[ARTICLE] Including a Lower-Extremity Component during Hand-Arm Bimanual Intensive Training does not Attenuate Improvements of the Upper Extremities: A Retrospective Study of Randomized Trials – Full Text

Hand-Arm Bimanual Intensive Therapy (HABIT) promotes hand function using intensive practice of bimanual functional and play tasks. This intervention has shown to be efficacious to improve upper-extremity (UE) function in children with unilateral spastic cerebral palsy (USCP). In addition to UE function deficits, lower-extremity (LE) function and UE–LE coordination are also impaired in children with USCP. Recently, a new intervention has been introduced in which the LE is simultaneously engaged during HABIT (Hand-Arm Bimanual Intensive Therapy Including Lower Extremities; HABIT-ILE). Positive effects of this therapy have been demonstrated for both the UE and LE function in children with USCP. However, it is unknown whether the addition of this constant LE component during a bimanual intensive therapy attenuates UE improvements observed in children with USCP. This retrospective study, based on multiple randomized protocols, aims to compare the UE function improvements in children with USCP after HABIT or HABIT-ILE. This study included 86 children with USCP who received 90 h of either HABIT (n = 42) or HABIT-ILE (n = 44) as participants in previous studies. Children were assessed before, after, and 4–6 months after intervention. Primary outcomes were the ABILHAND-Kids and the Assisting Hand Assessment. Secondary measures included the Jebsen-Taylor Test of Hand Function, the Pediatric Evaluation of Disability Inventory [(PEDI); only the self-care functional ability domain] and the Canadian Occupational Performance Measure (COPM). Data analysis was performed using two-way repeated-measures analysis of variance with repeated measures on test sessions. Both groups showed similar, significant improvements for all tests (test session effect p < 0.001; group × test session interaction p > 0.05) except the PEDI and COPM. Larger improvements on these tests were found for the HABIT-ILE group (test session effect p < 0.001; group × test session interaction p < 0.05). These larger improvements may be explained by the constant simultaneous UE–LE engagement observed during the HABIT-ILE intervention since many daily living activities included in the PEDI and the COPM goals involve the LE and, more specifically, UE–LE coordination. We conclude that UE improvements in children with USCP are not attenuated by simultaneous UE–LE engagement during intensive intervention. In addition, systematic LE engagement during bimanual intensive intervention (HABIT-ILE) leads to larger functional improvements in activities of daily living involving the LE.

Introduction

Cerebral palsy (CP) is the most common cause of pediatric motor disability with a prevalence ranging from 2 to 3.6 out of 1,000 children in western countries (1, 2). Motor disorders are often accompanied by sensation, perception, cognition, behavior, communication, and epilepsy disorders (1). Although the lesions are established from birth and are non-progressive, the motor impairments experienced by children with CP affect their autonomy and functional outcomes during their life-span. Moreover, motor symptoms such as impaired ability to walk may worsen during development (3).

One of the most disabling long-term functional deficits in children with unilateral spastic cerebral palsy (USCP) is impaired manual dexterity, i.e., impaired skilled hand movements and precision grip abilities (4). Upper-extremity (UE) impairments may affect functional independence, especially for activities of daily living requiring bimanual coordination (e.g., buttoning one’s shirt). It is now well known that intensive interventions based on motor skill learning principles and goal-directed training are effective for improving UE function in children with USCP (5). Constraint-Induced Movement Therapy (CIMT) was the first intensive intervention adapted to children with USCP (6). CIMT was first designed for adults with stroke and subsequently adapted to children with USCP showing improvements in hand function (5). Taking advantage of the key ingredient of CIMT (intensive practice with the affected UE), Charles and Gordon developed an alternative intensive bimanual approach termed “Hand-Arm Bimanual Intensive Therapy” (HABIT) (7). HABIT was developed with recognition that the combined use of both hands was necessary to increase functional independence in children with USCP (7). Focusing on improving bimanual coordination through structured play and functional activities during HABIT demonstrated efficacy to improve UE function in children with USCP (5).

Both HABIT and CIMT focus only on the UE of children with USCP. Though the lower extremity (LE) is generally less affected than UE in children with USCP, impairments observed in the affected LE range from an isolated equine ankle to hip flexion and adduction with a fixed knee (8). Children with USCP are then unable to achieve postural symmetry while standing, systematically presenting with an overload on one bodyside (8). They also frequently encounter limitations in walking abilities (3). Besides the LE impairments, UE–LE coordination is often impaired in children with USCP (9, 10). This coordination is frequently used in daily living activities (e.g., walking while carrying an object in the hand, climbing stairs while using the railing). A program that simultaneously trains the UE and LE in children with USCP is thus of interest since the UE impairments in children with CP remain stable through time (11) while walking and other LE abilities may decline during development (3). In 2014, taking advantage of the key ingredients in HABIT (intensive bimanual practice), Bleyenheuft and Gordon developed a new intervention focusing on both the UE and LE entitled “Hand-Arm Bimanual Intensive Therapy Including Lower Extremities” (HABIT-ILE) (12). Positive effects of this therapy focusing on both the UE and LE through structured play and functional activities have been demonstrated both for the UE and the LE of children with USCP (13) as well as, more recently, for children with bilateral CP (14). However, it is unknown whether the introduction of a systematic LE engagement in addition to a bimanual intervention may lead to attenuated improvements in UE compared to traditional HABIT due to shifts in attention (multitasking). This retrospective study aimed to compare changes in the UE of children with USCP undergoing 90 h of intensive bimanual intervention either with (HABIT-ILE) or without (HABIT) a LE component. We hypothesized that the introduction of systematic LE training simultaneously added to the bimanual training would lead to reduced improvements in the UE during HABIT-ILE compared to traditional HABIT. […]

Continue —> Frontiers | Including a Lower-Extremity Component during Hand-Arm Bimanual Intensive Training does not Attenuate Improvements of the Upper Extremities: A Retrospective Study of Randomized Trials | Neurology

[REVIEW] On the assessment of coordination between upper extremities: towards a common language between rehabilitation engineers, clinicians and neuroscientists – Full Text

Abstract

Well-developed coordination of the upper extremities is critical for function in everyday life. Interlimb coordination is an intuitive, yet subjective concept that refers to spatio-temporal relationships between kinematic, kinetic and physiological variables of two or more limbs executing a motor task with a common goal. While both the clinical and neuroscience communities agree on the relevance of assessing and quantifying interlimb coordination, rehabilitation engineers struggle to translate the knowledge and needs of clinicians and neuroscientists into technological devices for the impaired. The use of ambiguous definitions in the scientific literature, and lack of common agreement on what should be measured, present large barriers to advancements in this area. Here, we present the different definitions and approaches to assess and quantify interlimb coordination in the clinic, in motor control studies, and by state-of-the-art robotic devices. We then propose a taxonomy of interlimb activities and give recommendations for future neuroscience-based robotic- and sensor-based assessments of upper limb function that are applicable to the everyday clinical practice. We believe this is the first step towards our long-term goal of unifying different fields and help the generation of more consistent and effective tools for neurorehabilitation.

Background

This work was developed as part of the project “State of the Art Robot-Supported assessments (STARS)” in the frame of the COST Action TD1006 “European Network on Robotics for NeuroRehabilitation” [1]. The goal of STARS is to give neurorehabilitation clinical practitioners and scientists recommendations for the development, implementation, and administration of different indices of robotic assessments, grounded on scientific evidence.

Well-coordinated movements are a characteristic feature of well-developed motor behavior. From neuroscientists to clinicians, quantifying coordination of an individual is of critical importance. Not only does this help in understanding the neurophysiological components of movement (neuroscience field), but it can also help us identify and assess underlying neurological problems of a patient with movement disorders, and guide therapeutic interventions (clinical field).

The term ‘coordination’ is so strongly ingrained in our common language that we do not typically stop to think about the key underlying features that characterize good and bad coordination–even though we can all distinguish the well-coordinated movements of a trained dancer from those of a novice. What exactly is meant by coordination? And how should it be measured? Addressing these questions is particularly difficult when considering such an abstract concept, which encompasses many different aspects that are not straightforward to define formally.

Indeed, coordinated movements are multidimensional and require the organization of multiple subsystems, e.g., eye-hand coordination [2], intersegmental coordination [3], intralimb coordination [4], interlimb coordination [5]. Given the multiple connotations and associations to the word coordination, in this paper, we attempt to summarize how coordination between upper extremities-a form of interlimb coordination-is interpreted and measured by clinicians, neuroscientists and rehabilitation engineers.

As the reader will see in the following pages, the descriptors of interlimb coordination and how it is assessed vary considerably from field to field, and even within a field. This lack of a common language and standard terminology is a huge barrier to relate the observations from different fields, hindering the understanding and discussion needed to move forward. Further, such definitions are critical for engineers working in translational neurorehabilitation, who harness knowledge from basic and clinical neuroscience to produce technological tools (e.g., robotic devices, instrumented tools) to aid clinicians in their everyday practice. The lack of a common understanding has fostered the use of dozens of ad-hoc algorithms and assessment tools (see section 3), most of which have had limited transfer to everyday clinical applications.

Our long-term goal is to standardize the administration of robotic-and sensor-based assessments of sensory-motor function. Towards this end, we present a summary of different ways in which interlimb coordination has been studied and quantified. We start by presenting a general overview of why the study of coordination between upper limbs is relevant for clinicians and behavioral neuroscientists. We then present a summary of how interlimb coordination is typically assessed in clinical environments and during related motor control experiments. This is followed by a proposal of categorization of interlimb tasks and different outcome measures that are applicable to each task. We believe that the growing scientific community in translational neurorehabilitation research would benefit from this condensed review. …

Continue —> On the assessment of coordination between upper extremities: towards a common language between rehabilitation engineers, clinicians and neuroscientists | Journal of NeuroEngineering and Rehabilitation | Full Text