Combined intensive therapies at home in spastic unilateral cerebral palsy with high bimanual functional performance. What do they offer? A comparative randomised clinical trial

Rocío Palomo-Carrión, Cristina Lirio-Romero, Asunción Ferri-Morales, Patricia Jovellar-Isiegas, María-Dolores Cortés-Vega, Helena Romay-Barrero, Rocío Palomo-Carrión, Cristina Lirio-Romero, Asunción Ferri-Morales, Patricia Jovellar-Isiegas, María-Dolores Cortés-Vega, Helena Romay-Barrero

Abstract

Background: Children with unilateral spastic cerebral palsy (USCP) receive different treatments, including the application of modified constraint induced movement therapy (mCIMT) or bimanual intensive therapy (BIT) to increase affected upper limb functionality. The aim of this study was to compare the effectiveness of two protocols with different proportions and orders of mCIMT/BIT within combined intensive home-therapy in children with USCP (6-8 years old) with high bimanual functional performance, applied by the family.

Methods: The protocols were performed on 20 children with an average age of 7.12 years [standard deviation (SD): 0.70], allocated to two different combined therapies. The protocols were designed by 100 h of dose for 10 weeks: 80 h of mCIMT followed by 20 h of BIT (mCIMT-B group) and 80 h of BIT followed by 20 h of mCIMT (BIT-mCI group). Bimanual functional performance was measured with Assisting Hand Assessment Scale (AHA) and the affected upper limb-use experience with Children's Hand-use Experience Questionnaire (CHEQ). Parent satisfaction and expectations with therapy were measured using a specific questionnaire. There were five assessment timepoints (week 0, week 4, week 8, week 10 and week 34).

Results: There were no statistically significant (p > 0.05) inter- and intra-group changes in the bimanual functional performance of both groups. The affected upper limb-use experience obtained significant changes in BIT-mCI group, with statistically significant differences in the pairwise comparisons between week 0-10 and week 4-10 (p = 0.028) for use of the affected hand and the use of the affected hand to grasp between week 4 and week 8 (p = 0.028). Grasp efficacy and discomfort acquired statistically significant differences only in the BIT-mCI group for pairwise comparisons week 0-week 10/week 4-week 10 (p = 0.035). Although task execution time compared with a typically developing child of the same age obtained statistically significant differences only in the group mCIMT-B for pairwise comparisons week 0-week 8 (p = 0.03), week 0-week 10 (p = 0.03), week 4-week 8 (p = 0.04) and week 4-week 10 (p = 0.03). Family satisfaction and expectations acquired an increase between week 0 and week 10 (p ⩽ 0.02).

Conclusion: Applying 80 h of BIT for 8 weeks in children with high bimanual functional performance USCP (6-8 years old), executed at home with family involvement would be sufficient to obtain improvements in affected upper limb-use experience, without the need to use combined protocols of 100 h. However, no statistically significant increase in bimanual functional performance would be obtained, with the basal situation of the child being a factor to consider for the execution of mCIMT and BIT.Registration number and name of trial registry: [ClinicalTrials.gov identifier: NCT03465046].

Keywords: family; home; intensive therapies; unilateral spastic cerebral palsy; upper extremity.

Conflict of interest statement

Conflict of interest statement: The authors declare that there is no conflict of interest.

© The Author(s), 2021.

Figures

Figure 1.
Figure 1.
Partial unaffected hand containment.
Figure 2.
Figure 2.
Both pictures show a child with right USCP. The first picture shows a mCIMT activity: the child must throw the small ball with the affected hand (right) while the unaffected hand is contained (left hand). The second picture observes the child performing a BIT activity: the child must assemble and disassemble Lego bricks using both hands, where the affected hand has the operating role, and the unaffected hand is assisting. BIT, bimanual intensive therapy; mCIMT, modified constraint induced movement therapy; USCP, unilateral spastic cerebral palsy.
Figure 3.
Figure 3.
Assessment timepoints performed in the study period for both intervention groups. BIT, bimanual intensive therapy; mCIMT, modified constraint induced movement therapy.
Figure 4.
Figure 4.
Flow chart (consort style). Randomisation, allocation, follow up and analysis of the sample for both intervention groups. BIT, bimanual intensive therapy; mCIMT, modified constraint induced movement therapy.

References

    1. Rosenbaum P, Paneth N, Leviton A, et al.. A report: the definition and classification of cerebral palsy April 2006. Dev Med Child Neurol Suppl 2007; 109: 8–14. Erratum in: Dev Med Child Neurol 2007; 49: 480.
    1. Dunbar M, Kirton A.Perinatal stroke: mechanisms, management, and outcomes of early cerebrovascular brain injury. Lancet Child Adolesc Health 2018; 2: 666–676.
    1. Young NL, Williams JI, Yoshida KK, et al.. The context of measuring disability: does it matter whether capability or performance is measured? J Clin Epidemiol 1996; 49: 1097–1101.
    1. Hoare BJ, Wallen MA, Thorley MN, et al.. Constraint-induced movement therapy in children with unilateral cerebral palsy. Cochrane Database Syst Rev 2019; 1–274.
    1. Deluca SC, Echols K, Law CR, et al.. Intensive pediatric constraint-induced therapy for children with cerebral palsy: randomized, controlled, crossover trial. J Child Neurol 2006; 21: 931–938.
    1. Novak I, Honan I.Effectiveness of paediatric occupational therapy for children with disabilities: a systematic review. Aust Occup Ther J 2019; 66: 258–273.
    1. Snider L, Majnemer A.Virtual reality: we are virtually there. Phys Occup Ther Pediatr 2010; 30: 1–3.
    1. Löwing K, Bexelius A, Carlberg EB.Goal-directed functional therapy: a longitudinal study on gross motor function in children with cerebral palsy. Disabil Rehabil 2010; 32: 908–916.
    1. Kirkpatrick E, Pearse J, James P, et al.. EGect of parentdelivered action observation therapy on upper limb function in unilateral cerebral palsy: a randomized controlled trial. Dev Med Child Neurol 2016; 58: 1049–1056.
    1. Gilliaux M, Renders A, Dispa D, et al.. Upper limb robot-assisted therapy in cerebral palsy: a single-blind randomized controlled trial. Neurorehabil Neural Repair 2015; 29: 183–192.
    1. Xu K, He L, Mai J, et al.. Muscle recruitment and coordination following constraint-induced movement therapy with electrical stimulation on children with hemiplegic cerebral palsy: a randomized controlled trial. PLoS One 2015; 10: e0138608.
    1. Bruchez R, Jequier Gygax M, Roches S, et al.. Mirror therapy in children with hemiparesis: a randomized observer-blinded trial. Dev Med Child Neurol 2016; 58: 970–8.
    1. Novak I, Cusick A, Lannin N.Occupational therapy home programs for cerebral palsy: double-blind, randomized, controlled trial. Pediatrics 2009; 124: e606–e614.
    1. Facchin P, Rosa-Rizzotto M, Visonà Dalla Pozza L, et al.. Multisite trial comparing the eGicacy of constraint-induced movement therapy with that of bimanual intensive training in children with hemiplegic cerebral palsy: postintervention results. Am J Phys Med Rehabil 2011; 90: 539–553.
    1. Rosa-Rizzotto M, Visonà Dalla Pozza L, Turconi AC, et al.. Constraint-induced movement therapy vs bimanual intensive training in hemiplegic cerebral palsy: preliminary results. Eur J Paediatr Neurol 2010; 14: 547–548.
    1. Gordon AM, Hung YC, Brandao M, et al.. Bimanual training and constraint-induced movement therapy in children with hemiplegic cerebral palsy: a randomized trial. Neurorehabil Neural Repair 2011; 25: 692–702.
    1. Hung YC, Casertano L, Hillman A, et al.. The effect of intensive bimanual training on coordination of the hands in children with congenital hemiplegia. Res Dev Disabil 2011; 32: 2724–2731.
    1. de Brito Brandão M, Gordon AM, Mancini MC. Functional impact of constraint therapy and bimanual training in children with cerebral palsy: a randomized controlled trial. Am J Occup Ther 2012; 66: 672–681.
    1. de Brito Brandão M, Gordon AM, Mancini MC. The eGects of constraint-induced movement therapy (CIMT) and hand-arm bimanual intensive training (HABIT) on the daily functioning of children with cerebral palsy. Dev Med Child Neurol 2011; 53(Suppl. 5): 30.
    1. Geijen M, Ketelaar M, Sakzewski L, et al.. Defining functional therapy in research involving children with cerebral palsy: a systematic review. Phys Occup Ther Pediatr 2020; 40: 231–246.
    1. Beckers L, van der Burg J, Janssen-Potten Y, et al.. Process evaluation of two home-based bimanual training programs in children with unilateral cerebral palsy (the COAD-study): protocol for a mixed methods study. BMC Pediatr 2018; 18: 141.
    1. Rameckers E, Land N, Geerts M, et al.. Upper limb treatment principles in intensive functional therapy in school-aged children and adolescents with cerebral palsy: ‘guidance for therapist. Curr Neurobiol 2019; 10: 110–122.
    1. Fazzi E, Galli J.New clinical needs and strategies for care in children with neurodisability during COVID-19. Dev Med Child Neurol 2020; 62: 879–880.
    1. Beckers LWME, Smeets RJEM, van der Burg JJW. Therapy-related stress in parents of children with a physical disability: a specific concept within the construct of parental stress. Disabil Rehabil 2021; 43: 1185–1192.
    1. Ferre CL, Brandão M, Surana B, et al.. Caregiver-directed home-based intensive bimanual training in young children with unilateral spastic cerebral palsy: a randomized trial. Dev Med Child Neurol 2017; 59: 497–504.
    1. Hadders-Algra M, Boxum AG, Hielkema T, et al.. Effect of early intervention in infants at very high risk of cerebral palsy: a systematic review. Dev Med Child Neurol 2017; 59: 246–258.
    1. Novak I, McIntyre S, Morgan C, et al.. A systematic review of interventions for children with cerebral palsy: state of the evidence. Dev Med Child Neurol 2013; 55: 885–910.
    1. Chen HC, Kang LJ, Chen CL, et al.. Younger children with cerebral palsy respond better than older ones to therapist-based constraint-induced therapy at home on functional outcomes and motor control. Phys Occup Ther Pediatr 2016; 36: 171–185.
    1. Rostami HR, Malamiri RA.Effect of treatment environment on modified constraint-induced movement therapy results in children with spastic hemiplegic cerebral palsy: a randomized controlled trial. Disabil Rehabil 2012; 34: 40–44.
    1. Palomo-Carrión R, Romay-Barrero H, Romero-Galisteo RP, et al.. Modified constraint-induced movement therapy at home-is it possible? Families and children’s experience. Children 2020; 7: 248.
    1. Schnackers M, Beckers L, Janssen-Potten Y, et al..; COAD Focus Group. Home-based bimanual training based on motor learning principles in children with unilateral cerebral palsy and their parents (the COAD-study): rationale and protocols. BMC Pediatr 2018; 18: 139.
    1. Hung YC, Ferre CL, Gordon AM.Improvements in kinematic performance after home-based bimanual intensive training for children with unilateral cerebral palsy. Phys Occup Ther Pediatr 2018; 38: 370–381.
    1. Tervahauta MH, Girolami GL, Øberg GK.Efficacy of constraint-induced movement therapy compared with bimanual intensive training in children with unilateral cerebral palsy: a systematic review. Clin Rehabil 2017; 31: 1445–1456.
    1. Sakzewski L, Ziviani J, Boyd RN.Efficacy of upper limb therapies for unilateral cerebral palsy: a meta-analysis. Pediatrics 2014; 133: e175–e204.
    1. Hung YC, Charles J, Gordon AM.Bimanual coordination during a goal-directed task in children with hemiplegic cerebral palsy. Dev Med Child Neurol 2004; 46: 746–753.
    1. Taub E, Miller NE, Novack TA, et al.. Technique to improve chronic motor deficit after stroke. Arch Phys Med Rehabil 1993; 74: 347–354.
    1. Taub E, Uswatte G, Pidikiti R.Constraint-induced movement therapy: a new family of techniques with broad application to physical rehabilitation – a clinical review. J Rehabil Res Dev 1999; 36: 237–251.
    1. Taub E, Ramey SL, DeLuca S, et al.. Efficacy of constraint-induced movement therapy for children with cerebral palsy with asymmetric motor impairment. Pediatrics 2004; 113: 305–312.
    1. Jamali AR, Amini M.The effects of constraint-induced movement therapy on functions of cerebral palsy children. Iran J Child Neurol 2018; 12: 16–27.
    1. Page SJ, Levine P, Leonard AC.Modified constraint-induced therapy in acute stroke: a randomized controlled pilot study. Neurorehabil Neural Repair 2005; 19: 27–32.
    1. Eliasson AC, Krumlinde-Sundholm L, Gordon AM, et al..; European network for Health Technology Assessment (EUnetHTA). Guidelines for future research in constraint-induced movement therapy for children with unilateral cerebral palsy: an expert consensus. Dev Med Child Neurol 2014; 56: 125–137.
    1. Sakzewski L, Ziviani J, Abbott DF, et al.. Randomized trial of constraint-induced movement therapy and bimanual training on activity outcomes for children with congenital hemiplegia. Dev Med Child Neurol 2011; 53: 313–320.
    1. Wallen M, Ziviani J, Naylor O, et al.. Modified constraint-induced therapy for children with hemiplegic cerebral palsy: a randomized trial. Dev Med & Child Neuro 2011; 53: 1091–1099.
    1. Aarts PB, Jongerius PH, Geerdink YA, et al.. Effectiveness of modified constraint-induced movement therapy in children with unilateral spastic cerebral palsy: a randomized controlled trial. Neurorehabil Neural Repair 2010; 24: 509–518.
    1. Deppe W, Thuemmler K, Fleischer J, et al.. Modified constraint-induced movement therapy versus intensive bimanual training for children with hemiplegia - a randomized controlled trial. Clin Rehabil 2013; 27: 909–920.
    1. Geerdink Y, Aarts P, Geurts AC.Motor learning curve and long-term effectiveness of modified constraint-induced movement therapy in children with unilateral cerebral palsy: a randomized controlled trial. Res Dev Disabil 2013; 34: 923–931.
    1. Boyd RN, Ziviani J, Sakzewski L, et al.. 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. BMC Neurol 2013; 13: 68.
    1. Gordon AM, Schneider JA, Chinnan A, et al.. Efficacy of a hand-arm bimanual intensive therapy (HABIT) in children with hemiplegic cerebral palsy: a randomized control trial. Dev Med Child Neurol 2007; 49: 830–838.
    1. Gelkop N, Burshtein DG, Lahav A, et al.. Efficacy of constraint-induced movement therapy and bimanual training in children with hemiplegic cerebral palsy in an educational setting. Phys Occup Ther Pediatr 2015; 35: 24–39.
    1. Nordstrand L, Holmefur M, Kits A, et al.. Improvements in bimanual hand function after baby-CIMT in two-year old children with unilateral cerebral palsy: a retrospective study. Res Dev Disabil 2015; 41–42: 86–93.
    1. Eliasson AC, Krumlinde-Sundholm L, Rösblad B, et al.. The manual ability classification system (MACS) for children with cerebral palsy: scale development and evidence of validity and reliability. Dev Med Child Neurol 2006; 48: 549–554.
    1. Palisano R, Rosenbaum P, Walter S, et al.. Development and reliability of a system to classify gross motor function in children with cerebral palsy. Dev Med Child Neurol 1997; 39: 214–223.
    1. Lisa V., Wagner MHS, OTR/L, Jon R., Davids MD.Assessment tools and classification systems used for the upper extremity in children with cerebral palsy. Clin Orthop Relat Res 2012; 470: 1257–1271.
    1. Holmefur MM, Krumlinde-Sundholm L. Psychometric properties of a revised version of the Assisting Hand Assessment (Kids-AHA 5.0). Dev Med Child Neurol 2016; 58: 618–624.
    1. Krumlinde-Sundholm L, Eliasson AC.Development of the Assisting Hand Assessment: a Rasch-built measure intended for children with unilateral upper limb impairments. Scand J Occup Ther 2003; 10: 16–26.
    1. Holmefur M, Aarts P, Hoare B, et al.. Test-retest and alternate forms reliability of the assisting hand assessment. J Rehabil Med 2009; 41: 886–891.
    1. Krumlinde-Sundholm L, Holmefur M, Kottorp A, et al.. The assisting hand assessment: current evidence of validity, reliability, and responsiveness to change. Dev Med Child Neurol 2007; 49: 259–264.
    1. Sköld A, Hermansson LN, Krumlinde-Sundholm L, et al.. Development and evidence of validity for the Children’s Hand-use Experience Questionnaire (CHEQ). Dev Med Child Neurol 2011; 53: 436–442.
    1. Ryll UC, Eliasson AC, Bastiaenen CH, et al.. To explore the validity of change scores of the children’s hand-use experience questionnaire (CHEQ) in children with unilateral cerebral palsy. Phys Occup Ther Pediatr 2019; 39: 168–180.
    1. Weller C, McNeil J.CONSORT 2010 statement: updated guidelines can improve wound care. J Wound Care 2010, 19: 347–353.
    1. Schulz KF, Altman DG, Moher Dfor the CONSORT Group. CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials. Ann Int Med 2010; 152: 726–732.
    1. Eliasson AC, Krumlinde-Sundholm L, Shaw K, et al.. Effects of constraint induced movement therapy in young children with hemiplegic cerebral palsy: an adapted model. Dev Med Child Neurol 2005; 47: 266–275.
    1. Pinquart M.Parenting stress in caregivers of children with chronic physical condition-a meta-analysis. Stress Health 2018; 34: 197–207.
    1. Adams M, Caffrey L, McKevitt C.Barriers and opportunities for enhancing patient recruitment and retention in clinical research: findings from an interview study in an NHS academic health science centre. Health Res 2015, 8: 17.
    1. Beckers LWME, Rameckers EAA, Smeets RJEM, et al.. Barriers to recruitment of children with cerebral palsy in a trial of home-based training. Contemp Clin Trials Commun 2019; 15: 100371.
    1. Novak I.Parent experience of implementing effective home programs. Phys Occup Ther Pediatr 2011; 31: 198–213.
    1. Sgandurra G, Beani E, Inguaggiato E, et al.. Effects on parental stress of early home-based caretoy intervention in low-risk preterm infants. Neural Plast 2019; 2019: 7517351.
    1. Beckers LWME, Geijen MME, Kleijnen J, et al.. Feasibility and effectiveness of home-based therapy programmes for children with cerebral palsy: a systematic review. BMJ Open 2020; 10: e035454.
    1. Lord C, Rapley T, Marcroft C, et al.. Determinants of parent-delivered therapy interventions in children with cerebral palsy: a qualitative synthesis and checklist. Child Care Health Dev 2018; 44: 659–669.
    1. Cohen-Holzer M, Sorek G, Kerem J, et al.. The impact of combined constraint-induced and bimanual arm training program on the perceived hand-use experience of children with unilateral cerebral palsy. Dev Neurorehabil 2017; 20: 355–360.
    1. Palomo-Carrión R, Bravo-Esteban E, Ando-La Fuente S, et al.. Efficacy of the use of unaffected hand containment in unimanual intensive therapy to increase visuomotor coordination in children with hemiplegia: a randomized controlled pilot study. Ther Adv Chronic Dis 2021; 12: 20406223211001280.
    1. Surkar SM, Hoffman RM, Davies B, et al.. Impaired anticipatory vision and visuomotor coordination affects action planning and execution in children with hemiplegic cerebral palsy. Res Dev Disabil 2018; 80: 64–73.
    1. Sutcliffe TL, Logan WJ, Fehlings DL.Pediatric constraint-induced movement therapy is associated with increased contralateral cortical activity on functional magnetic resonance imaging. J Child Neurol 2009; 24: 1230–1235.
    1. Ferre CL, Gordon AM.Coaction of individual and environmental factors: a review of intensive therapy paradigms for children with unilateral spastic cerebral palsy. Dev Med Child Neurol 2017; 59: 1139–1145.
    1. Novak I, Cusick A.Home programmes in paediatric occupational therapy for children with cerebral palsy: where to start? Aust Occup Ther J 2006; 53: 251–264.
    1. McCall JV, Ludovice MC, Blaylock JA, et al.. A Platform for rehabilitation of finger individuation in children with hemiplegic cerebral palsy. IEEE Int Conf Rehabil Robot 2019; 2019: 343–348.
    1. El-Shamy SM.Efficacy of Armeo® robotic therapy versus conventional therapy on upper limb function in children with hemiplegic cerebral palsy. Am J Phys Med Rehabil 2018; 97: 164–169.
    1. Gygax MJ, Schneider P, Newman CJ.Mirror therapy in children with hemiplegia: a pilot study. Dev Med Child Neurol 2011; 53: 473–476.
    1. Smorenburg AR, Ledebt A, Deconinck FJ, et al.. Practicing a matching movement with a mirror in individuals with spastic hemiplegia. Res Dev Disabil 2013; 34: 2507–2513.

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