Improvements in Upper Extremity Function Following Intensive Training Are Independent of Corticospinal Tract Organization in Children With Unilateral Spastic Cerebral Palsy: A Clinical Randomized Trial

Background/Objectives: Intensive training of the more affected upper extremity (UE) has been shown to be effective for children with unilateral spastic cerebral palsy (USCP). Two types of UE training have been particularly successful: Constraint-Induced Movement Therapy (CIMT) and Bimanual training. Reorganization of the corticospinal tract (CST) early during development often occurs in USCP. Prior studies have suggested that children with an ipsilateral CST controlling the affected UE may improve less following CIMT than children with a contralateral CST. We tested the hypothesis that improvements in UE function after intensive training depend on CST laterality.Study Participants and Setting: Eighty-two children with USCP, age 5 years 10 months to 17 years, University laboratory setting.Materials/Methods: Single-pulse transcranial magnetic stimulation (TMS) was used to determine each child's CST connectivity pattern. Children were stratified by age, sex, baseline hand function and CST connectivity pattern, and randomized to receive either CIMT or Bimanual training, each of which were provided in a day-camp setting (90 h). Hand function was tested before, immediately and 6 months after the intervention with the Jebsen-Taylor Test of Hand Function, the Assisting Hand Assessment, the Box and Block Test, and ABILHAND-Kids. The Canadian Occupational Performance Measure was used to track goal achievement and the Pediatric Evaluation of Disability Inventory was used to assess functioning in daily living activities at home.Results: In contrast to our hypothesis, participants had statistically similar improvements for both CIMT and Bimanual training for all measures independent of their CST connectivity pattern (contralateral, ipsilateral, or bilateral) (p < 0.05 in all cases).Conclusions/Significance: The efficacy of CIMT and Bimanual training is independent of CST connectivity pattern. Children with an ipsilateral CST, previously thought to be maladaptive, have the capacity to improve as well as children with a contralateral or bilateral CST following intensive CIMT or Bimanual training.Clinical Trial Registration:www.ClinicalTrials.gov, identifier NCT02918890.

Novel integrative rehabilitation system for the upper extremity: Design and usability evaluation

Purpose Design and test the usability of a novel virtual rehabilitation system for bimanual training of gravity supported arms, pronation/supination, grasp strengthening, and finger extension. Methods A robotic rehabilitation table, therapeutic game controllers, and adaptive rehabilitation games were developed. The rehabilitation table lifted/lowered and tilted up/down to modulate gravity loading. Arms movement was measured simultaneously, allowing bilateral training. Therapeutic games adapted through a baseline process. Four healthy adults performed four usability evaluation sessions each, and provided feedback using the USE questionnaire and custom questions. Participant’s game play performance was sampled and analyzed, and system modifications made between sessions. Results Participants played four sessions of about 50 minutes each, with training difficulty gradually increasing. Participants averaged a total of 6,300 arm repetitions, 2,200 grasp counts, and 2,100 finger extensions when adding counts for each upper extremity. USE questionnaire data averaged 5.1/7 rating, indicative of usefulness, ease of use, ease of learning, and satisfaction with the system. Subjective feedback on the custom evaluation form was 84% favorable. Conclusions The novel system was well-accepted, induced high repetition counts, and the usability study helped optimize it and achieve satisfaction. Future studies include examining effectiveness of the novel system when training patients acute post-stroke.

Recent advances in cerebral palsy

The words unpreventable, incurable, and untreatable are still synonymous with cerebral palsy (CP). However, research and evidence coming from the fields of neuroplasticity, neuroregeneration, and neuroprotection provide considerable cause for optimism for children with CP. There are now at least 64 different interventions for CP seeking 131 outcomes. A search of the Cochrane Library, PubMed, and Google Scholar was made using the keywords: CP, static encephalopathy, birth asphyxia, perinatal insult, hypoxic-ischemic encephalopathy, and neonatal encephalopathy. We found evidence to suggest that following interventions: Anticonvulsant drugs, ankle casting, botulinum toxin for focal spasticity, bisphosphonates, diazepam, hip surveillance, and dorsal rhizotomy are effective. The following interventions improve function: Bimanual training, constraint-induced movement therapy, context focused therapy, goal-directed/functional training, home programs, and occupational therapy. These interventions are effective if started early in life. Therapies such as hyperbaric oxygen, hip bracing, and neurodevelopmental therapy when child contractures are already developed are ineffective. In the last decade, the evidence on CP has rapidly expanded, providing clinicians and families with the possibility of newer, safer, and more effective interventions. In this update, the author reviews the current evidence of the management of CP and provides a comprehensive evaluation and multidisciplinary management.