HABIT (Hand Arm Bimanual Intensive Therapy) M.S.Rekha SpR Paediatrics.

HABIT (Hand Arm Bimanual Intensive Therapy)

M.S.RekhaSpR Paediatrics

Outline

• Cerebral palsy• Embryology and patho-physiology• Key issues affecting therapy• HABIT• Future

24/05/2010 North West CP Network Meeting HABIT


• CP – incidence 1:500• 36% Hemiplegic CP• UL > LL• Impairment

– Spasticity, Posturing, Sensation, Reduced strength

• Intellectual capacity• Impact

Cerebral Palsy

UL problems in CP• Integrity of motor cortex

and cortico-spinal tracts affected

• Precision grasping affected• Fine control of hands and

fingers affected• Abnormal tone• Abnormal posturing • Tactile and proprioceptive

disturbances


Therapy - Pathophysiology• How nervous system develops and functions

• Basis for the neural impairments

• Neurogenesis• Neuroplasticity

– Synaptogenesis– Cortical Maps– Long term potentiation– Primary areas– Stem cells



Key issues

• Problems with bimanual coordination > uni-manual deficit

• Restraining a child’s non-involved limb– invasive – frustrating– de-motivating

• Children have never learned to use the affected limb

CIMT • Developed in adult to overcome learned non-use (children have to overcome developmental non-use)

• Invasive (it is practice not the restraint which helps)

• Uni-manual vs bimanual skills training (children compensate well with non-involved limb but not effectively) 24/05/2010 North West CP Network Meeting HABIT

HABIT• Motor learning• Neuroplasticity

• Use of involved hand as a typically developing child uses non-dominant hand

• Practice = Improvement in function• Structured practice based on how CNS responds• Ensure

– Optimum task & response– Gradually increase complexity– Motivation, Rewards


Evidence

• 1 Single blinded RCT (Gordon et al, 2007)• Hemiplegic CP with Mild – Moderate hand involvement• 20 children (3.5 – 15.5 yrs)• Randomized to intervention or delayed treatment control

group• Evaluation before and after and 1mth post intervention

– Assisting Hand Assessment– Increased involved extremity use (Accelerometry & Caregiver survey)– Bimanual items of Bruiniknks-Oseretsky test of Motor proficiency– Jebsen-Taylor test of hand function– Simultaneity of completing a draw opening task with 2 hands (p<0.)5

in all cases)24/05/2010 North West CP Network Meeting HABIT

HABIT• Select task: Functional activities - bimanual hand use (based

on individual child)

• Ground rules re use of non-involved limb

• Structured practice – for 15 – 20 mins at a time (6 hours /day for 10 days)

• Gradually increasing in complexity (tailored to each child)

• Child friendly (goals, parental involvement)

• Home practice 1 hr/day during and 2hrs/day after intervention 24/05/2010 North West CP Network Meeting HABIT


Taken from presentation by Charles & Gordon on webIntensity-based rehabilitation of the upper extremity in children with congenital hemiplegia

HABIT (Charles & Gordon, 2006)


Future

• Larger, robust, multi-centre RCTs would be needed comparing different strategies

• Boyd et al, 2010 conducting RCT comparing CIMT and BIM training


References• Development of hand-arm bimanual intensive training (HABIT) for improving

bimanual coordination in children with hemiplegic cerebral palsy. Charles J & Gordon A, Developmental Medicine & Child Neurology, 2006 Nov;48(11):931-6.

• Efficacy of a hand-arm bimanual intensive therapy (HABIT) in children with hemiplegic cerebral palsy: a randomized control trial, Gordon et al, Developmental Medicine & Child Neurology, 2007 Nov;49(11):830-8.

• Systematic Review and Meta-analysis of Therapeutic Management of Upper-Limb Dysfunction, Sakzewski et al. Pediatrics.2009; 123: 1111-1122.

• INCITE: A randomised trial comparing constraint induced movement therapy and bimanual training in children with congenital hemiplegia, Boyd et al. BMC Neurology 2010, 10:4 http://www.biomedcentral.com/1471-2377/10/4

• Neuroplasticity in Children, Mundkur N, Indian Journal of Paediatrics, 2005 72 (10): 855 - 7


http://www.biomedcentral.com/1471-2377/10/4

Thank youQuestions?


NeurogenesisPrenatal• Neurogenesis • Neuronal proliferation • Migration & Aggregation • Axonal growth &

synaptogenesis


Postnatal• Synaptogenesis and

myelination till 2yrs

Process continues at reduced rate

Synaptic pruning• Dynamic state• Birth – 2500 connections• @15,000 (double the adult

size) at the age of 2yrs• Apoptosis – Pruning

Neuroplasticity

• Ability of the brain to constantly reorganise neural pathways based on new experience and learning

• Ability of brain to change with learning– Several processes involved– Different types of plasticity at different times– Developmental/Adaptive – Environmental


Neuroplasticity• Individual connections - strengthened or removed• “Neurons that fire together wire together”• Neurons active together - synapses strengthened & preserved• Those not active are pruned (continues till 16yrs)• Activity between close neurons leads to

cortical maps becoming one

• Neural development – Gene expression– Neurotransmitters– Neurotrophins


Adaptation• Capacity to adapt and

change connections in response to new information, stimulation, damage

• Reorganisation of cellular &neural networks

• Synapses formed in response to stimulation

• Long term potentiation

• Primary areas not fixed• Neurogenesis after

damage


Neuroplasticity


HABIT (Hand Arm Bimanual Intensive Therapy) M.S.Rekha SpR Paediatrics.

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