Less Affected Hand in Unilateral Cerebral Palsy

Less Affected Hand in Unilateral Cerebral Palsy

When working with children who have hemiplegia, do you address the less affected hand in unilateral cerebral palsy?  Or do you assume that the less affected hand is within normal limits for typical child development?  Sometimes, the difference between the hands, gives the impression that the less affected hand is functional and age appropriate but in reality, there may be decreased function in both hands.

Neurorehabilitation and Neural Repair published research to compare hand function in 47 children, by timed motor performance on the Jebsen-Taylor Test of Hand Function (JTTHF) and grip strength of children with unilateral cerebral palsy to children with typical development.  Each participant was evaluated for baseline hand skills and single-pulse transcranial magnetic stimulation testing to assess corticospinal tract and motor threshold.

The results indicated the following:

• the mean difference of the less-affected hand of children with unilateral cerebral palsy to the dominant hand of children of typical development the JTTHF was 21.4 seconds.
• the mean difference in grip strength was −30.8 N
• resting motor thresholds between groups were not significant.
• age was significantly associated with resting motor threshold.

Regarding the single-pulse transcranial magnetic stimulation testing:

• children with unilateral cerebral palsy ipsilateral pattern of motor representation demonstrated greater mean differences between hands than children with contralateral pattern of motor representation.

The typical pattern is a contralateral motor pattern where the motor-evoked potential response is in the more-affected hand following stimulation of the contralateral, lesioned hemisphere.  An ipsilateral motor pattern describes an absent motor evoked potential response in the more-affected hand following stimulation of the lesioned hemisphere and a present motor-evoked response in the more-affected hand following stimulation of the nonlesioned hemisphere.

Overall, deficits in speed and strength of the less-affected hand in children with unilateral cerebral palsy were observed when compared to the dominant hand of typically developing peers.

The researchers concluded that the less-affected hand in children with unilateral cerebral palsy underperformed the dominant hand of children with typical development. The less affected hand should be assessed and intervene if necessary during rehabilitation.  Future research should focus on bilateral hand function.

Reference: Rich, T. L., Menk, J. S., Rudser, K. D., Feyma, T., & Gillick, B. T. (2017). Less-Affected Hand Function in Children With Hemiparetic Unilateral Cerebral Palsy: A Comparison Study With Typically Developing Peers. Neurorehabilitation and Neural Repair, 1545968317739997.

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Gait Analysis and Visual Input

The Journal of Physical Therapy Science published research on the effects of the modulation of optic flow speed on gait parameters in children with hemiplegic cerebral palsy.  Optic flow is the pattern of motion perceived at the retina, which specifies the direction of locomotion and provides vital feedback concerning an individual's regulation of walking velocity.

Gait analysis was completed on 10 children with hemiplegic cerebral palsy under 3 different conditions of optic flow speed: slow, normal, and fast optic flow speed. The children walked across the walkway of a GAITRite system, while watching a virtual reality screen, and walking velocity, cadence, stride length, step length, single support time, and double support time were recorded.

The results indicated the following:

• fast optic flow speed (2 times the normal speed) significantly increased walking velocity, cadence, normalized step length, base of support, and single support cycle of both lower limbs.


• the slow optic flow speed (0.25 times the normal speed) yielded a significantly decreased walking velocity, cadence, normalized step length, base of support, and single support cycle for both lower limbs.

The researchers concluded that: gait training involving modulation of the optic flow speed is feasible and suitable for resolving abnormal gait patterns in children with hemiplegic cerebral palsy.

I am wondering how this could be applied in regular therapy sessions?  Any ideas of off the shelf virtual reality to vary visual input speed?  All I can come up with is filming some video yourself with varying walking speeds?  The WiiFit has a Basic Run but the speed of the objects going by you is based on your own speed.  Any suggestions?

Reference:  Hyungwon Lim, PhD, PT. Effect of the modulation of optic flow speed on gait parameters in children with hemiplegic cerebral palsy. J Phys Ther Sci. 2014 Jan;26(1):145-8. doi: 10.1589/jpts.26.145. Epub 2014 Feb 6.

Full text article at https://www.jstage.jst.go.jp/article/jpts/26/1/26_jpts-2013-312/_pdf.

 

Goal Directed OT Programs Effective for Unilateral Cerebral Palsy

A systematic review of the efficacy of nonsurgical upper limb therapies for children with unilateral cerebral palsy was published in Pediatrics.  There were 42 randomized control or comparison trials that met the inclusion criteria.  The results indicated the following:

• moderate to strong effects were in favor of intramuscular injections of botulinum toxin A and occupational therapy (OT) to improve UL and individualized outcomes compared with OT alone were identified.
• constraint-induced movement therapy achieved modest to strong treatment effects on improving movement quality and efficiency of the impaired UL compared with usual care.
• weak treatment effects were reported for most outcomes when constraint therapy was compared with an equal dose of bimanual OT; both yielded similar improved outcomes.
•  action observation training and mirror therapy should be viewed as experimental.

The researchers concluded that there is:

• modest evidence for intensive activity-based, goal-directed interventions (eg, constraint-induced movement therapy, bimanual training) being more effective than standard care in improving UL and individualized outcomes.  
• little evidence to support block therapy alone as the dose of intervention is unlikely to be sufficient to lead to sustained changes in UL outcomes. 
• strong evidence that goal-directed OT home programs are effective and could supplement hands-on direct therapy to achieve increased dose of intervention.

Reference:  Leanne Sakzewski, Jenny Ziviani, and Roslyn N. Boyd. Efficacy of Upper Limb Therapies for Unilateral Cerebral Palsy: A Meta-analysis.  Pediatrics 2014; 133:1 e175-e204; published ahead of print December 23, 2013, doi:10.1542/peds.2013-0675

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Modified Constraint-Induced Movement Therapy Versus Intensive Bimanual Training

Clinical Rehabilitation published research on 47 children with unilateral cerebral palsy or other non-progressive hemiplegia (aged 3.3–11.4 years) who were randomly assigned to either a modified constraint-induced movement program (kid-CIMT - 60 hours of unilateral constraint-induced and 20 hours of bimanual training over four weeks) or intensive bimanual training (80 hours of bimanual training over four weeks). The following results were recorded: 

• modified constraint-induced therapy provided a significantly better outcome for isolated motor functions of the paretic arm than bimanual training 
• for spontaneous use of the paretic arm and hand in everyday life activities both methods led to similar improvement 
• more-disabled children showed greater improvement than less-disabled ones 
• age did not affect treatment outcome 

 
Reference: Wolfgang Deppe,Kerstin Thuemmler,Judith Fleischer,Claudia Berger,Susanne Meyer,and Baerbel Wiedemann. Modified constraint-induced movement therapy versus intensive bimanual training for children with hemiplegia – a randomized controlled trial Clin Rehabil October 2013 27: 909-920, first published on July 1, 2013 doi:10.1177/0269215513483764

Ankle Ligaments in Children with Hemiplegia

The Journal of Ultrasound in Medicine published research comparing lateral ankle ligaments between the unaffected and affected leg in children with spastic hemiplegia cerebral palsy. Eight children with a mean age of 5.2 years old underwent sonograms of the anterior talofibular ligament and calcaneofibular ligament and the anterior talofibular/calcaneofibular ligament thickness ratio was calculated. In addition, the modified Ashworth scale was used and passive ankle dorsiflexion was evaluated. The results indicated the following:

• anterior talofibular ligament thickness in the affected legs was significantly greater than that in the unaffected legs
• calcaneofibular ligament thickness in the affected legs was significantly less than that in the unaffected legs
• anterior talofibular/calcaneofibular ligament thickness ratio in the affected legs was significantly greater than that in unaffected legs (ratio was positively correlated with the modified Ashworth scale and age but negatively correlated with the passive ankle dorsiflexion angle in the affected legs).

The researchers concluded that there is an increased anterior talofibular ligament thickness and a decreased calcaneofibular ligament thickness in the affected legs compared with the unaffected legs. This discrepancy between the lateral ankle ligaments may play a role in the equinovarus deformity of the ankle together with spastic leg muscles in children with spastic hemiplegic cerebral palsy.

Reference: Kwon DR, Park GY. Differences in lateral ankle ligaments between affected and unaffected legs in children with spastic hemiplegic cerebral palsy. J Ultrasound Med. 2013 Feb;32(2):313-7.  

Use of Thumb Splint in Children with Hemiplegia

Clinical Rehabilitation published research on the functional abilities of 7 children (ages 2-7) with unilateral cerebral palsy who used a neoprene thumb opponens splint (McKie splint). The children were followed for 4 months - about one month baseline, 2 months intervention and one month follow up. Goal attainment scaling and visual analog scales were used to assess function. The results indicated that four children increased their scores following use of the splint. Only two children benefited from the splint when it was worn. All the children tolerated the splint well.

Reference: Ten Berge SR, Boonstra AM, Dijkstra PU, Hadders-Algra M, Haga N, Maathuis CG. A systematic evaluation of the effect of thumb opponens splints on hand function in children with unilateral spastic cerebral palsy. Clin Rehabil. 2011 Dec 1. [Epub ahead of print]

Wrist Extension and Hand Function

A recent studied examined the use of wrist monitors on 15 children with hemiplegia to study the hypothesis that wrist extension frequency is an indicator of functional hand use. Using video analysis and a wrist monitor that assessed wrist extension frequency, the subjects participated in the Assisting Hand Assessment (AHA). The results indicated that the wrist monitor was reliable to measure frequency of wrist extension. In addition, wrist extension frequency was significantly correlated with the AHA scores.

Reference: Howcroft J, Fehlings D, Zabjek K, Fay L, Liang J, Biddiss E. Wearable wrist activity monitor as an indicator of functional hand use in children with cerebral palsy. Dev Med Child Neurol. 2011 Aug 30. doi: 10.1111/j.1469-8749.2011.04078.x. [Epub ahead of print]

Bimanual Versus Constraint Therapy in Hemiplegia

Research was conducted comparing two groups of children ranging from 3.5 to 10 years old (42 in total) with hemiplegia. The children were randomly assigned to receive 90 hours of constraint induced movement therapy (CIMT) or 90 hours of bimanual training (HABIT). Following the training, both the CIMT and HABIT resulted in improved hand function as seen in scores on the Jebsen-Taylor Test of Hand Function (JTTHF) and Assisting Hand Assessment (AHA) scores. In addition, the Goal Attainment Scales revealed greater progress toward goals with the HABIT group. The researchers concluded that both treatment interventions, CIMT and HABIT, resulted in similar improvements in hand function with the HABIT possibly improving more on self determined goals.

Reference: Gordon AM, Hung YC, Brandao M, Ferre CL, Kuo HC, Friel K, Petra E, Chinnan A, Charles JR. Bimanual Training and Constraint-Induced Movement Therapy in Children With Hemiplegic Cerebral Palsy: A Randomized Trial. Neurorehabil Neural Repair. 2011 Jun 23. [Epub ahead of print]

Mirror Therapy and Children with Hemiplegia

Developmental Medicine and Child Neurology published research on mirror therapy in children with hemiplegia. Mirror therapy involves the use of a mirror to provide the illusion that the paretic arm is functional. This type of therapy has been used with adults who have had a stroke. For this pilot study, 15 children with hemiplegia were randomly assigned to complete 15 minutes of bimanual training for 3 weeks of therapy with and without the mirror. Training with the mirror significantly improved grasp strength and upper limb dynamic position. Training without the mirror significantly improved pincher strength.

I had never heard of mirror therapy prior to this research study. Seems like an interesting idea with minimal equipment involved. Has anyone had experience, good or bad, with mirror therapy and children with hemiplegia?

Reference: GYGAX, M. J., SCHNEIDER, P. and NEWMAN, C. J. , Mirror therapy in children with hemiplegia: a pilot study. Developmental Medicine & Child Neurology, no. doi: 10.1111/j.1469-8749.2011.03924.x

Bracing and Hemiplegia

Developmental Medicine and Child Neurology published research on the use of a wrist and thumb brace on bimanual activities in children with hemiplegia cerebral palsy. Twenty five children with spastic hemiplegia cerebral palsy (with mild to moderate hand deformity) performed bimanual activities wearing a brace and not wearing a brace. Assessment results indicated that when the children were wearing the brace the ability to complete the bimanual activities improved significantly compared to when the children were not wearing the wrist and thumb brace.

Reference: LOUWERS, A., MEESTER-DELVER, A., FOLMER, K., NOLLET, F. and BEELEN, A. (2011), Immediate effect of a wrist and thumb brace on bimanual activities in children with hemiplegic cerebral palsy. Developmental Medicine & Child Neurology, 53: 321–326. doi: 10.1111/j.1469-8749.2010.03849.x

Adapted Constraint Induced Therapy

Clinical Rehabilitation published research on an adapted version of constraint-induced movement therapy to promote functioning in children with cerebral palsy. Sixteen children with cerebral palsy (mean age 5 years 6 months) participated in constraint induced therapy for 2 weeks. The control group received the usual rehabilitation services during the 2 weeks. The intervention group had the non-involved extremity restricted for 10 hours per day with 3 hours of intensive training with the affected extremity. The experimental group also received bimanual functional training for one week following the constraint therapy. The self care domain of the Pediatric Evaluation of Disability Inventory and an adapted version of the Jebsen—Taylor test were completed at the start of the intervention, following completion of the intervention and at one month follow up.

Results indicated higher gains in the experimental group for functional skills and Independence. No differences were found in manual dexterity between the two groups.

References: Marina de Brito Brandão, Marisa Cotta Mancini, Daniela Virgínia Vaz, Ana Paula Pereira de Melo, and Sérgio Teixeira Fonseca Adapted version of constraint-induced movement therapy promotes functioning in children with cerebral palsy: a randomized controlled trial Clin Rehabil 2010 24: 639-647

Modified Constraint Induced Movement Therapy and Gait Characteristics

In a recent issue of Disability and Rehabilitation there was research published on an intervention using modified constraint induced movement therapy (mCIMT) wtih 12 preschool children with hemiplegic cerebral palsy. The intervention consisted of mCIMT for 5 consecutive days at 6 hours per day. Following the experiment, the data was analyzed revealing a significant decrease in base of support and improvements were noted in most other temporal spatial aspects of gait. The researchers recommend additional studies on the long term effects of mCIMT for the lower extremity deficits.

Reference: Patricia Coker‌, Tasos Karakostas‌, Cindy Dodds‌, Simon Hsiang‌ Gait characteristics of children with hemiplegic cerebral palsy before and after modified constraint-induced movement therapy Disability & Rehabilitation 2010, Vol. 32, No. 5, Pages 402-408

Grip in Children with Congential Hemiplegia

Neurorehabilitation and Neural Repair published research comparing predictive and reactive control of grip force in children with congenital hemiplegia. The precision grip of 12 children (ages 10-16 years) with hemiplegia were compared to a control group in two different conditions - predictive and reactive. For the predictive control, the child triggered the drop of an object to grip before it fell completely. For the reactive control, the examiner triggered the drop of the object for the child to grip before it fell completely. Results indicated the following:
1. Predictive grip in the hemiplegic hand was intact but was changed after impact "suggesting an inability to anticipate the consequences of a dynamic perturbation".
2. Under the reactive conditions, a delay was seen in the hemiplegic hand
3. Both predictive and reactive conditions were intact in the non hemiplegic hand.

Reference: Bleyenheuft, Yannick, Thonnard, Jean-Louis Predictive and Reactive Control of Precision Grip in Children With Congenital Hemiplegia Neurorehabil Neural Repair 2010 24: 318-327

Tele-Rehabilitation for Hemiparesis in Teens

A recent case study report of three teens with cerebral palsy (hemiplegia) and the use of remotely monitored in home video games was published in Archives of Physical Medicine and Rehabilitation January 2010. The three teens used a specially fitted sensor glove linked to a video game at home for 30 minutes a day, 5 times a week for 3 months. The video games played were specifically designed to improve hand function. After the three month training, all three teens showed improved hand function, brain activity changes on functional MRI's and 2/3 teens showed increased radial bone mineral content. Specifically, occupational therapy testing improved, finger range of motion improved and an increased ability to lift objects. All of this was tested remotely.

Reference: Golomb MR, McDonald BC, Warden SJ, Yonkman J, Saykin AJ, Shirley B, Huber M, Rabin B, AbdelBaky M, Nwosu ME, Barkat-Masih M, Burdea GC. In-home virtual reality videogame telerehabilitation in adolescents with hemiplegic cerebral palsy. Archives of Physical Medicine and Rehabilitation Volume 91, Issue 1, Pages 1-8.e1 (January 2010)