Abstract
The study highlights the role of OT in an intensive, theme-based summer camp program for children with unilateral upper-extremity paresis. A hybrid model of modified constraint-induced movement therapy and bimanual therapy for six hours per day over 10 days was shown to be effective in improving bimanual function for children with hemiparesis. The study also serves as an example of how research outcomes can be translated to regular OT practice in a pediatric hospital setting.
Primary Author and Speaker: Marielle Pascual
Additional Authors and Speakers: Gina Kim
Contributing Authors: Susan Rethlefsen
Children with upper extremity weakness or paresis have difficulty performing unimanual and bimanual activities affecting their ability to execute daily tasks for successful participation at home, school, and other environments (Gordon et al. 2005). Research studies investigating the effects of a hybrid model combining modified constraint induced movement and bimanual therapy are few but emerging (Aarts et al. 2010; Boyd et al., 2013). There is also significantly less evidence studying the effectiveness of CIMT for children with hemiparesis from other injuries such as perinatal brachial plexus injury. This investigation aims to address a selection of “knowledge gaps” in CIMT (Eliasson et al., 2014) including: type of practice, type of structured skills, long term outcomes, and predictive factors such as severity of impairments. The purpose of this study was to (1) assess the impact of an intensive camp-based intervention using a hybrid model of mCIMT with bimanual therapy; (2) assess the impact of this hybrid model on children with varying severity of neurologic hemiparesis; (3) assess the impact of this hybrid model on children with PBPI; and (4) investigate whether this model of intervention would sustain change over time. We hypothesized that participation in the camp would improve bimanual hand function in school-aged children with varying severities of neurologic hemiparesis and PBPI and improvements would be sustained long term, as measured by the Assisting Hand Assessment and Abilhand-Kids.
This is a repeated measures, prospective cohort study design. Subjects were recruited from pediatric outpatient clinics and hospitals in the greater Los Angeles area. Inclusion criteria for participation were: ages 6-12 years, hemiparesis or PBPI, Manual Ability Classification System level, no visual impairments, and ability to follow directions. Twenty-six children participated (22 neurologic, 4 perinatal brachial plexus injury). The Assisting Hand Assessment and Abilhand-Kids were administered before/after camp, and 3- and 12-months post-camp. Camp was held during the summer for six hours per day for ten days. Using a hybrid model, the intervention included two hours of mCIMT immediately followed by four hours of bimanual therapy. Activities were designed around hero themes. Data were collected over five yearly camp sessions. Data were analyzed using paired t-tests and multiple regression.
AHA score improved during the intervention phase for neurologically involved subjects at all MACS levels (p≤ 0.0001), and those with PBPI (p= 0.04). Improvement was maintained at 3-months but declined long-term (1 year), though only statistically significantly in the neurologically involved group. No changes were seen in Abilhand-Kids scores.
This paper describes an intensive, theme-based summer camp program using a hybrid model of modified constraint induced movement therapy and bimanual therapy which was effective in improving bimanual function for children with neurologic hemiparesis across MACS levels I-IV, with changes sustained at 3 months. Results of the study also suggest the hybrid model may be an effective intervention for children with perinatal brachial plexus injury. Further exploration is needed to determine if improvements seen after camp translate to improved bimanual function in daily activities performed at home. For the pediatric occupational therapists who aim to provide effective and impactful therapy services for children with neurological and peripheral based upper extremity hemiparesis experiencing limited participation in meaningful occupations, this paper explores how a hybrid model can be implemented in a summer camp setting as well as how the effectiveness of the intervention can be studied by the clinician-researcher.
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Boyd, R. N., Ziviani, J., Sakzewski, L., Miller, L., Bowden, J., Cunnington, R., . . . Rose, S. (2013). 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, 13, 68. doi:10.1186/1471-2377-13-68 Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/23809257
Eliasson, A. C., Krumlinde-Sundholm, L., Gordon, A. M., Feys, H., Klingels, K., Aarts, P. B. European network for Health Technology, A. (2014). Guidelines for future research in constraint-induced movement therapy for children with unilateral cerebral palsy: An expert consensus. Developmental Medicine & Child Neurology, 56(2), 125-137. doi:10.1111/dmcn.12273 Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/24266735
Gordon, A. M., Charles, J., & Wolf, S. L. (2005). Methods of constraint-induced movement therapy for children with hemiplegic cerebral palsy: Development of a child-friendly intervention for improving upper-extremity function. Archives of Physical Medicine and Rehabilitation, 86(4), 837-844. doi:10.1016/j.apmr.2004.10.008 Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/15827942