Neurodevelopment and intervention - research projects

Constraint Induced Movement Therapy for children

Research group leader: Ann-Christin Eliasson

Constraint Induced Movement therapy (CI therapy) has recently regained attention as a possible intervention for children with hemiplegic cerebral palsy (CP). The main principle of the treatment is twofold: restraint of the uninvolved hand and intensive and specialised practice with the involved hand during a specified time period.

The main research question has been to evaluate the effects of a modified version of CI therapy and make comparisons with conventional paediatric treatment in young children with hemiplegic CP. In particular, we would like to consider whether this type of unimanual treatment has an effect on the performance of tasks where, commonly, two hands are needed. We have been involved in developing this intervention for children of different ages since the beginning of the year 2000, and this has resulted in several publications from our research group.

One of the projects has been to make this model suitable for small children from 18 months of age onwards. In this case we have developed an individualised home training programme. Data collection from a randomised controlled trial has just been completed.

The other project is to adjust the intervention programme to make it fun enough to attract teenagers. A day-camp programme primarily consisting of performing daily and recreational activities has been developed. This programme has been running in a motivating setting, in an open recreational area that is very different from traditional treatment settings. For these older children and teenagers, the training period was mainly concentrated into two weeks and the restraints were mainly worn during the practice hours, and never for less than six hours per day. For younger children, a modified version with fewer hours per day over a longer time period was used.

The challenge is to explore children's possibilities to improve their hand use in daily life. Today, CI therapy is one of the most evidence-based interventions available in paediatrics

Future research

Although this form of therapy is promising, there are recurrent questions, for example of whether there is a certain age where this intervention is more effective than others, whether the degree of functional limitation influences the outcome, or whether certain types of brain lesion are more responsive to intervention than others. We are also working on developing the concept further, to include younger children. The next important step is to implement the method in clinical practice. We are writing a handbook which will be available free on the Internet.

Ann-Christin Eliasson, Professor, Occupational therapist, research group leader

Development of assessments

For most people, using both hands together is a natural part of everyday activities. But for children with a unilateral disability in the arm and hand, activities requiring two hands are often a challenge.

In order to evaluate interventions that optimise the use of the affected or assisting hand, valid and reliable measures are needed. The Assisting Hand Assessment (AHA) is a newly developed test with the expressed purpose of measuring and describing how effectively children with a unilateral disability in arm and hand use their assisting hand during bimanual tasks. An AHA assessment involves a video-taped play session, which elicits spontaneous use of the hands by using toys that require bimanual handling. The play session is scored using a 4-point rating scale for 22 items which are describing object-related hand actions. The AHA was initially validated for children aged 18 months to 5 years with unilateral cerebral palsy (CP) or obstetric brachial plexus palsy (OBPP) (Small Kids AHA). A test kit for older children containing two board games suitable for children aged 6-12 years has been developed (School Kids AHA). The aim of the research was to evaluate the psychometric properties of the AHA including the expanded age group and to describe the longitudinal development of assisting hand use in children with unilateral CP.

AHA validation

The validity of the AHA for ages ranging from 18 months to 12 years was investigated. Using a Rasch measurement model, 409 AHAs of children with unilateral CP or OBPP were analyzed. Results showed that the items measure a unidimensional construct and that the four-point rating scale overall functions well. An excellent targeting between the item difficulties and the childrens abilities was found. A high person separation indicates that the AHA can effectively separate between children of different ability into seven distinct ability strata. Differential item functioning between diagnostic groups was identified in some items and discussed.

AHA reliability

The reliability of the AHA as regards the inter- and intrarater, retest and alternate forms reliability was investigated. In all trials high reliability coefficients (Intraclass Correlation Coefficients) were found, ranging from 0.97 to 0.99. The retest evaluation indicated that the smallest detectable difference measurable with the AHA is a change of 4 points (6% of the scale). It was further found that all tested versions, the Small Kids vs. School Kids AHA and the two board games in School Kids AHA, produce equal results and measure the same construct.

Development of assisting hand use

The development of assisting hand use between the ages 18 months and 8 years was investigated among 43 children with unilateral CP. The children were regularly assessed using the AHA for on average 4.5 years. All children increased their assisting hand use during the course of the study. A non-linear mixed model was used to create separate average development curves for children at different levels on the Manual Ability Classification System (MACS). The maximum level (limit) of development differed between children in MACS levels I-III. The rate of change was similar in levels I and II and significantly slower in children at level III. The children were also divided into two groups based on their AHA-score at 18 months. The limit and rate of change differed significantly between the groups. The AHA score at 18 months can be used for approximate prediction of future development of assisting hand use.

Marie Holmefur, PhD, Occupational therapist

Early diagnosis and intervention for hemiplegic CP

In this new project, we are going to investigate at what age it is possible to detect and measure asymmetrical hand function that might lead to hemiplegic CP.

A brain lesion involving one hemisphere typically leads to hemiplegic CP. Some of the children are born preterm but maldevelopment and neonatal stroke can also lead to this diagnosis. Some children have early lesions that have gone unnoticed by the parents until they recognize that their child is mainly using only one hand. This happens between 4 and 8 months of the child's age.

Today, no assessment is available which is sensitive enough to detect this early dysfunction. A previously developed test, Assisting Hand Assessment (AHA) measures the effectiveness of the hemiplegic hand in bimanual activities. It was developed for children aged from 18 months onwards and has now been adapted for children aged from 3 months and named Infant Asymmetrical Hand Assessment (IAHA). This assessment is under statistical review for validity on children with typical development and children with a risk of developing hemiplegic CP.

By using IAHA, we will be able for the first time to describe the early development of hand function for children with hemiplegic CP. Then, we are aiming to invite families to participate in a training study that will use a modified form of Constraint Induced Movement therapy (CI therapy). This method has previously been used for children from 18 months with good effect. In CI therapy the child wears a simple glove on the most developed hand to reduce the use of that hand in favour of the less developed hand. From clinical practice, we know that even young babies stop using the less developed hand already at 4 months of age.

The aim of the training is to make sure that the children do not avoid using the less developed hand and to stimulate them to develop ability in both hands. The training must be undertaken at intervals during the first year, depending on the type of brain lesion and on the motor projection pattern

Ann-Christin Eliasson, Professor, Occupational therapist, group leader
Lena Krumlinde-Sundholm, Med Dr, Occupational therapist, group leader