Thinking about the evidence of new therapeutic approaches (supposed the most “efficient”) in the rehabilitation of the child’s hand with hemiparesis

How can ICF help us?

   

Ascensión Martín Diez Physiotherapist-phycomotor therapist, CDIAP Mollet

HEMIPARESIS IN CHILDREN

Children with hemiparesis spontaneously learn to manage daily tasks: manipulating, playing, eating, dressing, undressing, sitting, moving, drawing… Primarily on the unaffected side (because on this side movements are faster and more functional, even if only there is slight disorder of the affected limb).

◦  (Kuhtz-Buschbeck 2000).

Factors affecting the use of the hand

�  Sensory abnormalities, �  Rate of motion alteration, slowness �  Impaired fine motor skills, little variability of movements �  Alteration of fine movements of the wrist and fingers �  Alteration of force �  Lack of anticipation and adaptation (need + practice) �  Grip weakness �  Retention grasp reflex �  Mirror movements and / or associated reactions �  Spasticity, hypotonia / (flaccidity, weakness) and / or dystonic movements

OVER TIME: �  Loss of range of movement in the last degrees of movement �  Muscle-tendinous retractions �  Contractures and deformities with predominance in some muscle groups rather than in

others �  Pain, rejection, shame �  DISUSE

(Brown 1987; Eliasson 1995; Eliasson 2000).

Bimanual coordination in hemiparetic CP

◦  Bimanual coordination consists in the ability to anticipate the force control and the selection of movements between both hands to solve a task quickly and efficiently.

◦  In bimanual activities decreases the efficiency of the movement and function, including the activity of the healthy hand

◦  They are faster and effective in

use only the non affected hand. (Eliasson, 2009)

“Restriction of development”

�  Eliasson 2003 suggested that "learned nonuse" may be different in children, as they had no experience of normal motor function of the limb as in adults.

�  A child with hemiparesis may restrict, or "learn not to use", the affected limb during development of motor function.

Marco Teórico de la Atención Temprana �  Interdisciplinary approach:

◦  Addressing the psychosocial aspects. Classification (ICF)

�  Comprehensive care: child and family

�  Evidence on the effectiveness of some specific interventions

◦  Model focused on the needs of the family and the environment (daily life tasks)

◦  Significant task identification. Functional approach.

◦  Intervention Protocols

◦  Registration and Evaluation (R.Palisano 2009)

Law et al. Phys Occ Ther in Ped. 1998, Ketelaar et al Phys Ther 2001 Ekstrom Ahl et al. Dev Med Child Neurol. 2005

TRENDS IN REHABILITATION IN

HEMIPARETIC CP Current research in the CP is more focused on studying: What the child can do for himself in the different environments more than in the structures and motion analysis If most of the current neuro-rehabilitation based on the assumption that patients can improve if they experience and practice functional and meaningful tasks in natural environments…

We should consider if:

◦ There is improvement ◦ The effects persist after the intervention ◦ The improvements are generalized in daily

tasks (Learning)

…with the therapy

Possible types of intervention for improved hand function?

�  Medical treatment �  Botulinum toxin �  Hand surgery �  Electrical stimulation �  Orthotics �  Task-orientated treatment approach �  Learning specific activities �  Age related activities �  Computer games �  Training of general competence

�  CI therapy �  Bimanual training �  Movement training �  Computer game/virtual reality �  Environmental changes �  Technical aids �  Adjustment of environment

Emerging therapies focused on the activity for the treatment of the affected upper extremity

in hemiparesis CP

Level of evidence?

Level of evidence and limitations mCIMT/HABIT

mCIMT HABIT

Focused in function

Improvement in unimanual performance for the affected upper extremity

Limited improvement in social

participation

Protocols should be review

Focused in activity

Improvement in bimanual performance and achievement of children own goals

Limited improvement in social

participation

Protocols should be review

More risk of compensatory movements

Recent evidence suggest that a combined use of both therapies could be more efficient

Studies comparing the efficacy of mCIMT and BIT in children with unilateral cerebral palsy: A systematic review.

An-Qin Dond et al. Dev Neurorehab, 2012 1-11

Clinical Case Health Condition

Cardiopathy, H CP

Body Function & Structure

Cardiopathy + 2 surgeries Arterial Isquemic Stroke

DAFO + jig

Hand splints: day & night

Activity

Independent mobility

Little bimanual activity

Difficulties in daily tasks

GMFCS: level I AHA < 15

MACS: level II

Participation

Home Aquatic activity

Hipotherapy Day care centre Church meeting

Park Social relations

Environmental factors

Little economical resources Good adaptation

Physical independence Emotional support

Personal factors

Age: 2.4 Loves play and moving

Good mood Independent +++

Activities for rehabilitation

�  Film

amartin@molletvalles.cat @Ascen46721309