Self-care and hand function in preschool children with unilateral or bilateral cerebral palsy: A cross-sectional study.

AIMS: To describe self-care capabilities among children with cerebral palsy (CP) and explore associations between self-care and hand function for children with unilateral cerebral palsy (UCP) and children with bilateral cerebral palsy (BCP) separately. METHOD: Cross-sectional data on self-care capabilities (Pediatric Evaluation of Disability Inventory, PEDI), manual abilities (Manual Ability Classification System, MACS) and hand use during bimanual performance (Assisting Hand Assessment, AHA; Both Hands Assessment, BoHA) were retrieved from the Norwegian Quality and Surveillance Registry for Cerebral Palsy (NorCP). Eighty-seven children with CP (UCP, n = 61, mean age 4 years 1 month, SD 1 year 3 months, range 56) or BCP (n = 26, mean age 4 years 4 months, SD 1 year, range 41), classified at MACS level I (n = 26), II (n = 40) or III (n = 21), were included. RESULTS: No significant differences in self-care capabilities were found between children with UCP and children with BCP. Analysis of variance showed significant differences in self-care between MACS levels for the whole group. No significant differences in self-care between MACS levels were observed for children with UCP (p = 0.36), but significant differences were found for those with BCP (p < 0.001). Whereas a small correlation (r = 0.3) between PEDI and AHA scores was found for children with UCP, a large correlation (r = 0.6) was found for those with BCP. Children with BCP with symmetric hand use during bimanual performance (BoHA) had higher PEDI scores than children with asymmetric hand use. CONCLUSION: Though children with UCP and children with BCP who were classified at MACS I-III exhibited similar self-care capabilities, the limited hand use seems to contribute differently between the two groups. The two different measures of hand use exhibit different associations with self-care capabilities for young children with UCP and BCP, respectively, and illustrate the need to treat UCP and BCP as two distinct groups, each requiring tailored interventions according to their specific needs.

Clinical utility of a pediatric hand exoskeleton: identifying users, practicability, and acceptance, and recommendations for design improvement.

BACKGROUND: Children and adolescents with upper limb impairments can experience limited bimanual performance reducing daily-life independence. We have developed a fully wearable pediatric hand exoskeleton (PEXO) to train or compensate for impaired hand function. In this study, we investigated its appropriateness, practicability, and acceptability. METHODS: Children and adolescents aged 6-18 years with functional limitations in at least one hand due to a neurological cause were selected for this cross-sectional evaluation. We characterized participants by various clinical tests and quantified bimanual performance with the Assisting Hand Assessment (AHA). We identified children whose AHA scaled score increased by ≥ 7 points when using the hand exoskeleton and determined clinical predictors to investigate appropriateness. The time needed to don each component and the number of technical issues were recorded to evaluate practicability. For acceptability, the experiences of the patients and the therapist with PEXO were evaluated. We further noted any adverse events. RESULTS: Eleven children (median age 11.4 years) agreed to participate, but data was available for nine participants. The median AHA scaled score was higher with PEXO (68; IQR: 59.5-83) than without (55; IQR: 37.5-80.5; p = 0.035). The Box and Block test, the Selective Control of the Upper Extremity Scale, and finger extensor muscle strength could differentiate well between those participants who improved in AHA scaled scores by ≥ 7 points and those who did not (sensitivity and specificity varied between 0.75 and 1.00). The median times needed to don the back module, the glove, and the hand module were 62, 150, and 160 s, respectively, but all participants needed assistance. The most critical failures were the robustness of the transmission system, the electronics, and the attachment system. Acceptance was generally high, particularly in participants who improved bimanual performance with PEXO. Five participants experienced some pressure points. No adverse events occurred. CONCLUSIONS: PEXO is a safe exoskeleton that can improve bimanual hand performance in young patients with minimal hand function. PEXO receives high acceptance. We formulated recommendations to improve technical issues and the donning before such exoskeletons can be used under daily-life conditions for therapy or as an assistive device. Trial registration Not appropriate.

To Explore the Validity of Change Scores of the Children's Hand-use Experience Questionnaire (CHEQ) in Children with Unilateral Cerebral Palsy.

AIMS: To explore the validity of change scores of the Children's Hand-use Experience Questionnaire (CHEQ). METHODS: Analysis of the CHEQ included 44 children (15 girls) between 6-16 years (median 9.0; IQR 8-11) with unilateral cerebral palsy, with baseline and post- (two-week intensive) intervention assessments using the Goal Attainment Scale (GAS) as external anchor for change. Hypotheses on the magnitude of expected change were formulated and correlation coefficients and effect sizes calculated. Receiver operating curve analysis was performed and the area under the curve (AUC) calculated to investigate the ability of CHEQ to discriminate between improvement and non-improvement according to GAS. RESULTS: All hypotheses about the magnitude of change were confirmed supporting longitudinal validity of CHEQ scales to measure change in the perception of bimanual performance. AUCs for the Grasp efficacy and the Time utilization were slightly below, and for the Feeling bothered slightly above the threshold. The latter one accurately discriminating between children that improved and did not improve according to the GAS. CONCLUSIONS: Evidence was found that CHEQ scales capture change in bimanual performance but with limited accuracy for two out of three scales. The validity of CHEQ change scores needs to be further explored in a wider population.

Cognition and bimanual performance in children with unilateral cerebral palsy: protocol for a multicentre, cross-sectional study.

BACKGROUND: Motor outcomes of children with unilateral cerebral palsy are clearly documented and well understood, yet few studies describe the cognitive functioning in this population, and the associations between the two is poorly understood. Using two hands together in daily life involves complex motor and cognitive processes. Impairment in either domain may contribute to difficulties with bimanual performance. Research is yet to derive whether, and how, cognition affects a child's ability to use their two hands to perform bimanual tasks. METHODS/DESIGN: This study will use a prospective, cross-sectional multi-centre observational design. Children (aged 6-12 years) with unilateral cerebral palsy will be recruited from one of five Australian treatment centres. We will examine associations between cognition, bimanual performance and brain neuropathology (lesion type and severity) in a sample of 131 children. The primary outcomes are: Motor - the Assisting Hand Assessment; Cognitive - Executive Function; and Brain - lesion location on structural MRI. Secondary data collected will include: Motor - Box and Blocks, ABILHAND- Kids, Sword Test; Cognitive - standard neuropsychological measures of intelligence. We will use generalized linear modelling and structural equation modelling techniques to investigate relationships between bimanual performance, executive function and brain lesion location. DISCUSSION: This large multi-centre study will examine how cognition affects bimanual performance in children with unilateral cerebral palsy. First, it is anticipated that distinct relationships between bimanual performance and cognition (executive function) will be identified. Second, it is anticipated that interrelationships between bimanual performance and cognition will be associated with common underlying neuropathology. Findings have the potential to improve the specificity of existing upper limb interventions by providing more targeted treatments and influence the development of novel methods to improve both cognitive and motor outcomes in children with unilateral cerebral palsy. TRIAL REGISTRATION: ACTRN12614000631606 ; Date of retrospective registration 29/05/2014.

Home-based bimanual training based on motor learning principles in children with unilateral cerebral palsy and their parents (the COAD-study): rationale and protocols.

BACKGROUND: Home-based training is considered an important intervention in rehabilitation of children with unilateral cerebral palsy. Despite consensus on the value of home-based upper limb training, no evidence-based best practice exists. Promoting compliance of children to adhere to an intensive program while keeping parental stress levels low is an important challenge when designing home-based training programs. Incorporating implicit motor learning principles emerges to be a promising method to resolve this challenge. METHODS: Here we describe two protocols for home-based bimanual training programs, one based on implicit motor learning principles and one based on explicit motor learning principles, for children with unilateral spastic cerebral palsy aged 2 through 7 years. Children receive goal-oriented, task-specific bimanual training in their home environment from their parents for 3.5 h/week for 12 weeks according to an individualized program. Parents will be intensively coached by a multidisciplinary team, consisting of a pediatric therapist and remedial educationalist. Both programs consist of a preparation phase (goal setting, introductory meetings with coaching professionals, design of individualized program, instruction of parents, home visit) and home-based training phase (training, video-recordings, registrations, and telecoaching and home visits by the coaching team). The programs contrast with respect to the teaching strategy, i.e. how the parents support their child during training. In both programs parents provide their child with instructions and feedback that focus on the activity (i.e. task-oriented) or the result of the activity (i.e. result-oriented). However, in the explicit program parents are in addition instructed to give exact instructions and feedback on the motor performance of the bimanual activities, whereas in the implicit program the use of both hands and the appropriate motor performance of the activity are elicited via manipulation of the organization of the activities. DISCUSSION: With the protocols described here, we aim to take a next step in the development of much needed evidence-based home-based training programs for children with unilateral cerebral palsy.

Development and Validation of the Both Hands Assessment for Children With Bilateral Cerebral Palsy.

AIMS: To develop a hand function test for children with bilateral cerebral palsy (CP) measuring bimanual performance, including quantification of possible asymmetry of hand use. METHOD: The Both Hands Assessment (BoHA) content was developed through adaptation of the Assisting Hand Assessment (version 5.0). Data from 171 children with bilateral CP, 22-months to 13 years olds (75 females; mean age: 6 years and 6 months) classified at Manual Ability Classification System (MACS) levels I-III, was entered into Rasch measurement model analyses to evaluate internal scale validity and aspects of reliability. RESULTS: Sixteen items (11 unimanual and 5 bimanual) exhibited evidence for good internal scale validity and item and person reliability when analyzed separately for children with asymmetric or symmetric hand use. By calibrating the BoHA logit measures into the same frame of reference through linking, the overall measure of bimanual performance is comparable between children with asymmetric or symmetric hand use, still allowing use of separate item difficulty hierarchies. CONCLUSIONS: The Both Hands Assessment (BoHA), showed strong evidence of internal construct validity for measuring effectiveness of bimanual performance and the extent of asymmetric hand use in children with bilateral cerebral palsy, MACS levels I-III.

Assisting Hand Assessment and Children's Hand-Use Experience Questionnaire -Observed Versus Perceived Bimanual Performance in Children with Unilateral Cerebral Palsy.

AIMS: To explore the differences, relationship, and extent of agreement between the Assisting Hand Assessment (AHA), measuring observed ability to perform bimanual tasks, and the Children's Hand-Use Experience Questionnaire (CHEQ), assessing experienced bimanual performance. METHODS: This study investigates a convenience sample of 34 children (16 girls) with unilateral cerebral palsy aged 6-18 years (mean 12.1, SD 3.9) in a cross-sectional design. RESULTS: The AHA and CHEQ subscales share 8-25% of their variance (R2). Bland-Altman plots for AHA and all three CHEQ subscales indicate good average agreement, with a mean difference approaching zero but large 95% confidence intervals. Limits of agreement were extremely wide, indicating considerable disagreement between AHA and CHEQ subscales. CONCLUSION: AHA and CHEQ seem to measure different though somewhat related constructs of bimanual performance. Results of this investigation reinforce the recommendation to use both instruments to obtain complementary information about bimanual performance including observed and perceived performance of children with unilateral cerebral palsy.

Hand Function in a Population-Based Sample of Young Children with Unilateral or Bilateral Cerebral Palsy.

AIM: To describe aspects of hand function in a population-based sample of young children with clinical signs of unilateral or bilateral cerebral palsy (CP). METHOD: A cross-sectional study with data from national CP registers in Norway. Manual ability was classified with the Manual Ability Classification System (MACS) or Mini-MACS. Hand use in bimanual activities was measured with the Assisting Hand Assessment (AHA) for unilateral CP or the newly developed Both Hands Assessment (BoHA) for bilateral CP. RESULTS: From 202 children, 128 (57 females) were included (Mini-MACS/MACS levels I-V, mean age 30.4 months; SD = 12.1). Manual abilities were distributed across levels I-III in unilateral CP and levels I-V in bilateral CP. Variations in AHA and BoHA units were large. One-way ANOVA revealed associations between higher AHA or BoHA units and Mini-MACS/MACS levels of higher ability (p < 0.01) and higher age (p < 0.04). CONCLUSIONS: Compared with young children with unilateral CP, children with bilateral CP showed greater variation in Mini-MACS/MACS levels, and both sub-groups showed large variations in AHA or BoHA units. The classifications and assessments used in this study are useful to differentiate young children's ability levels. Such information is important to tailor upper limb interventions to the specific needs of children with CP.

Does somatosensory discrimination therapy alter sensorimotor upper limb function differently compared to motor therapy in children and adolescents with unilateral cerebral palsy: study protocol for a randomized controlled trial.

BACKGROUND: Besides motor impairments, up to 90% of the children and adolescents with unilateral cerebral palsy (uCP) present with somatosensory impairments in the upper limb. As somatosensory information is of utmost importance for coordinated movements and motor learning, somatosensory impairments can further compromise the effective use of the impaired upper limb in daily life activities. Yet, intervention approaches specifically designated to target these somatosensory impairments are insufficiently investigated in children and adolescents with uCP. Therefore, the aim of this randomized controlled trial (RCT) is to compare the effectiveness of somatosensory discrimination therapy and dose-matched motor therapy to improve sensorimotor upper limb function in children and adolescents with uCP, who experience somatosensory impairments in the upper limb. We will further explore potential behavioral and neurological predictors of therapy response. METHODS: A parallel group, evaluator-blinded, phase-II, single-center RCT will be conducted for which 50 children and adolescents with uCP, aged 7 to 15 years, will be recruited. Participants will be randomized to receive 3 weekly sessions of 45 minutes of either somatosensory discrimination therapy or upper limb motor therapy for a period of 8 weeks. Stratification will be performed based on age, manual ability, and severity of tactile impairment at baseline. Sensorimotor upper limb function will be evaluated at baseline, immediately after the intervention and after 6 months follow-up. The primary outcome measure will be bimanual performance as measured with the Assisting Hand Assessment. Secondary outcomes include a comprehensive test battery to objectify somatosensory function and measures of bimanual coordination, unimanual motor function, and goal attainment. Brain imaging will be performed at baseline to investigate structural brain lesion characteristics and structural connectivity of the white matter tracts. DISCUSSION: This protocol describes the design of an RCT comparing the effectiveness of somatosensory discrimination therapy and dose-matched motor therapy to improve sensorimotor upper limb function in children and adolescents with uCP. The results of this study may aid in the selection of the most effective upper limb therapy, specifically for children and adolescents with tactile impairments. TRIAL REGISTRATION: ClinicalTrials.gov (NCT06006065). Registered on August 8, 2023.

Reliability of an observation-based scoring grid to assess bimanual performance during unstandardized tasks in adults living with cerebral palsy.

PURPOSE: Most activities of daily living (ADLs) require the use of both upper extremities. However, few assessments exist to assess bimanual performance, especially among adults living with cerebral palsy (CP). The aim of this preliminary study is to assess the interrater reliability and convergent validity of the Assisting Hand Assessment (AHA) scoring grid applied to unstandardized ADLs. MATERIALS AND METHODS: For this validation study, nineteen adults living with spastic unilateral CP were videotaped performing seven bimanual ADLs. Three raters assessed the videos independently using the 20-item grid of the AHA. Gwet's AC2 was used to assess interrater reliability. Kendall's Tau-b correlation was used between the observation-based scoring grid and Jebsen-Taylor Hand Function Test (JTHFT) scores to assess convergent validity. RESULTS: Interrater reliability was good (0.84, SD = 0.02). The correlation with the JTHFT was high (τb = -0.74; p < 0.001). CONCLUSION: The results show the potential of using an observation-based scoring grid with unstandardized ADLs to assess bimanual performance in adults living with CP, but further research on psychometric properties is needed. This method allows for an assessment that is occupation-oriented, ecological, and meaningful.

An observation-based scoring grid (Assisting Hand Assessment) can be applied in unstandardized activities of daily living to assess bimanual performance in adults with cerebral palsy.This method allows an occupation-oriented, ecological, and client-meaningful assessment.Although this approach is a pilot measure, it can be used by clinicians and researchers until further psychometric analyses are undertaken.

Bimanual performance in children with unilateral perinatal arterial ischaemic stroke or periventricular haemorrhagic infarction.

BACKGROUND: Long term outcome data on bimanual performance in children with perinatal arterial ischaemic stroke (PAIS) and periventricular haemorrhagic infarction (PVHI) with and without unilateral spastic cerebral palsy (USCP) is sparse. AIMS: To assess bimanual performance in children with PAIS or PVHI with and without USCP and to explore the relationship with unilateral hand function and full-scale IQ (FSIQ) in a cross-sectional study. METHODS: Fifty-two children with PAIS (n = 27) or PVHI (n = 25) participated at a median age of 12 years and 1 month (range 6-20 years). The Bruininks Oseretsky Test of Motor Proficiency-2 (bimanual precision and dexterity subtest), Assisting Hand Assessment, Purdue Pegboard Test and Wechsler Intelligence scale were administered. RESULTS: Bimanual dexterity was worse in children with USCP (p < 0.02) without a difference for the pathology groups. In children without USCP (n = 21), those with PAIS showed a better bimanual precision compared to children with PVHI (p < 0.04). The AHA score and the Purdue Pegboard score of the dominant hand explained 51% of the variance in bimanual precision and dexterity in children with USCP. In absence of USCP, FSIQ together with AHA scores explained 66% of the variance in bimanual precision and FSIQ together with the Purdue Pegboard Test score of the dominant hand, 71% of the variance in bimanual dexterity. CONCLUSIONS: Children with PAIS without USCP have a more favourable bimanual hand function compared to children with PVHI. This difference appears to be associated with a preserved FSIQ.

PROPENSIX: pressure garment therapy using compressive dynamic Lycra® sleeve to improve bi-manual performance in unilateral cerebral palsy: a multicenter randomized controlled trial protocol.

BACKGROUND: Upper limb impairment affects activity and participation in children with unilateral cerebral palsy (UCP). Pressure garment therapy (PGT) using compressive dynamic Lycra® garments is an innovative intervention proposed for the management of cerebral palsy consequences. The PROPENSIX study aims to evaluate the efficacy of a therapy using a Lycra® sleeve as compared to a placebo sleeve to improve bi-manual performance measured by the Assisting Hand Assessment (AHA) in children with unilateral cerebral palsy. METHODS: The PROPENSIX trial is a multicenter, prospective, placebo-controlled, double-blinded, randomized study. One hundred children with UCP, aged from 5 to 10, are randomly assigned as soon as they are recruited in a 1:1 ratio to perform usual daily activities, especially activities involving bimanual performances, with Lycra® sleeve or placebo sleeve during 6 months. The primary endpoint is the change in bimanual performance from inclusion to 6 months, evaluated by AHA. The secondary endpoints evaluate changes from inclusion to 6 months in other dimensions of the International Classification of Functioning (ICF), upper limb movement capacity assessed by Quality of Upper Extremity Skill Test (QUEST), and health-related quality of life evaluated by Pediatric Quality of Life Inventory 3.0 Cerebral Palsy Module (PedsQLTM 3.0 CP Module) and in body structures and functions domain assessed by neuro-orthopedic examination and somatosensory evoked potentials (SEP). DISCUSSION: The PROPENSIX study is the largest randomized controlled trial (RCT) aiming to evaluate the efficacy of a PGT using compressive dynamic Lycra® sleeve in UCP. Enhancement of children's bimanual performance at the end of the 6 months wear of the Lycra® sleeve should improve evidence regarding this type of treatment and expand discussion about their recommendation in clinical practice. Data from secondary outcomes assessments should bring interesting arguments to discuss the Lycra® sleeve action on mobility, tonus, and sensory impairments in children with unilateral cerebral palsy. TRIAL REGISTRATION: ClinicalTrials.gov NCT02086214 . Retrospectively registered on March 13, 2014 TRIAL STATUS: Study start data: December 2012. Recruitment status: completed. Primary completion date: April 2021. Estimated study completion date: December 2022. Protocol version 10 (date: February 2018).

Assessment of bimanual performance in 3-D movement analysis: Validation of a new clinical protocol in children with unilateral cerebral palsy.

BACKGROUND: The "Be an Airplane Pilot" (BE-API) protocol is a novel 3-D movement analysis (3DMA) protocol assessing the bimanual performance of children during a game. OBJECTIVE: This study aimed to investigate the reliability and validity of this protocol in children with unilateral cerebral palsy (uCP). METHODS: Angular waveforms (WAVE), maximum angles (MAX) and range of motion (ROM) of the trunk, shoulder, elbow and wrist joints were collected in children with uCP and in typically developing children (TDC) during 4 tasks of the BE-API protocol designed to explore specific degrees of freedom (DoF). The inter-trial reliability for children with uCP was assessed with the coefficient of multiple correlation (CMC) for WAVE and the intraclass correlation coefficient (ICC) and standard error of measurement (SEM) for MAX and ROM. Clinical performance-based measures, including the Assisting Hand Assessment (AHA) and ABILHAND-Kids scores, were used to explore correlations between clinical measures and kinematic parameters in children with uCP. RESULTS: 20 children with uCP (13 boys; mean age 12.0 [SD 3.2] years) and 20 TDC (11 boys; mean age 11.9 [SD 3.4] years) were included. In children with uCP, most kinematic parameters showed high reliability (WAVE: CMC≥0.82; MAX and ROM: ICC≥0.85, SEM≤4.7°). Elbow extension, forearm supination, and wrist adduction were reduced and wrist flexion was increased for children with uCP versus TDC (P<0.01). In children with uCP, MAX and ROM values were moderately correlated with clinical assessments (AHA score: r=0.48-0.65; ABILHAND-Kids score: r=0.48-0.49). CONCLUSIONS: The BE-API protocol is a 3DMA-bimanual performance-based assessment that is highly reliable in children with uCP. Children with uCP and TDC significantly differed in some clinically relevant kinematic parameters. The BE-API is a promising playful tool, helpful for better understanding upper-limb motor movement abnormalities in bimanual conditions and for tailoring treatments to individual deficits.

Effect of Object and Task Properties on Bimanual Transport.

The use of both hands simultaneously when manipulating objects is fairly commonplace, but it is not known what factors encourage people to use two hands as opposed to one during simple tasks such as transport. In particular, we are interested in three possible transport strategies: unimanual transport, handing off between hands, and symmetric bimanual transport. In this study, we investigate the effect of object size, weight, and starting and ending position (configuration) as well as the need to balance the object on the use of these three strategies in a bowl-moving task. We find that configuration and balance have a strong effect on choice of strategy, and size and weight have a weaker effect. Hand-offs are most often used when the task requires moving an object from left to right and vice versa, while the unimanual strategy was frequently used when passing front to back. The bimanual strategy is only weakly affected by configuration. The need to balance an object causes subjects to favor unimanual and bimanual strategies over the hand-off. In addition, an analysis of transport duration and body rotation suggests that strategy choice may be driven by the desire to minimize body rotation.

The development of anticipatory action planning in children with unilateral cerebral palsy.

Background Previous studies suggest that compromised bimanual performance experienced by children with unilateral cerebral palsy (CP) is not only due to difficulties in action execution but may also be a result of impaired anticipatory action planning. Aims The effect of age and side of hemiplegia were examined and the relationship between anticipatory action planning, unimanual capacity and bimanual performance was explored. Methods and procedures Using a multi-centre, prospective, cross-sectional observational design, anticipatory action planning was analyzed in 104 children with unilateral cerebral palsy, aged 6-12 years, using the sword task. Outcomes and results Anticipatory action planning did not improve with age in children with unilateral CP, aged between 6-12 years. No differences were found between children with left or right hemiplegia. Finally, anticipatory action planning was not related to unimanual capacity or bimanual performance. Conclusion and implications This study demonstrates anticipatory action planning, measured using the sword task, does not improve with age in children with unilateral CP and is not related to bimanual performance or laterality. Future studies of anticipatory action planning in children with unilateral CP should consider using measures that require effective anticipatory action planning for successful task completion rather than end state comfort.

Influence of aging on bimanual coordination control.

Degeneration in the neuromuscular system due to aging can affect daily activities that need to be controlled by bimanual coordination with both hands. However, little is known about the influence of aging on grip strength and bimanual coordination control between hands. The purpose of this study was to investigate the influence of aging on the maximum grip force output and capacity of coordination control of two hands. Ten healthy elderly and 21 young adults were recruited and asked to execute maximum grip force tests and bimanual coordination control tasks with reciprocal grasping, holding, and releasing of a dynamometer with both hands at three target force levels (10, 20 and 40% maximal voluntary contraction, MVC). Compared with the young group, the maximum grip force of the hands of the elderly group was significantly lower by 77.5% (p<0.05) and 71.1% (p<0.05) in the dominant and non-dominant hands, respectively. The elderly adults also displayed a significantly longer alternating time control in the dominant to non-dominant and non-dominant to dominant hands at the 20% MVC target force level (p<0.05). Aging reduces the maximum hand grip force output and the performance of bimanual coordination control of two hands, which may lead to difficulty with the execution of daily activities requiring both hands.