Remind to move : a comparison of its effect with constraint-induced movement therapy and conventional therapy on upper limb functions for children with hemiplegic cerebral palsy

Abstract

Development of an effective intervention for children with hemiplegic cerebral palsy (CP) is imperative during development to reduce the overall impact of the disability in daily life. Children with hemiplegic or unilateral cerebral palsy (CP) are typically characterized by motor impairments primarily lateralized to one side of the body, usually presenting with greater upper limb than lower limb involvement. These motor impairments frequently limit daily activities, including school participation, of children with hemiplegic CP. Such children often learn strategies to manage bimanual activities with the unaffected hand only and gradually develop a pattern of non-use in the more affected (hemiplegic) hand, which usually referred to as 'developmental disregard'. This unilateral use and subsequently disregard leads to asymmetrical motor development greater impairment due to the lack of routine and spontaneous hand use in everyday life. Paediatric Constraint-induced movement therapy (pCIMT) and intensive bimanual training (BIT) are two fairly new approaches of upper limb management commonly used among occupational therapists with children who have hemiplegic CP. pCIMT involves utilizing a restraint on the less affected hand along with forced use of the more affected hand; thereby improving the unilateral capacity of the more affected hand. BIT provides bimanual activities which focus on improving the coordination of both arms by using structured tasks in bimanual play and functional activities with intensive practice. A systematic review (Dong, Tung, Siu, & Fong, 2013) included in this thesis aims: 1) to review the previous studies comparing the efficacy of the pCIMT and the BIT in improving impaired arm function and overall functional performance for children with hemiplegic CP; 2) to identify the strengths and limitations of both interventions; 3) to address the key successful factors of arm rehabilitation. Briefly the overall findings indicated that both pCIMT and BIT produced similar effects on upper limb functions, but pCIMT shows greater potential to increase the spontaneous hand use and reduce 'developmental disregard', whereas BIT is more effective in improving bimanual coordination during performance of bimanual functional tasks. The review concluded that successful arm rehabilitation in children with CP should involve intensive practice, immediate feedback, age-appropriate and child-friendly interaction and activities. pCIMT does present some limitations. A major concern with pCIMT studies is the choice of restraints. Most agree that restraints for children are problematic since such populations generally do not like their arms restrained, particularly when when they are playing outdoors. The other limitation is the intensive external verbal and physical promotion required to encourage children to properly practice the training tasks. Perhaps the most important limitation is that pCIMT only focuses on unimanual tasks and does not allow practice of bimanual activities. In response to these limitations, an innovative and original approach - 'Remind to move' (RTM) treatment was developed to target hemiplegic arm functions in children with CP. RTM treatment involves two key elements: sensory cueing on the more affected arm and structured bimanual coordination and/or unimanual practice. A portable sensory cueing wristwatch device - worn as an external cue on the more affected arm as opposed to a restraint on the less affected hand - is set up to emit continuous sensory cues to increase the user's attention on the more affected hand and reminding the user to be aware of and promote the use of the more affected hand. After receiving a cue, the participant uses the more affected hand to perform predetermined, tailor-made, activities intensively. Two preliminary studies have shown that RTM treatment is useful in improving a child's arm motor-functions and functional hand use (Dong & Fong, 2015a; Fong et al., 2012). The first preliminary study (Fong et al., 2012) investigated the effects of a 3-week treatment using the same protocol stated above (i.e. cue, then performance), by comparing the effects of sham treatment (participants wore an inactivated wristwatch on the more affected arm) with RTM treatment (sensory cueing emitted from the wristwatch device along with intensive arm movement) for eight children with hemiplegic CP who attended a special school. The findings showed that the RTM treatment is useful for promoting hemiplegic arm motor efficiency, the sham treatment showed no changes. This pilot study provides proof-of-concept data indicating that a wearable device might be useful to remind children with CP to perform a set of pre-determined arm exercises to promote hemiplegic arm functions in children with hemiplegic CP. Another preliminary study (Dong & Fong, 2015a) was conducted as a randomised cross-over design for 12 children with hemiplegic CP. This study also examined the RTM treatment a 3-week sensory cueing treatment involving repetitive practice of tasks involving hemiplegic upper limb functions. Again, the RTM treatment outperformed the sham treatment. Encouragingly, both functional hand use and arm impairment level significantly improved after the 3-week sensory cueing treatment for the combined sample between groups, unfortunately, no significant carryover effects were found for either treatment. Although the beneficial effects of RTM treatment were found in the two pilot studies, it was still unknown if this treatment could be used interchangeably with other common upper limb interventions, such as pCIMT. In order to clarify whether the RTM treatment would yield an equivalent outcome with the pCIMT for both activity performance, spontaneous hand use and participation, we performed the first multi-centre randomised controlled trial (RCT) to compare the effects of RMT treatment with the dosage-matched pCIMT and conventional therapy on upper limb functions in children with hemiplegic CP (Dong, Fong, Chen, Tseng, & Wong, 2016). The results demonstrated that a greater improvement in motor efficiency and spontaneous use of the affected hand in the children treated with either RTM or pCIMT, compared with those from the conventional therapy group. Thus, the findings confirmed that RTM treatment can be used as an alternative treatment for the hemiplegic upper limb in children with CP (Dong, et al., 2016). This thesis also presents validation data for two assessments. The Chinese version of Caregiver Functional User Survey (C-CFUS) (Dong & Fong, 2015b) was developed to assess caregivers' perceptions of how frequently and how well their children used the involved arm to perform everyday bimanual tasks in real situations. C-CFUS had previously been used as an outcome measure for evaluating the effectiveness pCIMT and intensive bimanual training in children with hemiplegic CP. A Chinese version of The School Function Assessment (SFA) was developed and validated for children with CP in primary special schools for measuring their school performance and participation (Li, Dong, & Fong, 2015). It consists of three parts -- participation, task supports, and activity performance, which systematically and comprehensively identify the student's strengths as well as the limitations that may influence his/her participation in a variety of tasks in the school environment.