Thesis (Ph. D.)--University of Oregon, 2006. / Typescript. Includes vita and abstract. Includes bibliographical references (leaves 124-134). Also available for download via the World Wide Web; free to University of Oregon users.

Syftet med studien var att sammanställa arbetsterapeutiska interventioner inom CI-terapi och dess effekter på aktivitetsförmåga för barn med unilateral CP i åldrarna 2-18 år. Åtta artiklar granskades i litteraturöversikten, varav sex var randomiserade kontrollerade studier. De kvantitativa artiklarna analyserades enligt en deduktiv ansats och beskrevs under tre av fyra arbetsterapeutiska interventionsmodeller. I kategorin Modell för kompensation framkom att anpassning av den sociala miljön var av vikt för att främja motivation. I kategorin Modell för aktivitetsträning framkom att aktiviteter bör vara åldersanpassade och att målsättningen ska vara personlig. I kategorin Modell för förbättring av personliga faktorer och kroppsfunktioner framkom att rörelser isolerades genom lek för att ge förbättrad kroppsfunktion. I kategorin Effekter framkom att alla studier beskrev olika ökade positiva effekter med påverkan på aktivitetsförmåga. Resultatet av denna studie visar att motivation och engagemang hos barnet med unilateral cerebral pares vid mottagande av CI-terapi är betydande. Positiv effekt påvisas gällande handfunktion, vilket har en fortsatt märkbar effekt i tre till sex månader. För att få en bild av vilka interventioner som är bäst lämpade för den effekt som önskas finns ett behov av vidare forskning. / The purpose of the study was to compile occupational interventions within Constraint induced movement therapy and their effects on occupational ability for children with unilateral cerebral palsy in the ages 2-18 years. Eight articles were examined in this literature review, of which six of them were Randomised Control Trials. The quantitative articles were analysed according to a deductive approach and described under three out of four occupational intervention models. In the category Compensatory Model results showed that adaptations to the social environment were of importance to enhance motivation. In the category Acquisitional Model results showed that activities should be adapted to age and that the goal should be set individually. In the category Restorative Model results showed that movements could be isolated through play with the purpose of enhancing motor functions. In the category Effects results showed that all articles described different increasing positive effects concerning occupational ability. The result of study shows that motivation and commitment of the child with unilateral cerebral palsy is of great importance when recieving Constraint Induced Movement Therapy. The results concerning hand function show positive effect at the follow-up 3-6 months later. Further research is needed to understand which interventions are most suited to get the desired effect.

Partial paralysis of the hand is one of the main impairments after stroke. Constraint Induced Movement Therapy (CIT) is a new treatment technique that appears to improve upper extremity function after stroke. CIT consists of 6 hours of training/day for the affected arm (mainly with shaping exercises) and of restraint (mitt) of the non affected arm for two weeks. There are concerns about the practicality and resource issues in carrying out CIT according to the original model. In this thesis the benefit of modifications of CIT, of an assessment tool and of two common types of hand training have been evaluated.   CIT (n=16) administered in groups for two weeks (paper I) seems to be a feasible alternative to improve upper limb motor function after chronic stroke. The arm/hand motor performance improved significantly on Motor Assessment Scale (MAS; p= 0.003) and on Sollerman hand function test (p= 0.037). The median self reported motor ability (MAL) also improved (p < 0.001). No additional effect was seen from wearing a mitt for an extended period of three months. The reliability of the Sollerman hand function test (paper II) was studied in patients with chronic stroke. Three examiners observed 24 patients at three experimental sessions. There was agreement (kappa ≥ 0.4) between the examiners for 15/20 subtests. Using total sum scores, the agreement within the examiners was higher than 0.96 (for Spearman’s rhos and ICCs) and agreement between the examiners was higher than 0.96 (Spearman’s rhos) and 0.92 (ICCs), respectively. In a cohort of 24 patients with subacute stroke (paper III) forced use therapy (FUT; mitt use and 3 hours of training/day for 2 weeks) improved arm/hand function, but not more than regular arm therapy given to the control group. Significant improvements in arm/hand motor performance were found in the FUT group (n=12) as well as in the control group (n=12) on the Sollerman hand function test (p= 0.001), on MAS (p< 0.05) and on MAL (p < 0.05). No significant differences were seen between the groups pre- or post training or at three months follow up, demonstrating that the mitt had limited importance. In a separate study on 30 healthy subjects (paper IV), employing transcranial magnetic brain stimulation (TMS), we found that shaping exercises but not general activity training increased dexterity (p<0.05; Purdue peg board test) of the trained non dominant hand. After shaping exercises the cortical motor map shifted forwardly into the premotor area but did not expand. After general activity training the cortical motor map expanded significantly (p=0.03) in the posterior (sensory) direction. Shift of location of active TMS positions rather than their numbers might therefore be a critical factor for the interpretation of cortical plasticity.   In conclusion, the studies in this thesis have shown that less resource consuming modifications of CIT may be feasible to improve upper limb motor function after stroke. The type and amount of training for the more affected arm seems to be an important factor rather than the mitt use in itself. Shaping exercises, at least in healthy people, are effective in improving dexterity and the Sollerman hand function test reliable to evaluate arm/hand function after stroke.

Constraint-induced movement therapy (CIMT) has been demonstrated to yield functional improvements for children with spastic hemiplegic cerebral palsy (CP); however, many studies have reported inconsistent findings with regards to the extent of the benefits observed following the intervention. This study sought to examine the effects of CIMT in the context of a day camp in this population; it also examined the child-therapist (C-T) interaction during the assessment sessions as a potential factor influencing the child’s scores on tests of motor performance. This interaction has not yet been formally measured in the literature, and may influence the perceived outcomes of CIMT. Motor Outcomes: Results demonstrated significant improvements in quality of use of the upper extremity following the intervention; the improvements were maintained at the 3-month follow-up. Analysis of each individual participant yielded additional information on clinically significant improvements. C-T Outcomes: Results demonstrated that the strength of the C-T interaction was significantly and positively correlated with the scores obtained by participants on motor assessments. The results of this study indicate that modified CIMT is effective in inducing lasting and meaningful changes in children with spastic hemiplegic CP. They also suggest that the C-T interaction may contribute to a participant’s performance during the assessment session, which may ultimately affect the perceived outcomes of CIMT. / UOIT

Abstract Background Congenital hemiplegia is the most common form of cerebral palsy accounting for 1 in 1300 live births. Children usually present with greater upper limb than lower limb involvement. Impaired unimanual capacity of the involved upper limb and deficits in bimanual performance contribute to difficulties with day to day activities and participation in home, school and community life. Interventions to address these deficits in upper limb unimanual capacity and bimanual performance have recently shifted focus to address limitations in activity performance rather than underlying impairments. One intensive intervention approach is constraint induced movement therapy, which entails placing a constraint on the unimpaired upper limb to focus intense and repetitive training of the impaired upper limb. To date, it is unclear whether constraint induced movement therapy is superior to a more traditional bimanual therapy to improve activity performance and participation outcomes for children with congenital hemiplegia, as there has been no direct comparison of the two approaches. Aim The primary aim of this research was to determine whether constraint induced movement therapy was more effective than bimanual training to improve activity performance and participation for children with congenital hemiplegia. The specific aims were to: i) determine the efficacy of therapeutic upper limb interventions on activity and participation outcomes for children with congenital hemiplegia, ii) systematically review the clinimetric properties (psychometric properties and clinical utility) of participation assessment tools for children with congenital hemiplegia, iii) examine the relationship between impairments, unimanual capacity and bimanual performance in children with congenital hemiplegia and, iv) determine whether constraint induced movement therapy is more effective than bimanual training to improve activity and participation outcomes for children with congenital hemiplegia. Research Design A matched pairs randomised design was chosen with children matched for age, gender, side of hemiplegia and upper limb function. Children were randomised within pairs to receive either constraint induced movement therapy or bimanual training in equal dosages. Both interventions used a day camp model, with groups receiving the same dosage and content of intervention delivered in the same environment. A novel circus theme was used in the camps to enhance children’s engagement and motivation. Children in the constraint induced movement therapy group wore a tailor made glove on their unimpaired hand during the intervention camp. Outcomes were measured across all domains of the International Classification of Functioning, Disability and Health at baseline, 3 and 26 weeks post intervention. The primary outcome measure for unimanual capacity of the impaired upper limb was the Melbourne Assessment of Unilateral Upper Limb Function, and bimanual performance was the Assisting Hand Assessment. A secondary outcome measure for unimanual capacity was the Jebsen Taylor Test of Hand Function. The Canadian Occupational Performance Measure was used as the primary outcome for participation and three measures, the Assessment of Life Habits, Children’s Assessment of Participation and Enjoyment and the School Function Assessment were included to explore their research utility and responsiveness to change. Results Two systematic reviews were performed prior to the commencement of the randomised trial. The first systematic review and meta-analysis of all upper limb interventions for children with congenital hemiplegia identified four treatment approaches with varying evidence to support their efficacy. Interventions included the use of intramuscular Botulinum toxin A injections to the upper limb augmenting upper limb training, neurodevelopmental treatment, constraint induced movement therapy and hand arm intensive bimanual training. Data were pooled for upper limb, self care and individualised outcomes. Results indicated a small to medium treatment effect favouring all four interventions on upper limb outcomes. Large treatment effects favoured intramuscular Botulinum toxin A injections combined with upper limb training for individualised outcomes. Overall, the systematic review and meta-analysis found no upper limb training approach to be superior although Botulinum toxin A injections appeared to provide a consistent supplementary benefit to a variety of upper limb training approaches. However it was unclear which type of upper limb training was optimal. Findings suggested that the two intensive intervention approaches that are the focus of this randomised controlled trial, constraint induced movement therapy and bimanual intensive training, required further research to support their efficacy. The second systematic review was performed to inform choice of participation measures for the randomised comparison trial. The review identified five specific measures of participation suitable for school aged children with congenital hemiplegia (Assessment of Life Habits, Children’s Assessment of Participation and Enjoyment, School Function Assessment (participation domain), Children Helping Out: Responsibilities and Expectations, School Outcome Measure) and two measures of individualised outcomes that could include specific participation goals (Goal Attainment Scaling and Canadian Occupational Performance Measure). Results suggested that no one measure adequately captured all aspects of participation as outlined in the International Classification of Functioning, Disability and Health, and a combination of assessments would be required to broadly assess children’s participation in home, school and community life. The Canadian Occupational Performance Measure was selected as the primary outcome measure in the randomised trial as it had strong evidence for validity and reliability, had been used in paediatric clinical trials and was responsive to change. Three measures of participation, the Assessment of Life Habits which was completed by the parent/caregiver, the Children’s Assessment of Participation and Enjoyment which was completed by the child, and the School Function Assessment, which was completed by the child’s teacher, were selected to explore the research utility of the measures and their responsiveness to change. Analysis of cross-sectional data collected during screening and baseline assessments for the randomised trial found a strong relationship between bimanual performance and unimanual capacity. Scores on the Melbourne Assessment of Unilateral Upper Limb Function and stereognosis accounted for a significant amount of variance in scores on the Assisting Hand Assessment. There were only moderate associations between impairments (eg. sensory deficits and reduced grip strength) and bimanual performance and unimanual capacity. Age, gender, grip strength and two-point discrimination did not significantly influence bimanual performance. Results of the randomised controlled trial found no differences between groups on any baseline measure. A significant difference between groups favouring the constraint induced movement therapy group was found at 26 weeks on the Melbourne Assessment of Unilateral Upper Limb Function. There were no differences between groups on any other measure at either immediately post intervention at 3 weeks or in the medium term at 26 weeks. The constraint induced movement therapy group made significant gains in unimanual capacity (Melbourne Assessment of Unilateral Upper Limb Function and Jebsen Taylor Test of Hand Function) from baseline to 3 and 26 weeks. The bimanual group demonstrated significant improvement in movement efficiency (Jebsen Taylor Test of Hand Function) by 26 weeks. Significant gains in bimanual performance (Assisting Hand Assessment) were evidenced for both groups from baseline to 3 weeks. These gains were maintained at 26 weeks by the bimanual group only. There were no differences between groups on any participation measures. Both constraint induced movement therapy and bimanual training groups made statistically and clinically significant changes in perceived performance and satisfaction of identified functional goals from baseline to 3 and 26 weeks. Significant gains were made by both groups in personal care on the Assessment of Life Habits from baseline to 26 weeks. There were no changes for either group on the School Function Assessment and Children’s Assessment of Participation and Enjoyment. Conclusions This study found minimal differences between the two training approaches. Outcomes achieved by children reflected the mode of upper limb training, that is, improved and sustained gains in unimanual capacity were achieved with a unimanual approach (constraint induced movement therapy), and significant change in bimanual performance was achieved following bimanual training. The constraint induced movement therapy group made initial improvements in bimanual performance that were not sustained at 26 weeks, suggesting that intensive unimanual training may need to be followed by bimanual training in order to retain effects. Both interventions resulted in significant improvements in the achievement of individualised outcomes. Small gains in participation appeared to correspond with specific goal areas identified by children and their caregivers and highlighted the importance of goal directed training and measuring individualised outcomes. Regardless of the type of approach, intervention needs to be goal-directed, focusing on areas of central importance for children and their families.

Thesis (Ph. D.)--University of Alabama at Birmingham, 2009. / Title from PDF title page (viewed Mar. 31, 2010). Additional advisors: N. Shastry Akella, James E. Cox, Gitendra Uswatte, Victor W. Mark. Includes bibliographical references (p. 50-60).

Bakgrund: Cerebral pares (CP) är den vanligaste fysiska funktionsnedsättningen bland barn. Constraint-induced movement therapy (CIMT) syftar till att öka funktion i den nedsatta handen. Det finns en kunskapslucka kring föräldrars upplevelser av CIMT-träning i barnets vardag. Syfte: Syftet var att undersöka och beskriva upplevelser av CIMT via funktionell terapi bland föräldrar till barn med spastisk hemiplegisk cerebral pares, med fokus på föräldramedverkan, genomförande och följsamhet. Metod: Designen var en kvalitativ intervjustudie med semistrukturerade intervjuer. Metodansatsen var en induktiv kvalitativ innehållsanalys. Resultat: Nio föräldrar från sju familjer deltog i studien. Föräldrarna hade barn i åldrarna fyra till sju år med Gross Motor Function Classification System (GMFCS) 1. Studien resulterade i fyra huvudkategorier; Hinder som måste övervinnas, Draghjälp och stöd, Hantera förväntningar och Lösningar för att få träning att fungera i vardagskontexten, med tillhörande underkategorier. Resultatet visade att tiden är det största hindret och att inblandning av lek är den bästa lösningen att få till träningen i vardagen. Egna förväntningar på sig själv och vikten av yttre stöd beskrevs. Föräldramedverkan visades vara avgörande för genomförande av interventionen. Konklusion: Det är av vikt att ta vara på föräldrarnas upplevelser för bästa genomförande och för att gynna följsamhet vid CIMT. Resultatet kan användas för att utveckla interventionen inom aktuell region.

No description available.

Introdução: A hemiplegia ou hemiparesia é uma sequela decorrente de afecções cerebrais que resultam em limitações funcionais contralaterais ao hemisfério lesado. Esta afecção pode causar alterações de tônus, de coordenação e de equilíbrio podendo resultar em desuso do membro acometido e restrição na participação social de crianças. A Terapia de Movimento Induzido por Restrição (CIMT) é uma técnica que objetiva melhora na função motora dos membros superiores com consequente diminuição das limitações funcionais. Essa técnica possui três componentes fundamentais: treino intensivo de terapia orientada à tarefa, conjunto de métodos comportamentais e uso de restrição no membro superior não afetado pela hemiparesia. Objetivo: Partindo do princípio de que a terapia é mais eficiente quando iniciada em idade precoce, o objetivo deste estudo é investigar os efeitos do protocolo adaptado da CIMT em lactentes com hemiparesia ou assimetria de membros superiores. Método: Participaram do estudo 5 lactentes com idade entre 6 e 24 meses que apresentaram hemiparesia ou assimetria dos membros superiores. Os instrumentos utilizados para avaliar a função motora foram Pediatric Motor Activity Log (PMAL) e Avaliação da Função Manual (AMIGO). O Inventário de Avaliação Pediátrica de Incapacidade (PEDI) foi aplicado aos cuidadores afim de avaliar a percepção dos mesmos sobre a participação funcional do lactente em tarefas de vida diária. Todas as avaliações ocorreram antes, imediatamente após a intervenção, e após 4 meses da aplicação do protocolo para registro de follow-up. Os dados foram analisados descritivamente e por meio de análise utilizando o método Jacobson-Truax. Resultados: Os resultados demonstraram aumento quantitativo e qualitativo na utilização do membro lesado, bem como, na função unimanual e bimanual. / Introduction: The hemiplegia or hemiparesis is a sequel caused by cerebral conditions resulting in contralateral functional limitations to the damaged hemisphere. Such conditions may cause tonus, coordination, and equilibrium alterations, which may result in disuse of committed limb and a restriction in social living of the affected infants. The Constraint-Induced Movement Therapy (CIMT) is a technique aiming the improvement of superior limb motor function and consequent decrease of functional limitations. This technique presents three fundamental components: task-oriented intensive training, a set of behavioral methods, and the use of restraining in the limb not affected by hemiplegia. Objective: Assuming that the therapy is more efficient when initiated in early years, the objective of this study is to investigate the effects of CIMT in nursing children presenting hemiparesis or superior limbs asymmetry. Method: Five infants with ages between 6 and 24 months presenting hemiparesis or superior limb asymmetry were selected. Pediatric Motor Activity Log (PMAL) and Avaliação da Função Manual (AMIGO) were used to evaluate the motor function. The Pediatric Evaluation of Disability Inventory (PEDI) was filled by the caretakers to evaluate their perception about the functional participation of the infant on dairy tasks. All evaluations were performed prior, during, and after the CIMT. Additionally the infants were re-evaluated after 4 months of MIRT to keep the follow-up register. All data were analyzed descriptively and by analysis for Jacobson-Truax method. Results: The results present a quantitative and qualitative increase in the use of affected member, as well as in the unimanual and bimanual function.

Introdução: A hemiplegia ou hemiparesia é uma sequela decorrente de afecções cerebrais que resultam em limitações funcionais contralaterais ao hemisfério lesado. Esta afecção pode causar alterações de tônus, de coordenação e de equilíbrio podendo resultar em desuso do membro acometido e restrição na participação social de crianças. A Terapia de Movimento Induzido por Restrição (CIMT) é uma técnica que objetiva melhora na função motora dos membros superiores com consequente diminuição das limitações funcionais. Essa técnica possui três componentes fundamentais: treino intensivo de terapia orientada à tarefa, conjunto de métodos comportamentais e uso de restrição no membro superior não afetado pela hemiparesia. Objetivo: Partindo do princípio de que a terapia é mais eficiente quando iniciada em idade precoce, o objetivo deste estudo é investigar os efeitos do protocolo adaptado da CIMT em lactentes com hemiparesia ou assimetria de membros superiores. Método: Participaram do estudo 5 lactentes com idade entre 6 e 24 meses que apresentaram hemiparesia ou assimetria dos membros superiores. Os instrumentos utilizados para avaliar a função motora foram Pediatric Motor Activity Log (PMAL) e Avaliação da Função Manual (AMIGO). O Inventário de Avaliação Pediátrica de Incapacidade (PEDI) foi aplicado aos cuidadores afim de avaliar a percepção dos mesmos sobre a participação funcional do lactente em tarefas de vida diária. Todas as avaliações ocorreram antes, imediatamente após a intervenção, e após 4 meses da aplicação do protocolo para registro de follow-up. Os dados foram analisados descritivamente e por meio de análise utilizando o método Jacobson-Truax. Resultados: Os resultados demonstraram aumento quantitativo e qualitativo na utilização do membro lesado, bem como, na função unimanual e bimanual. / Introduction: The hemiplegia or hemiparesis is a sequel caused by cerebral conditions resulting in contralateral functional limitations to the damaged hemisphere. Such conditions may cause tonus, coordination, and equilibrium alterations, which may result in disuse of committed limb and a restriction in social living of the affected infants. The Constraint-Induced Movement Therapy (CIMT) is a technique aiming the improvement of superior limb motor function and consequent decrease of functional limitations. This technique presents three fundamental components: task-oriented intensive training, a set of behavioral methods, and the use of restraining in the limb not affected by hemiplegia. Objective: Assuming that the therapy is more efficient when initiated in early years, the objective of this study is to investigate the effects of CIMT in nursing children presenting hemiparesis or superior limbs asymmetry. Method: Five infants with ages between 6 and 24 months presenting hemiparesis or superior limb asymmetry were selected. Pediatric Motor Activity Log (PMAL) and Avaliação da Função Manual (AMIGO) were used to evaluate the motor function. The Pediatric Evaluation of Disability Inventory (PEDI) was filled by the caretakers to evaluate their perception about the functional participation of the infant on dairy tasks. All evaluations were performed prior, during, and after the CIMT. Additionally the infants were re-evaluated after 4 months of MIRT to keep the follow-up register. All data were analyzed descriptively and by analysis for Jacobson-Truax method. Results: The results present a quantitative and qualitative increase in the use of affected member, as well as in the unimanual and bimanual function.