Early Intervention to Improve Hand Function in Hemiplegic Cerebral Palsy

Abstract

Children with hemiplegic cerebral palsy often have marked hand involvement with excessive thumb adduction and flexion and limited active wrist extension from infancy. Post-lesional aberrant plasticity can lead to progressive abnormalities of the developing motor system. Disturbances of somatosensory and visual function and developmental disregard contribute to difficulties with hand use. Progressive soft tissue and bony changes may occur, leading to contractures, which further limit function in a vicious cycle. Early intervention might help to break this cycle, however, the precise nature and appropriateness of the intervention must be carefully considered. Traditional approaches to the hemiplegic upper limb include medications and botulinum toxin injections to manage abnormalities of tone, and surgical interventions. Therapist input, including provision of orthoses, remains a mainstay although many therapies have not been well evaluated. There has been a recent increase in interventions for the hemiplegic upper limb, mostly aimed outside the period of infancy. These include trials of constraint-induced movement therapy (CIMT) and bimanual therapy as well as the use of virtual reality and robot-assisted therapy. In future, non-invasive brain stimulation may be combined with therapy. Interventions under investigation in the infant age group include modified CIMT and action observation therapy. A further approach which may be suited to the infant with thumb-in-palm deformity, but which requires evaluation, is the use of elastic taping. Enhanced cutaneous feedback through mechanical stimulation to the skin provided by the tape during movement has been postulated to modulate ongoing muscle activity. If effective, this would represent a low-cost, safe, widely applicable early intervention.

Participatory design in the development of an early therapy intervention for perinatal stroke

“…A case notes review covering a 10 year period [25], a national survey of therapist management of perinatal stroke undertaken by our group (under submission) and reviews of the literature [23, 26] all indicated the lack of any standardised therapy approach for perinatal stroke in the first 6 months of life, though there is current research into modified constraint [27] and action-observation [28, 29] approaches starting from around 3 months of age in infants with emerging motor asymmetries regardless of aetiology. Despite the obvious challenges in delivery, the basic science literature from neurophysiological [30, 31], animal [32] and behavioural [33] studies suggests that for infants with predominantly unilateral stroke who are at risk of unilateral cerebral palsy, early intervention could improve long-term motor outcome.…”

Development of hand function during the first year of life in children with unilateral cerebral palsy

“…In Western countries, determining the trajectory of hand development can only be considered in the context of infants already receiving some kind of early intervention or involvement in research interventions. New knowledge of increased plasticity of the young brain indicates that early intensive intervention might be more effective than later treatment and enhances development of the neuromotor system …”

“…New knowledge of increased plasticity of the young brain indicates that early intensive intervention might be more effective than later treatment and enhances development of the neuromotor system. [5][6][7] Early development for children at high risk of CP has previously been described for reaching, in which children demonstrate some development over time but with reduced kinematic quality than typically developing children. 8,9 For older children with unilateral CP, from 18 months of age, the ability to use the impaired hand in bimanual activities has been described and it increases over time, but to a varying extent depending on the child's initial ability.…”

Fifteen-minute consultation: Management of the upper limb in unilateral cerebral palsy

“…Early intervention influencing reorganisation could be beneficial or harmful 17. While there is some evidence of benefit in the literature for ‘baby CIMT’, there remains important questions with respect to a safe time window.…”