Children With Cerebral Palsy Show Higher Static-But Not Higher Dynamic-Motor Fatigability in Grip and Pinch Tasks Than Children With Typical Development Do.

OBJECTIVE: The purpose of this study was to investigate differences in static and dynamic motor fatigability during grip and pinch tasks between children with unilateral spastic cerebral palsy (USCP) and children with typical development (TD) and between preferred and nonpreferred hands. METHODS: Fifty-three children with USCP and 53 age-matched children with TD (mean = 11 years 1 month; SD = 3 years 8 months) participated in 30-second maximum exertion sustained and repeated grip and pinch tasks. For sustained tasks, the Static Fatigue Index and the ratio of mean force between the first and last thirds of the curve were calculated. For repeated tasks, the ratio of mean force and the ratio of numbers of peaks between the first and last thirds of the curve were calculated. RESULTS: Higher Static Fatigue Index scores for grip and pinch were found with USCP in both hands and between hands in both groups. Dynamic motor fatigability showed inconsistent results, with higher levels of fatigability in children with TD than in children with USCP for grip in the ratio of mean force between the first and last thirds of the curve in nonpreferred hands and in the ratio of number of peaks between the first and last thirds of the curve in preferred hands. CONCLUSION: Higher motor fatigability in children with USCP than in children with TD was found for static but not dynamic grip and pinch. Underlying mechanisms may play different roles in static and dynamic motor fatigability. IMPACT: These results highlight that static motor fatigability in grip and pinch tasks should be part of a comprehensive upper limb assessment and that this could be the target of individualized interventions.

The Effect of Bimanual Intensive Functional Training on Somatosensory Hand Function in Children with Unilateral Spastic Cerebral Palsy: An Observational Study.

(1) Background: Next to motor impairments, children with unilateral spastic cerebral palsy (CP) often experience sensory impairments. Intensive bimanual training is well known for improving motor abilities, though its effect on sensory impairments is less known. (2) Objective: To investigate whether bimanual intensive functional therapy without using enriched sensory materials improves somatosensory hand function. (3) Methods: A total of twenty-four participants with CP (12-17 years of age) received 80-90 h of intensive functional training aimed at improving bimanual performance in daily life. Somatosensory hand function was measured before training, directly after training, and at six months follow-up. Outcome measures were: proprioception, measured by thumb and wrist position tasks and thumb localization tasks; vibration sensation; tactile perception; and stereognosis. (4) Results: Next to improving on their individual treatment goals, after training, participants also showed significant improvements in the perception of thumb and wrist position, vibration sensation, tactile perception, and stereognosis of the more affected hand. Improvements were retained at six months follow-up. Conversely, proprioception measured by the thumb localization tasks did not improve after training. (5) Conclusions: Intensive functional bimanual training without environmental tactile enrichment may improve the somatosensory function of the more affected hand in children with unilateral spastic CP.

Effectiveness of functional intensive therapy on mobility and self-care activities in children and adolescents with cerebral palsy - a prospective clinical study.

PURPOSE: Cerebral palsy (CP) is a major cause of childhood disability. Children with CP often lack motor skills to effectively perform activities of daily living. The aim is to assess the effectiveness of a functional intensive therapy program focused on improving individual goals in the domain of mobility and self-care in children and adolescents with CP. MATERIAL AND METHODS: Thirty-five CP patients, aged 11-19 years, GMFCS I-IV, received daily 6-7 h of functional therapy for 15 days. Outcomes were assessed at baseline, immediately after the program and at three months follow-up. RESULTS: Significant post-intervention improvement was seen on all primary and secondary outcome measures; personal goals (GAS score; COPM performance and COPM satisfaction), daily activities (ACTIVLIM), hand function (ABILHAND-Kids), mobility (ABILOCO-Kids; GMFM-66-IS score). There was no loss to follow up during the program and after three months. At follow-up, improvements were retained except for ABILOCO and GMFM-66-IS. CONCLUSIONS: Functional intensive therapy appears feasible and seems to be effective in improving treatment goals focused on mobility and self-care, even in older and more severely affected children and adolescents with CP. After three months, these possible effects were still present.Implications for rehabilitationShort intensive functional training is feasible and showing no loss to follow up in the older and more severely affected children and adolescents with cerebral palsy (CP).Short intensive functional training appears effective in improving individual goals in children and adolescents with CP and improvements endorse three months.Short intensive functional training seems to be effective on both mobility and self-care domains of the ICF-CY.

Feasibility and effectiveness of home-based therapy programmes for children with cerebral palsy: a systematic review.

OBJECTIVE: To assess the feasibility and effectiveness of home-based occupational therapy and physiotherapy programmes in children with cerebral palsy (CP), focusing on the upper extremity and reporting on child-related and/or parent-related outcomes. DESIGN: Systematic review. DATA SOURCES: Electronic searches were performed in MEDLINE, EMBASE, CINAHL, PsycINFO, OTseeker and PEDro, and in ICTRP and CENTRAL trial registers, from inception to 6 June 2019. ELIGIBLE CRITERIA: The review included all types of original studies concerning feasibility or effectiveness of home-based therapy in children aged <18 years with any type of CP. No language, publication status or publication date restrictions were applied. DATA EXTRACTION AND SYNTHESIS: Study and intervention characteristics and the demographics of participating children and their parents were extracted. Feasibility was assessed by outcomes related to acceptability, demand, implementation, practicality, adaptation, expansion or integration. Regarding effectiveness, child-related outcome measures related to any level of the International Classification of Functioning, Disability and Health, or parent-related outcomes were investigated. Two authors independently extracted the data. Risk of bias was assessed using the Downs and Black checklist and the Joanna Briggs Institute Critical Appraisal Checklist. RESULTS: The search resulted in a total of 92 records: 61 studies and 31 conference abstracts. Feasibility studies reported mainly on acceptability and implementation. Overall compliance to home-based training programmes (implementation) was moderate to high, ranging from 56% to 99%. In the effectiveness studies, >40 different child-related outcome measures were found. Overall, an improvement in arm-hand performance within group across time was shown. Only two studies reported on a parent-related outcome measure. No increase in parental stress was found during the intervention. CONCLUSIONS: Based on the results of the included studies, home-based training programmes seem to be feasible. However, conclusions about the effectiveness of home programmes cannot be made due to the large variability in the study, patient and intervention characteristics, comparators, and outcome measures used in the included studies. PROSPERO REGISTRATION NUMBER: CRD42016043743.

Upper Extremity Muscle Strength in Children With Unilateral Spastic Cerebral Palsy: A Bilateral Problem?

OBJECTIVE: The objective was to investigate whether muscle strength in the nonaffected and affected upper extremities (UEs) in children (7-12 years) with unilateral spastic cerebral palsy (USCP) differs from that in children with typical development (TD). METHODS: A cross-sectional study design was used. Isometric arm strength (wrist flexion, wrist extension with flexed and extended fingers, elbow flexion/extension) was assessed in 72 children (mean age = 9.3 [SD = 1.9] years) with USCP, and isometric grip/pinch strength was assessed in 86 children (mean age = 9.3 [SD = 1.8] years) with USCP. Arm/grip/pinch strength was assessed in 120 children (mean age = 9.5 [SD = 1.7] years) with TD. Arm strength was measured with a hand-held dynamometer, and grip/pinch strength was measured with a calibrated, modified (digitized) grip dynamometer and a pinch meter. The nonaffected UE of children with USCP was compared with the preferred UE of children with TD because both sides represent the preferred UE. The affected UE was compared with the nonpreferred UE of children with TD, as both sides represent the nonpreferred UE. RESULTS: In all measurements except for grip strength of the preferred UE, children with USCP were weaker than children with TD. CONCLUSIONS: In children with USCP, muscle strength weakness exists in both UEs. IMPACT: When unimanual or bimanual ability limitations are present in children with unilateral cerebral palsy, investigation of the muscle strength of the nonaffected UE should be part of the assessment.

Reliability of maximum isometric arm, grip and pinch strength measurements in children (7-12 years) with unilateral spastic cerebral palsy.

Purpose: To investigate test-retest and inter-rater reliability of maximum isometric arm muscle strength measurements using the hand-held dynamometer (HDD) and maximum isometric grip and pinch strength measurements using the Biometrics E-Link Evaluation System in children aged 7-12 years with unilateral spastic cerebral palsy.Materials and methods: All data were obtained using a test-retest study design. The study met the conditions of the COSMIN criteria to achieve good methodological quality.Results: For arm strength measurements, all test-retest reliability intraclass correlation coefficient (ICC) values and all but one inter-rater reliability ICC value indicated excellent reliability. For grip- and pinch strength measurements, all test-retest reliability and inter-rater reliability ICC values showed excellent reliability. The standard error of measurement values ranged from 4.97 to 11.36 N (HDD) and 0.37 to 1.81 kg (E-link). Smallest detectable change values ranged from 13.79 to 31.49 N (HDD) and 1.03 to 5.02 kg (E-link).Conclusions: The HDD and E-link system are usable measurement instruments for cross-sectional muscle strength measurements in children with unilateral spastic cerebral palsy. It is not clear if both instruments are usable to measure changes in muscle strength within an individual, especially if a child with unilateral spastic cerebral palsy has low muscle strength. Caution in the interpretation of changes in muscle strength is therefore necessary.Implications for RehabilitationThe hand-held dynamometer and E-Link Evaluation System are reliable measurement instruments to measure muscle strength of the arm and hand in children with unilateral spastic cerebral palsy, aged 7-12 years.Cross-sectional measurements; it is possible to measure upper extremity muscle strength in children with unilateral spastic cerebral palsy with the hand-held dynamometer and E-link system.Longitudinal measurements; changes in upper extremity muscle strength within one person should be interpreted with care, especially if a child with unilateral spastic cerebral palsy has low muscle strength.

Psychometric Evaluation of 2 New Upper Extremity Functional Strength Tests in Children With Cerebral Palsy.

BACKGROUND: For children with unilateral spastic cerebral palsy (USCP), reduced muscle strength can lead to activity limitations. However, none of the existing measures of upper extremity strength measure strength in the context of functional activities in which strength must be maintained for several seconds. OBJECTIVE: The objective of this study was to evaluate the psychometric properties of 2 newly developed functional hand and upper extremity muscle-strength tests (Cup-Task and Box-Task) in children aged 7 to 12 years with USCP. DESIGN: A longitudinal study design was used. METHODS: A standardized protocol with detailed descriptions of all procedures and measurements was used to determine test-retest reliability, interrater reliability, and criterion validity. RESULTS: A total of 86 children (53 males, 33 females, mean age = 9.3 years) with USCP participated in this study, with a subset performing each measurement. Only the results of children who were able to perform the measurement were included for analysis. Excellent test-retest reliability (intraclass correlation coefficients = 0.887-0.944; 95% confidence intervals = 0.713-0.969) and interrater reliability (intraclass correlation coefficients = 0.896-0.960; 95% confidence intervals = 0.813-0.980) were observed. The Cup-Task Affected-Hand and Box-Task were moderately correlated with maximum isometric grip strength. The Cup-Task Nonaffected-Hand had a low correlation with maximum isometric grip strength. LIMITATIONS: Age, sex, and manual ability were not normally distributed, which could have influenced the results. CONCLUSIONS: For children with USCP who can perform the tasks, the Cup-Task and Box-Task are reliable and valid instruments for measuring functional upper extremity muscle strength.

Process evaluation of two home-based bimanual training programs in children with unilateral cerebral palsy (the COAD-study): protocol for a mixed methods study.

BACKGROUND: As part of the COAD-study two home-based bimanual training programs for young children with unilateral Cerebral Palsy (uCP) have been developed, both consisting of a preparation phase and a home-based training phase. Parents are coached to use either an explicit or implicit motor learning approach while teaching bimanual activities to their child. A process evaluation of these complex interventions is crucial in order to draw accurate conclusions and provide recommendations for implementation in clinical practice and further research. The aim of the process evaluation is to systematically assess fidelity of the home-based training programs, to examine the mechanisms that contribute to their effects on child-related and parent-related outcomes, and to explore the influence of contextual factors. METHODS: A mixed methods embedded design is used that emerges from a pragmatism paradigm. The qualitative strand involves a generic qualitative approach. The process evaluation components fidelity (quality), dose delivered (completeness), dose received (exposure and satisfaction), recruitment and context will be investigated. Data collection includes registration of attendance of therapists and remedial educationalists to a course regarding the home-based training programs; a questionnaire to evaluate this course by the instructor; a report form concerning the preparation phase to be completed by the therapist; registration and video analyses of the home-based training; interviews with parents and questionnaires to be filled out by the therapist and remedial educationalist regarding the process of training; and focus groups with therapists and remedial educationalists as well as registration of drop-out rates and reasons, to evaluate the overall home-based training programs. Inductive thematic analysis will be used to analyse qualitative data. Qualitative and quantitative findings are merged through meta-inference. DISCUSSION: So far, effects of home-based training programs in paediatric rehabilitation have been studied without an extensive process evaluation. The findings of this process evaluation will have implications for clinical practice and further research regarding development and application of home-based bimanual training programs, executed by parents and aimed at improving activity performance and participation of children with uCP.

Home-based bimanual training based on motor learning principles in children with unilateral cerebral palsy and their parents (the COAD-study): rationale and protocols.

BACKGROUND: Home-based training is considered an important intervention in rehabilitation of children with unilateral cerebral palsy. Despite consensus on the value of home-based upper limb training, no evidence-based best practice exists. Promoting compliance of children to adhere to an intensive program while keeping parental stress levels low is an important challenge when designing home-based training programs. Incorporating implicit motor learning principles emerges to be a promising method to resolve this challenge. METHODS: Here we describe two protocols for home-based bimanual training programs, one based on implicit motor learning principles and one based on explicit motor learning principles, for children with unilateral spastic cerebral palsy aged 2 through 7 years. Children receive goal-oriented, task-specific bimanual training in their home environment from their parents for 3.5 h/week for 12 weeks according to an individualized program. Parents will be intensively coached by a multidisciplinary team, consisting of a pediatric therapist and remedial educationalist. Both programs consist of a preparation phase (goal setting, introductory meetings with coaching professionals, design of individualized program, instruction of parents, home visit) and home-based training phase (training, video-recordings, registrations, and telecoaching and home visits by the coaching team). The programs contrast with respect to the teaching strategy, i.e. how the parents support their child during training. In both programs parents provide their child with instructions and feedback that focus on the activity (i.e. task-oriented) or the result of the activity (i.e. result-oriented). However, in the explicit program parents are in addition instructed to give exact instructions and feedback on the motor performance of the bimanual activities, whereas in the implicit program the use of both hands and the appropriate motor performance of the activity are elicited via manipulation of the organization of the activities. DISCUSSION: With the protocols described here, we aim to take a next step in the development of much needed evidence-based home-based training programs for children with unilateral cerebral palsy.

Functional electrical stimulation of the ankle dorsiflexors during walking in spastic cerebral palsy: a systematic review.

AIM: To assess the effect of functional electrical stimulation (FES) of ankle dorsiflexors in children and adolescents with spastic cerebral palsy (CP) during walking. METHOD: A systematic review was performed using the American Academy of Cerebral Palsy and Developmental Medicine methodology and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Six databases were searched for studies applying interventions to patients aged younger than 20 years. Outcomes were classified according to the International Classification of Functioning, Disability and Health (ICF). RESULTS: Seven hundred and eighty abstracts were found, 35 articles were fully screened, and 14 articles were used for analysis. Only five articles (three studies) were of level I to III evidence. At ICF participation and activity level, there is limited evidence for a decrease in self-reported frequency of toe-drag and falls. At ICF body structure and function level, there is clear evidence (I-III) that FES increased (active) ankle dorsiflexion angle, strength, and improved selective motor control, balance, and gait kinematics, but decreased walking speed. Adverse events include skin irritation, toleration, and acceptation issues. INTERPRETATION: There are insufficient data supporting functional gain by FES on activity and participation level. However, evidence points towards a role for FES as an alternative to orthoses in children with spastic CP. WHAT THIS PAPER ADDS: Effects of functional electrical stimulation (FES) point towards a potential role as an alternative to orthoses for patients with spastic cerebral palsy (CP). Some evidence for a decrease in self-reported frequency of toe-drag and falls with the use of FES in spastic CP. Limited evidence for improvements in activity and participation in patients with spastic CP using FES.

Cross-cultural Translation and Adaptation of the Lifestyle Assessment Questionnaire (LAQ-CP) Into Dutch: A Brief Report.

PURPOSE: To produce a Dutch translation of the Lifestyle Assessment Questionnaire for children with cerebral palsy (LAQ-CP), adapted for cross-cultural differences. METHODS: The translation process consisted of 6 stages, following a guideline for cross-cultural adaptations including duplicate forward- and back-translations, expert group review, pilot-testing, and a process audit. RESULTS: Several adaptations to the questionnaire were required due to cross-cultural differences. As a result of the pilot-test, the layout was adapted to the desires of the users. The process auditor stated that the process had been comprehensive and valued the quality of the work. CONCLUSION: The project resulted in a Dutch translation of the LAQ-CP, adapted for cross-cultural differences. Validation of the translated questionnaire is required before use in clinical practice and research is recommended (Dutch abstract, Supplemental Digital Content 1, available at: http://links.lww.com/PPT/A164).

Effects of botulinum toxin A and/or bimanual task-oriented therapy on upper extremity activities in unilateral Cerebral Palsy: a clinical trial.

BACKGROUND: This study reports on the effects of botulinum toxin A (BoNT-A) injections in the upper extremity (UE) in children with unilateral Cerebral Palsy (uCP) combined with bimanual task-oriented therapy (BITT) or either treatment modality performed separately. Bimanual activities were measured with the Assisting Hand Assessment (AHA), the ABILHand-Kids questionnaire (AK), the Observational Skills Assessment Score (OSAS). Goal achievement was measured with Goal Attainment Scaling (GAS), using blind video assessment, and the Canadian Occupational Performance Measure (COPM). METHODS: Thirty-five children, mean age 7.14 years (SD 2.63), 11 Manual Ability Classification Score (MACS) I, 15 MACS II and 9 MACS III, participated. The trial started with four study groups: BoNT-A-only (n = 5), BITT-only (n = 11), BoNT-A + BITT (n = 13), and control (n = 6). Twenty-two children were randomised, 13 children received their parents' preferred treatment: BoNT-A + BITT or BITT-only. Three comparisons were analysed: BITT (BoNT-A + BITT and BITT-only; n = 24) versus no BITT (BoNT-A-only and control; n = 11), BoNT-A (BoNT-A-only and BoNT-A + BITT; n = 18) versus no BoNT-A (BITT-only and control; n = 17), and the additional effect of BoNT-A (BoNT-A + BITT versus BITT-only). Follow-up time: 24 weeks. RESULTS: No significant differences between the groups were found on the AHA. The amount of use of both hands on the OSAS was significantly better in the BoNT-A group in the beading and sandwich-making task. The BoNT-A group also showed significant improvement in the quality scores of the OSAS: the wrist position during grasping and holding, especially in the younger children. The BITT group improved significantly on the AK and significantly more on the performance and satisfaction scores of the COPM at 12 and 24 weeks regarding several goals. BoNT-A showed a significant negative effect at 12 and 24 weeks in the most important goal. BITT, more than BoNT-A + BITT, showed positive effects on the GAS score at 12 (significant), 18 and 24 weeks. CONCLUSIONS: BoNT-A has a positive effect on quality of movement and amount of use of the affected UE during the 3 months' working time. BoNT-A has no additional effect on bimanual performance and goal achievement. BITT has a positive effect on goal achievement and bimanual performance, even up to 6 weeks after therapy had stopped. TRIAL REGISTRATION: Current Controlled Trials ISRCTN69541857.

Recognizing complex upper extremity activities using body worn sensors.

To evaluate arm-hand therapies for neurological patients it is important to be able to assess actual arm-hand performance objectively. Because instruments that measure the actual quality and quantity of specific activities in daily life are lacking, a new measure needs to be developed. The aims of this study are to a) elucidate the techniques used to identify upper extremity activities, b) provide a proof-of-principle of this method using a set of activities tested in a healthy adult and in a stroke patient, and c) provide an example of the method's applicability in daily life based on readings taken from a healthy adult. Multiple devices, each of which contains a tri-axial accelerometer, a tri-axial gyroscope and a tri-axial magnetometer were attached to the dominant hand, wrist, upper arm and chest of 30 healthy participants and one stroke patient, who all performed the tasks 'drinking', 'eating' and 'brushing hair' in a standardized environment. To establish proof-of-principle, a prolonged daily life recording of 1 participant was used to identify the task 'drinking'. The activities were identified using multi-array signal feature extraction and pattern recognition algorithms and 2D-convolution. The activities 'drinking', 'eating' and 'brushing hair' were unambiguously recognized in a sequence of recordings of multiple standardized daily activities in a healthy participant and in a stroke patient. It was also possible to identify a specific activity in a daily life recording. The long term aim is to use this method to a) identify arm-hand activities that someone performs during daily life, b) determine the quantity of activity execution, i.e. amount of use, and c) determine the quality of arm-hand skill performance.

Effects of botulinum toxin A and/or bimanual task-oriented therapy on upper extremity impairments in unilateral Cerebral Palsy: an explorative study.

OBJECTIVE: This study reports on the effects of botulinum toxin A (BoNT-A) injections in the upper extremity (UE) of children with unilateral Cerebral Palsy (uCP) combined with bimanual task oriented therapy (BITT) or either treatment modality performed separately on UE range of motion (ROM), spasticity and (functional) strength. METHODS: Thirty-five children, mean age 7.14 years (SD 2.63) of whom 11 had a Manual Ability Classification Score (MACS) I, 15 MACS II and 9 MACS III, participated. The trial started with four study groups: BoNT-A-only (n = 5), BITT-only (n = 11), BoNT-A + BITT (n = 13), and control (n = 6). Twenty-two children were randomized and, due to recruitment problems 13 children received their parents' preferred treatment: BoNT-A + BITT or BITT-only. Three comparisons were analysed: BITT (BoNT-A + BITT and BITT-only; n = 24) versus no BITT (BoNT-A-only and control; n = 11), BoNT-A (BoNT-A-only and BoNT-A + BITT; n = 18) versus no BoNT-A (BITT-only and control; n = 17), and the additional effect of BoNT-A (BoNT-A + BITT versus BITT-only). RESULTS: BoNT-A significantly decreased key grip strength and finger flexion tone, had a clinically relevant (additional) positive effect on active thumb abduction and supination and a significantly negative effect on unilateral functional strength. BITT + BoNT-A significantly increased active supination. BITT reduced elbow flexor tone and BITT-only resulted in more improvement than BoNT-A + BITT in functional unimanual and, to a lesser extent, in bimanual grip strength. CONCLUSIONS: In comparison with BoNT-A + BITT, BITT-only gives more improvement on functional grip strength and, therefore, could possibly increase bimanual performance. In this case, the (additional) role of BoNT-A may be an increase in active supination and thumb abduction.

To What Extent Can Arm-Hand Skill Performance--of Both Healthy Adults and Children-Be Recorded Reliably Using Multiple Bodily Worn Sensor Devices?

Neurological patients often encounter arm-hand problems in daily life. Bodily worn sensors may be used to assess actual performance by quantifying specific movement patterns associated with specific activities. However, signal reliability during activities of daily living should be determined first. The aim is to determine to what extent standardized arm-hand skill performance of both healthy adults and healthy children can be recorded reliably using a combination of multiple sensor devices. Thirty adults (aged > 50 years) and thirty-two children (aged between 6-18 years) performed the activities drinking, eating and combing five times in a standardized setting. Sensor devices, each containing a triaxial accelerometer, gyroscope and magnetometer were attached to the arms, hands and trunk of the participants. Within-subject and between-subject reliability of the signal patterns amongst skill repetitions was determined by calculating Intraclass Correlation Coefficients (ICCs). Median reliability was good to very good for all activities performed (both within and between subjects). Regarding within-subject reliability (instruction-condition), median ICCs ranged between 0.76-0.90 and 0.68-0.92 for the adults and children, respectively. For between-subject reliability (instruction-condition), median ICCs ranged 0.75-0.86 and 0.61-0.90 for the adults and children, respectively. It can be concluded that the above-mentioned sensor system can reliably record activities of daily living in a standardized setting.

Accelerometry measuring the outcome of robot-supported upper limb training in chronic stroke: a randomized controlled trial.

PURPOSE: This study aims to assess the extent to which accelerometers can be used to determine the effect of robot-supported task-oriented arm-hand training, relative to task-oriented arm-hand training alone, on the actual amount of arm-hand use of chronic stroke patients in their home situation. METHODS: This single-blind randomized controlled trial included 16 chronic stroke patients, randomly allocated using blocked randomization (n = 2) to receive task-oriented robot-supported arm-hand training or task-oriented (unsupported) arm-hand training. Training lasted 8 weeks, 4 times/week, 2 × 30 min/day using the (T-)TOAT ((Technology-supported)-Task-Oriented-Arm-Training) method. The actual amount of arm-hand use, was assessed at baseline, after 8 weeks training and 6 months after training cessation. Duration of use and intensity of use of the affected arm-hand during unimanual and bimanual activities were calculated. RESULTS: Duration and intensity of use of the affected arm-hand did not change significantly during and after training, with or without robot-support (i.e. duration of use of unimanual use of the affected arm-hand: median difference of -0.17% in the robot-group and -0.08% in the control group between baseline and after training cessation; intensity of the affected arm-hand: median difference of 3.95% in the robot-group and 3.32% in the control group between baseline and after training cessation). No significant between-group differences were found. CONCLUSIONS: Accelerometer data did not show significant changes in actual amount of arm-hand use after task-oriented training, with or without robot-support. Next to the amount of use, discrimination between activities performed and information about quality of use of the affected arm-hand are essential to determine actual arm-hand performance. TRIAL REGISTRATION: Controlled-trials.com ISRCTN82787126.

Arm hand skilled performance in cerebral palsy: activity preferences and their movement components.

BACKGROUND: Assessment of arm-hand use is very important in children with cerebral palsy (CP) who encounter arm-hand problems. To determine validity and reliability of new instruments to assess actual performance, a set of standardized test situations including activities of daily living (ADL) is required. This study gives information with which such a set for upper extremity skill research may be fine-tuned, relative to a specific research question. Aim of this study is to a) identify upper extremity related ADL children with CP want to improve on, b) determine the 10 most preferred goals of children with CP, and c) identify movement components of all goals identified. METHOD: The Canadian Occupational Performance Measure was used to identify upper extremity-related ADL preferences (goals) of 53 children with CP encountering arm-hand problems (mean age 9 ± 4.5 year). Goals were ranked based on importance attributed to each goal and the number of times a goal was mentioned, resulting in a gross list with goals. Additionally, two studies were performed, i.e. study A to determine the 10 most preferred goals for 3 age groups (2.5-5 years; 6-11 years, 12-19 years), based on the total preference score, and study B to identify movement components, like reaching and grasping, of all goals identified for both the leading and the assisting arm-hand. RESULTS: Seventy-two goals were identified. The 10 most preferred goals differed with age, changing from dressing and leisure-related goals in the youngest children to goals regarding personal care and eating for children aged 6-11 years. The oldest children preferred goals regarding eating, personal care and computer use. The movement components 'positioning', 'reach', 'grasp', and 'hold' were present in most tasks. 'Manipulating' was more important for the leading arm-hand, whereas 'fixating' was more important for the assisting arm-hand. CONCLUSION: This study gave insight into the preferences regarding ADL children with CP would like to improve on, and the movement components characterizing these activities. This information can be used to create a set of standardized test situations, which can be used to assess the validity and reliability of new measurement instruments to gauge actual arm-hand skilled performance.

Upper extremity strength measurement for children with cerebral palsy: a systematic review of available instruments.

BACKGROUND: In order to make inferences about strength related to development or treatment interventions, it is important to use measurement instruments that have sound clinimetric properties. PURPOSE: The objective of this review is to systematically evaluate the level of evidence of the clinimetric properties of instruments for measuring upper extremity muscle strength at the "body functions & structures" level of the International Classification of Functioning, Disability and Health for Children and Youth (ICF-CY) for children with cerebral palsy (CP). DATA SOURCES: A systematic search of the PubMed, EMBASE, OTseeker, CINAHL, PEDro, and MEDLINE databases up to November 2012 was performed. STUDY SELECTION: Two independent raters identified and examined studies that reported the use of upper extremity strength measurement instruments and methods for children and adolescents with CP aged 0 to 18 years. DATA EXTRACTION: The COSMIN (COnsensus-based Standards for the selection of health status Measurement INstruments) checklist with 4-point rating scale was used by 2 independent raters to evaluate the methodological quality of the included studies. Best evidence synthesis was performed using COSMIN outcomes and the quality of the clinimetric properties. DATA SYNTHESIS: Six different measurement instruments or methods were identified. Test-retest, interrater, and intrarater reliability were investigated. Two test-retest reliability studies were rated as "fair" for the level of evidence. All other studies were rated as "unknown" for the level of evidence. LIMITATIONS: The paucity of literature describing clinimetric properties, especially other than reliability, of upper limb strength measurement instruments for children with CP was a limitation of the study. CONCLUSIONS: For measuring grip strength, the Jamar dynamometer is recommended. For other muscle groups, handheld dynamometry is recommended. Manual muscle testing (MMT) can be used in case of limited (below MMT grade 4) wrist strength or for total upper limb muscle strength. Based on lacking information regarding other clinimetric properties, caution is advised regarding interpretation of the results.

Observational skills assessment score: reliability in measuring amount and quality of use of the affected hand in unilateral cerebral palsy.

BACKGROUND: The Observational Skills Assessment Score (OSAS) measures amount and quality of use of the affected hand in children with unilateral Cerebral Palsy (CP) in bimanual activities and could therefore be a valuable addition to existing assessment tools. The OSAS consists of tasks that are age appropriate and require use of the affected hand. METHODS: To measure the agreement and reliability of the OSAS a convenience sample of two groups of 16 children with unilateral spastic CP (2.5-6 and 12-16 years old), performed age specific bimanual tasks in 2 measurement sessions. Three experienced raters took part in testing and 8 in scoring. Intra class correlation (ICC) values for intra- and inter-rater reliability, and the mean and standard deviation of the differences between measurements were calculated. For test-retest reliability beside ICC scores, Smallest Detectable Differences (SDDs) were calculated in 16 older and 10 younger children. RESULTS: Generally, there seems to be good agreement between repeated measurements of the OSAS, as indicated by the small SDDs on most scales for quality of movement, compared to the range of their scales. This indicates potentially good sensitivity to change if used for patient evaluation purposes. The exceptions were the 'quality of reach' score for all tasks, and all quality scores for the stacking blocks task for the young children. As used in the present study, the OSAS has good discriminative capacity within patient populations as indicated by the high ICCs for most quality scores. Measuring the amount of use does not seem to be useful for either discrimination or evaluation. CONCLUSION: In general, the OSAS seems to be a reliable tool for assessing the quality of use of the affected hand in bimanual activities in younger and older children with unilateral CP. Some modifications may improve its usefulness and efficiency.

Valid and reliable instruments for arm-hand assessment at ICF activity level in persons with hemiplegia: a systematic review.

BACKGROUND: Loss of arm-hand performance due to a hemiparesis as a result of stroke or cerebral palsy (CP), leads to large problems in daily life of these patients. Assessment of arm-hand performance is important in both clinical practice and research. To gain more insight in e.g. effectiveness of common therapies for different patient populations with similar clinical characteristics, consensus regarding the choice and use of outcome measures is paramount. To guide this choice, an overview of available instruments is necessary. The aim of this systematic review is to identify, evaluate and categorize instruments, reported to be valid and reliable, assessing arm-hand performance at the ICF activity level in patients with stroke or cerebral palsy. METHODS: A systematic literature search was performed to identify articles containing instruments assessing arm-hand skilled performance in patients with stroke or cerebral palsy. Instruments were identified and divided into the categories capacity, perceived performance and actual performance. A second search was performed to obtain information on their content and psychometrics. RESULTS: Regarding capacity, perceived performance and actual performance, 18, 9 and 3 instruments were included respectively. Only 3 of all included instruments were used and tested in both patient populations. The content of the instruments differed widely regarding the ICF levels measured, assessment of the amount of use versus the quality of use, the inclusion of unimanual and/or bimanual tasks and the inclusion of basic and/or extended tasks. CONCLUSIONS: Although many instruments assess capacity and perceived performance, a dearth exists of instruments assessing actual performance. In addition, instruments appropriate for more than one patient population are sparse. For actual performance, new instruments have to be developed, with specific focus on the usability in different patient populations and the assessment of quality of use as well as amount of use. Also, consensus about the choice and use of instruments within and across populations is needed.