Bilateral training to increase functional independence in hemiplegic CP children – May 2007 Fact Sheet Increasing attention is being given to intensive functional training as a means of increasing motor function in the disabled. One form of intensive training is constraint-induced movement therapy (CIMT), which aims to increase the amount and quality of upper extremity movement in children with hemiplegic cerebral palsy (CP). A number of studies have suggested that CIMT is beneficial for many individuals with CP (see CIMT fact sheet, March 2007). However, CIMT has a number of limitations, including the fact that it is potentially invasive, and it focuses exclusively on one hand impairments, which does not greatly impact functional independence and quality of life. Given recent work showing impaired coordination of both hands, a better goal of upper extremity rehabilitation would be to increase functional independence and quality of life by improving use of both hands in cooperation. Bilateral (or bimanual training) is a new class of interventions aimed at increasing the efficiency of movement in the context of using both hands together. The brain and spinal cord underlying human dexterity are capable of considerable reorganization after damage, likely responsible for recovery of function. Pathways on the same (ipsilateral) side of the impaired upper extremity have been implicated in the control of the affected hand in CP as well as the recovery of function after stroke in adults. Thus, task recruitment of these ipsilateral pathways, such as symmetrical bilateral movements, may be beneficial. Bilateral practice may result in changes in cortical representations and excitability in the undamaged hemisphere. This reasoning has provided the basis for bilateral training protocols in adults with stroke (e.g., 1). The efficacy of bilateral training in the stroke population is not clear, although several studies report positive outcomes. However, it should be noted that most of these training protocols involve non-functional, repetitive symmetrical movements (e.g., upper extremity cycling). Such tasks are unlikely to sustain interest for sufficient periods of time in children. Thus, protocols need to be created that are child friendly. To date, there is limited work on bilateral training in the pediatric population. One protocol, Hand-Arm Bimanual Intensive Training (HABIT) has recently been developed and tested with support from the United Cerebral Palsy Research and Education Foundation (2). HABIT takes advantage of the key element of CIMT, intensive practice, but does not involve restraint of the less affected upper extremity. Instead, it utilizes structured (part and whole) task practice embedded in bimanual play and functional activities. Task difficulty is increased by progressing the more affected hand from a passive stabilizer to an active manipulator. HABIT is performed in a day-camp setting and is based on understanding of the mechanisms of underlying hand impairments in CP, recognized benefit of treatment intensity, principles of motor learning and neuroplasticity using prototypical behaviors, goal orientation, knowledge of results, motivation and rewards. In a small randomized trial, researchers at Teachers College, Columbia University have presented the results of a preliminary study of HABIT (3). A single-blinded randomized control study was performed to examine its efficacy in 20 children (3.5-15.5 yrs). Children were engaged in play and functional activities that provided structured bimanual practice six-hours per day for 10 days. Children who received HABIT demonstrated improved scores on the Assisting Hand Assessment and bimanual items of the Bruininks-Oseretsky Test of Motor Proficiency, increased involved extremity use measured using accelerometry and a caregiver survey, and better coordination completing a draw-opening task with two hands measured kinematically. Thus, the results from this report were encouraging. Comment: Bimanual training is based on sound scientific principles, and in theory, should address some of the limitations of CIMT. Despite its promise, a more complete understanding of the neurological basis of hemiplegia and mechanisms of recovery are needed to fine-tune such protocols. Larger studies across a more diverse subject population with long-term follow-up are required. The appropriate age and impairment levels need to be identified and factors such as side and location of brain damage, attention span, optimal dosage and identification of key ingredients need to be considered to ultimately define the most efficacious rehabilitation strategy. Finally, the extent to which it may compliment CIMT will be of interest. (1) Cauraugh JH, Summers JJ (2005) Neural plasticity and bilateral movements: A rehabilitation approach for chronic stroke. Prog Neurobiol:75:309-320 (2) Charles J, Gordon AM (2006) Development of Hand-Arm Bimanual Intensive Therapy (HABIT) for Improving Bimanual Coordination in Children with Hemiplegic Cerebral Palsy. Dev Med Child Neurol 48:931-936. (3) Charles J, Gordon AM (2006) Efficacy of Hand-Arm Intensive Bimanual Training (HABIT) on upper extremity movement in children with hemiplegic cerebral palsy. Dev Med Child Neurol 48: 24 (Supplement No. 106)

Could robotics improve walking ability of children with cerebral palsy?
By Paolo Bonato, PhD – July 2007 Fact Sheet

A decrease in walking proficiency and economy is a major cause of physical disability in children with CP. High lower limb agonist-antagonist muscle coactivations, increased tone, tightness of Achilles tendon, and knee and hip musculature cause abnormal gait and high energy expenditure while walking. As a result, a high precentage of children with CP have a gait that is characterized by slow speed and disturbed motor control.

Training interventions to improve gait outcomes in CP usually include strength training, balance control and weight bearing activities. Recent studies have demonstrated beneficial effects of intensive task-specific gait training on motor recovery in children with CP 1-2 as well as adults with paraparesis and hemiparesis.

Recent developments in the neuro-rehabilitation field have been stimulated by information on neuronal recovery processes and their modulation by various physical and pharmacological interventions. There is a growing body of evidence demonstrating that the human brain is capable of significant recovery providing that the amount and frequency of treatments are applied appropriately. In addition to quantity, the quality of the intervention is equally important with task specific interventions enhancing neural reorganization and behavioral recovery.3-5

Task oriented rehabilitative gait techniques include Body Weight Supported Treadmill Training (BWSTT). BWSTT enables severely affected individuals to follow principles of motor learning and to train while walking. Treadmill training has been often cited as task-specific training because it allows for complete gait cycles with multiple repetitions facilitated by the treadmill’s consistent rate of movement. Several studies have shown the potential of this technique in patients after stroke, spinal cord injuries and children with CP.1,2,6

Despite the potential benefits of BWSTT, its application in the clinical setting is physically demanding and limited by personnel time and labor requirements. At least two therapists are involved in a gait training session. They manually guide the lower extremities of the patient to facilitate movement of the limbs during ambulation. Often a third individual is involved to stabilize the pelvis. Recently, robotic devices referred to as driven gait orthoses (DGOs) have been developed to assist in the delivery of BWSTT. A DGO is a computer-controlled exoskeleton that is secured to a person’s legs while he/she is supported over a motorized treadmill using an unloading system. A DGO replaces the manual assistance provided by therapists with guided lower extremity trajectories that are consistent with physiological gait patterns.

Led by Paolo Bonato, PhD and Donna Nimec, MD and supported by UCP Research and Educational Foundation, a group of researchers at Spaulding Rehabilitation Hospital in Boston MA (which is home to the Harvard Medical School Department of Physical Medicine and Rehabilitation) is conducting a study on the use of a DGO (Lokomat, Hocoma AG, Switzerland) to enhance gait retraining in children with CP. The robotic components of the device drive the knee and hip joints, which enables movement through symmetric, coordinated trajectories that mimic physiological walking patterns. Although studies with this robotic-assisted BWSTT have been performed and are underway in the adult spinal cord injured and post-stroke populations, to date there is no published literature on the use a DGO in the pediatric population. Therefore, there is a great deal of excitement about this ongoing study in children with CP at Harvard Medical School.

The research team (including Anat Mirelman, PT and Ben Patritti, PhD, who are responsible for carrying out the training and evaluation sessions) anticipates that the use of a DGO will maximize locomotor function in children with CP by increasing the duration, intensity and specificity of training while overcoming the limitations of the labor intensive interventions provided by therapists during traditional BWSTT. The research is a pilot study to investigate the suitability of the DGO for training children with CP, and to develop protocols that will allow clinicians to achieve in children with CP the encouraging results already attained in other adult patient populations.

Schindl MR, Forstner C, Kern H, Hesse S. (2000) Treadmill training with partial body weight support in nonambulatory patients with cerebral palsy. Arch Phys Med Rehabil 81:301-306

Maltais D, Bar-Or O, Pierrynowski M, Galea V. (2003) Repeated treadmill walks affect physiologic responses in children with cerebral palsy. Med Sci Sports Exerc. 35(10):1653-1661

Nudo RJ, Wise BM, SiFuentes F, Milliken GW. (1996) Neural substrates for the effects of rehabilitative training on motor recovery after ischemic infarct. Science 272:1791-1794

Liepert J, Bauder H, Miltner WHR, Taub E, Weiller C. (2000) Treatment- induced cortical reorganization after stroke in humans. Stroke. 31:1210-1216

Barbeau H. (2003) Locomotor training in neurorehabilitation: emerging rehabilitation concepts. Neurorehabilitation & Neural Repair 17(1):3-11

McNevin NH, Coraci L, Schafer J. (2000) Gait in adolescent cerebral palsy: the effect of partial unweighting. Arch Phys Med Rehabil 81:525-528

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Could robotics improve walking ability of children with cerebral palsy?
By Paolo Bonato, PhD – July 2007 Fact Sheet

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Could robotics improve walking ability of children with cerebral palsy? By Paolo Bonato, PhD – July 2007 Fact Sheet

Could robotics improve walking ability of children with cerebral palsy?
By Paolo Bonato, PhD – July 2007 Fact Sheet