 participants in the modified constraint‐induced therapy group and by one of the 25 in the intensive occupational therapy group. All adverse events were related to participants’ lack of acceptance of therapy. Interpretation Modified constraint‐induced therapy is no more effective than intensive occupational therapy for improving completion of activities of daily living or upper limb function in children with hemiplegic CP.     

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 3 y 6 mo-15 y 6 mo) were randomized to either an intervention (n=10: seven males, three females; mean age 8 y 7 mo, SD 4 y) or a delayed treatment control group (n=10: seven males, three females; mean age 6 y 10 mo, SD 2 y 4 mo). 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.