title: Remodeling the Brain: Plastic Structural Brain Changes Produced by Different Motor Therapies After Stroke Assessment of upper‐limb function and movement in children with cerebral palsy wearing lycra garments Lycra(®) arm splints improve movement fluency in children with cerebral palsy. Neuromuscular electrical stimulation and dynamic bracing for the management of upper-extremity spasticity in children with cerebral palsy. Lycra arm splints in conjunction with goal-directed training can improve movement in children with cerebral palsy. Bimanual Training and Constraint-Induced Movement Therapy in Children With Hemiplegic Cerebral Palsy Modified constraint-induced therapy for children with hemiplegic cerebral palsy: a randomized trial. Randomized trial of constraint-induced movement therapy and bimanual training on activity outcomes for children with congenital hemiplegia. Efficacy of a hand-arm bimanual intensive therapy (HABIT) in children with hemiplegic cerebral palsy: a randomized control trial. Immediate effect of a wrist and thumb brace on bimanual activities in children with hemiplegic cerebral palsy. Occupational Therapy Home Programs for Cerebral Palsy: Double-Blind, Randomized, Controlled Trial
abstract: Background and Purpose — Studies on adult stroke patients have demonstrated functional changes in cortical excitability , metabolic rate , or blood flow after motor therapy , measures that can fluctuate rapidly over time . This study evaluated whether evidence could also be found for structural brain changes during an efficacious rehabilitation program . Methods — Chronic stroke patients were r and omly assigned to receive either constraint-induced movement therapy ( n=16 ) or a comparison therapy ( n=20 ) . Longitudinal voxel-based morphometry was performed on structural MRI scans obtained immediately before and after patients received therapy . Results — The group receiving constraint-induced movement therapy exhibited far greater improvement in use of the more affected arm in the life situation than the comparison therapy group . Structural brain changes paralleled these improvements in spontaneous use of the more impaired arm for activities of daily living . There were profuse increases in gray matter in sensory and motor areas both contralateral and ipsilateral to the affected arm that were bilaterally symmetrical , as well as bilaterally in the hippocampus . In contrast , the comparison therapy group failed to show gray matter increases . Importantly , the magnitude of the observed gray matter increases was significantly correlated with amount of improvement in real-world arm use . Conclusions — These findings suggest that a previously overlooked type of brain plasticity , structural remodeling of the human brain , is harnessed by constraint-induced movement therapy for a condition once thought to be refractory to treatment : motor deficit in chronic stroke patients It has recently been suggested that lycra garments are helpful for children with cerebral palsy ( CP ) . Twelve children , with athetosis , ataxia , and spasticity , were fitted with lycra garments ( Kendall‐Camp UK Ltd ) . Scores on the Paediatric Evaluation of Disability Inventory ( PEDI ) scales were determined before and after wearing the garment for at least 6 hours a day for 6 weeks . Five children with motor problems representative of the whole group were investigated during a reach‐ and ‐grasp task by kinematic motion analysis ; reflective markers were used with and without the garment . Carers were given a question naire concerning the practicalities of using the garments . All 12 children made improvements in at least one of the functional scales of the PEDI , and scores for the whole group showed significant gains ( Wilcoxon X2 test , self‐help p<0.01 ; mobility p<0.5 ; social p<0.1 ) . These changes were usually slight , although noticed by carers . Six children made gains of at least one scale of the caregiver assistance scores , two of the children showed losses ( due to difficulties removing the garment for toileting ) , and four showed no change . Motion analysis indicated that ( 1 ) two children with athetosis had improved proximal stability in sitting and in smoothness of arm movements , ( 2 ) one child with ataxia had improved in proximal and distal stability , and ( 3 ) two children with spasticity had more jerky movements , although one improved in proximal stability . All children had problems in wearing the garments , including problems with toileting and incontinence of urine ; the parents of only one child wanted to continue using it . Results suggest that the functional benefit of lycra garments for children with CP is mainly due to improvements in proximal stability but this should be weighed against the inconvenience and loss of independence AIMS To determine changes in upper limb movement substructures that denote fluency of movement in children with cerebral palsy ( CP ) following lycra ( ® ) splint wear  . Secondarily , to explore the efficacy of lycra ( ® ) splints for those with spastic and dystonic hypertonia . DESIGN R and omised clinical trial whereby participants were r and omised to parallel groups with waiting list control . METHOD Sixteen children ( mean age 11.5 years SD=2.2 ) with hypertonic upper limb involvement ( 13 hemiplegia , 4 quadriplegia ) were recruited . Children were r and omly allocated either to a control group or to wear the lycra ( ® ) splint for a period of three months . Three-dimensional ( 3D ) upper limb kinematics was used to assess four functional tasks at baseline , on initial lycra ( ® ) splint application , three months after lycra ( ® ) splint wear , and immediately after splint removal . Movement substructures of the motion of the wrist joint center were analysed . RESULTS A significant difference was observed between baseline and three months of lycra ( ® ) splint wear in the movement substructures ; movement time , percentage of time and distance in primary movement , jerk index , normalised jerk and percentage of jerk in primary and secondary movements . The magnitude of changes in normalised jerk and the percentage of jerk in the primary movement from baseline to three months was greatest in children with dystonic hypertonia . CONCLUSIONS The results indicate that lycra ( ® ) arm splinting induced significant changes in movement substructures and motor performance in children with CP . This research demonstrates that fluency of movement can be quantified and is amenable to change with intervention A prospect i ve study was design ed to determine whether the combined use of neuromuscular electrical stimulation ( NMES ) and dynamic bracing was more effective than use of either alone in reducing upper-extremity spasticity in children with spastic hemiplegic cerebral palsy . Twenty-four patients ( 12 males , 12 females ; mean age 8y 7mo [ SD 4y 2mo ] ; age range 3 - 18y ) diagnosed with spastic hemiplegic CP were r and omly allocated to three groups : group 1 had two 30-minute sessions of NMES a day applied on the antagonist extensors without bracing ; group 2 had two 30-minute sessions of dynamic bracing per day ; and group 3 had two 30-minute sessions of NMES and dynamic bracing every day . Treatment was continued for 6 months in all groups and applied only to the affected extremity . Patients were evaluated before therapy , at monthly intervals during the therapy , and 3 months after completion of the therapy . Three measures of outcome were taken : the Melbourne Assessment , grip strength , and posture evaluation with Zancolli 's classification . The therapist performing the outcome assessment s was blinded as to groups . Statistically significant differences were found in all three measures for only those treated with combined NMES and dynamic bracing . However , this significant effect lasted for only 2 months after discontinuation of the treatment . We conclude that the combined use of NMES and bracing is more effective than either alone but requires continuous application OBJECTIVES To investigate the effects of lycra ® arm splint wear on goal attainment and three dimensional ( 3D ) kinematics of the upper limb and trunk in children with cerebral palsy ( CP ) . DESIGN R and omised clinical trial whereby participants were r and omised to parallel groups with waiting list control . PARTICIPANTS Sixteen children with CP ( hypertonia ) aged 9 to 14 years . INTERVENTION Three months lycra arm splint wear combined with goal directed training . MAIN OUTCOME MEASURE Goal attainment scale , and 3D upper limb and trunk kinematics across four upper limb movement tasks . RESULTS 17/18 children achieved their movement goals following three months of splinting . Selected joint kinematics improved on immediate splint application . Further improvements in joint kinematics were demonstrated following 3 months of splint wear , particularly in elbow extension , shoulder flexion and abduction and in thorax flexion . Only improvements in movement compensations at the thorax remained following removal of the splint . CONCLUSIONS The lycra ® arm splint , made a quantifiable change to the attainment of movement goals of importance to the child . Furthermore , improvements were demonstrated in selected maximum range of movement and joint kinematics during functional tasks at the elbow and shoulder joints and thorax segment in children with CP Background . Constraint-induced movement therapy ( CIMT ) promotes h and function using intensive unimanual practice along with restraint of the less-affected h and . CIMT has not been compared with a treatment with equivalent dosing frequency and intensity in children with cerebral palsy ( CP ) . Objectives . The authors report a r and omized trial comparing CIMT and a bimanual intervention ( h and -arm intensive bimanual therapy ; HABIT ) that maintains the intensity of practice associated with CIMT but where children are engaged in functional bimanual tasks . Methods . A total of 42 participants with hemiplegic CP between the ages of 3.5 and 10 years ( matched for age and h and function ) were r and omized to receive 90 hours of CIMT or an equivalent dosage of functional bimanual training ( HABIT ) conducted in day-camp environments . A physical therapist blinded to treatment allocation tested h and function before and after treatment . The primary outcomes were changes in Jebsen-Taylor Test of H and Function ( JTTHF ) and Assisting H and Assessment ( AHA ) scores . Secondary measures included the Goal Attainment Scale ( GAS ) . Results . Both the CIMT and HABIT groups demonstrated comparable improvement from the pretest to immediate posttest in the JTTHF and AHA ( P < .0001 ) , which were maintained at 6 months . GAS , however , revealed greater progress toward goals for the HABIT group ( P < .0001 ) , with continued improvement across test sessions for both groups ( P < .0001 ) . Conclusions . Both CIMT and bimanual training lead to similar improvements in h and function . A potential benefit of bimanual training is that participants may improve more on self-determined goals AIM Conventional constraint-based therapies are intensive and dem and ing to implement , particularly for children . Modified forms of constraint-based therapies that are family-centred may be more acceptable and feasible for families of children with cerebral palsy (CP)-but require rigorous evaluation using r and omized trials . The aim of this study was to determine the effects of modified constraint-induced therapy compared with intensive occupational therapy on activities of daily living and upper limb outcomes in children with hemiplegic CP . METHOD In this assessor-blinded pragmatic r and omized trial , 50 children ( 27 males , 23 females ; age range 19 mo-7 y 10 mo ) with hemiplegic CP were r and omized using a concealed allocation procedure to one of two 8-week interventions : intensive occupational therapy ( n = 25 ) , or modified constraint-induced therapy ( n = 25 ) . Manual Ability Classification System ( MACS ) levels of the participants were , level I n = 2 , II n = 37 , III n = 8 , and level IV n = 1 ; Gross Motor Function Classification System ( GMFCS ) levels were , level I n = 33 , level II n = 15 , and level III n = 1 . Participants were recruited through three specialist CP centres in Australia and r and omized between January 2008 and April 2010 . Children r and omized to modified constraint-induced therapy wore a mitt on the unaffected h and for 2 hours each day , during which time the children participated in targeted therapy . The primary outcome was the Canadian Occupational Performance Measure ( COPM -- measured on a 10-point scale ) at completion of therapy . Other outcome measures were Goal Attainment Scaling , Assisting H and Assessment , Pediatric Motor Activity Log , Modified Ashworth Scale , Modified Tardieu Scale , and a parent question naire . Assessment s were carried out at 10 weeks and 6 months following r and omization . RESULTS All participants were included in the analysis . Between-group differences for all outcomes were neither clinical ly important nor statistically significant . The mean difference in COPM was 0.3 ( 95 % confidence interval [ CI ] -0.8 to 1.4 ; p=0.61 ) and mean difference in COPM satisfaction was 0.1 ( 95 % CI -1.1 to 1.2 ; p=0.90 ) . Minor adverse events were reported by five of the 25 participants in the modified constraint-induced therapy group and by one of the 25 in the intensive occupational therapy group . All adverse events were related to participants ' lack of acceptance of therapy . INTERPRETATION Modified constraint-induced therapy is no more effective than intensive occupational therapy for improving completion of activities of daily living or upper limb function in children with hemiplegic CP AIM To determine if constraint-induced movement therapy ( CIMT ) is more effective than bimanual training ( BIM ) in improving upper limb activity outcomes for children with congenital hemiplegia in a matched-pairs r and omized trial . METHOD Sixty-three children ( mean age 10.2 , SD 2.7 , range 5 - 16 y ; 33 males , 30 females ) , 16 in Manual Ability Classification System level I , 46 level II , and 1 level III and 16 in Gross Motor Function Classification level I , 47 level II ) were r and omly allocated to either CIMT or BIM group day camps ( 60 hours over 10 days ) . The Melbourne Assessment of Unilateral Upper Limb Function assessed unimanual capacity of the impaired limb and Assisting H and Assessment evaluated bimanual coordination at baseline , 3 and 26 weeks , scored by blinded raters . RESULTS After concealed r and om allocation , there was no baseline difference between groups .  CIMT had superior outcomes compared with BIM for unimanual capacity at 26 weeks ( estimated mean difference [ EMD ] 4.4 , 95 % confidence interval [ CI ] 2.2 - 6.7 ; p < 0.001 ) . There was no other significant difference between groups post-intervention . Both groups demonstrated significant improvements in bimanual performance at 3 weeks , with gains maintained by BIM at 26 weeks ( EMD 2.3 ; 95 % CI 0.6 - 4.0 ; p = 0.008 ) . Interpretation Overall , there were only small differences between the two training approaches . CIMT yielded greater changes in unimanual capacity of the impaired upper limb compared with BIM . Results generally reflect specificity of practice , with CIMT  improving unimanual capacity and BIM improving bimanual performance . Considerable inter-individual variation in response to either intervention was evident . Future research should consider serial sequencing unimanual then BIM approaches to optimize upper limb outcomes for children with congenital hemiplegia Children with hemiplegic cerebral palsy ( CP ) have impairments in bimanual coordination above and beyond their unilateral impairments . Recently we developed h and -arm bimanual intensive therapy ( HABIT ) , using the principles of motor learning , and neuroplasticity , to address these bimanual impairments . A single-blinded r and omized control study of HABIT was performed to examine its efficacy in children with hemiplegic CP with mild to moderate h and involvement . Twenty children ( age range 3 y 6 mo-15 y 6 mo ) were r and omized to either an intervention ( n=10 : seven males , three females ; mean age 8 y 7 mo , SD 4 y ) or a delayed treatment control group ( n=10 : seven males , three females ; mean age 6 y 10 mo , SD 2 y 4 mo ) . Children were engaged in play and functional activities that provided structured bimanual practice 6 hours per day for 10 days . Each child was evaluated immediately before and after the intervention , and again at 1-month post-intervention . Children in the intervention group demonstrated improved scores on the Assisting H and Assessment , increased involved extremity use measured using accelerometry and a caregiver survey , bimanual items of the Bruininks-Oseretsky Test of Motor Proficiency , and the simultaneity of completing a draw-opening task with two h and s ( p<0.05 in all cases ) . The results suggest that for this carefully selected subgroup of children with hemiplegic CP , HABIT appears to be efficacious in improving bimanual h and use AIM The aim of this study was to determine the immediate effect of wearing a wrist and thumb brace on the performance of bimanual activities in children with spastic hemiplegic cerebral palsy . METHOD In a pre- and post-test cohort study of 25 children ( age range 4 - 11y ; mean age 8y 4mo [ SD 2y 2mo ] ; 16 males , 9 females ) with spastic hemiplegic cerebral palsy with a Zancolli classification h and score of I , IIA , or IIB ( mild and moderate h and dysfunction ; children with a Zancolli classification of III - severe h and dysfunction - were excluded from this study ) , performance of bimanual activities was evaluated with the Assisting H and Assessment ( AHA ) on three occasions : one assessment with a static wrist and thumb brace placed on the affected h and and two other assessment s without a brace . The differences between AHA scores obtained at the three assessment s were evaluated using the repeated measures analysis of variance . RESULTS Performance of bimanual activities while wearing the brace improved significantly compared to performance without the brace ( p<0.001 ) . With the brace , the mean AHA score increased by 3.2 ( 95 % confidence interval 2.1 - 4.3 ) from 59.1 to 62.3 . The scores of the two assessment s without the brace did not differ significantly . INTERPRETATION In children with spastic hemiplegic cerebral palsy , bracing of the wrist and thumb immediately improves spontaneous use of the affected upper limb in bimanual activities , possibly because bracing permits a more functional h and position OBJECTIVE : The goal was to assess the effectiveness of an occupational therapy home program ( OTHP ) , compared with no OTHP , with respect to function and parent satisfaction with child function , participation , goal attainment , and quality of upper limb skill in school-aged children with cerebral palsy . METHODS : Thirty-six children with cerebral palsy ( mean age : 7.7 years ; male : 69 % ; Gross Motor Function Classification System : level I , 47 % ; level II , 14 % ; level III , 16 % ; level IV , 7 % ; level V , 16 % ; spasticity , 85 % ; dyskinesia , 14 % ; ataxia , 3 % ) were r and omly and equally assigned to OTHPs for 8 or 4 weeks or to no OTHP . The primary end point was Canadian Occupational Performance Measure scores 8 weeks after baseline . Secondary measures were recorded at 4 and 8 weeks . RESULTS : Eight weeks of OTHP produced statistically significant differences in function and parent satisfaction with function , compared with no OTHP . Parents in the 4-week OTHP group did not discontinue use at 4 weeks , as instructed , and continued for 8 weeks ; results demonstrated statistically significant differences , compared with no OTHP . There was no difference in primary or secondary end point measures between intervention groups . CONCLUSION : Pediatricians can advise families that OTHPs developed with a collaborative , evidence -based approach and implemented by parents at home were clinical ly effective if implemented 17.5 times per month for an average of 16.5 minutes per session
target: INTERPRETATION In children with CP , h and splints may have a small benefit for upper limb skills .
  However , results are diminished after splint wearing stops .
background: AIM The aim of this review was to determine the effectiveness of h and splinting for improving h and function in children with cerebral palsy ( CP ) and brain injury .