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The literature review would be represented according to the following items: I. II.

Evidence based practice. Systematic review.


Cerebral palsy.



V. VI.

Bimanual performance. Bimanual training.

I) Evidence based practice Evidence-based medicine (EBM) was initially called “critical appraisal” to describe the application of basic rules of evidence as they evolve into application in daily practices. Evidence-based medicine is defined as an explicit and judicious use of current best evidence in making decisions about the care of individual patients. Evidence-based practice is defined based on 4 basic and important events, which include recognition of the patient’s problem and construction of a structured clinical question, thorough search of medical literature to retrieve the best available evidence to answer the question, critical appraisal of all available evidence, and integration of the evidence with all aspects and contexts of the clinical circumstances (Manchikanti, 2008). In daily practice the need for valid information about diagnosis , prevention, intervention, prognosis and harm are growing .it is estimated 9

that a clinician would need an answer for many questions and the answer for such questions should be based on solid research evidence rather than an opinion or past undocumented and untested experiences. However, in reality the answer to these questions for the same patient usually differ from one clinician to another even in the same situations as clinicians are used to base their decisions on subjective rather than objective standards (Elstein 2004). The adoption of an evidence-based approach in medical practice will help clinicians adopt a lifelong learning process to stay up to date with the current literature, to overcome some of the limitations of the current medical practice and to rationalize their clinical decision-making process, also providing the "scientifically proven" current best diagnostic or treatment modality to their patients (Choudhry et al., 2005). The Shift toward Evidence Based Practice Evidence Based Practice (EBP) requires a shift from the traditional paradigm of clinical practice grounded in clinical experience, and pathophysiological rationale. In the EBP paradigm, clinical expertise is combined with integration of best scientific evidence, patient values and preferences, and the clinical circumstances (Susan, 2007). Evidence Based Practice is a clinical decision-making approach critical to promote best patient outcomes and problem solving approach in which physicians seek solution for question that arise during their day to day clinical practice, EBP aims to apply evidence gained from the scientific method to certain parts of medical practice and to assess the quality of evidence relevant to the risks and benefits of treatments (Sackett et al., 2000).


Evidence Based Medicine involves two fundamental principles in clinical decision-making. First, the evidence is always interpreted together with the patient's values and preferences by weighing the benefits and risks, and the costs associated to the treatment compared to the alternatives. Second, the strength of the available evidence may be variable, constituting a hierarchy of evidence on the basis of the ability of the study to avoid systematic bias (Anttila, 2008). Evidence Based Medicine is the integration of clinical expertise, patient values, and the best evidence into the decision making process for patient care. Clinical expertise refers to the clinician's cumulated experience, education and clinical skills. The patient brings to the encounter his or her own personal and unique concerns, expectations, and values. The best evidence is usually found in clinically relevant research that has been conducted using sound methodology (Sackett, 2002). Steps of Evidence Based Medicine According to Shaheen (2009), practicing EBM includes the following steps (5 as model) as shown in figure (1): 1. Assessment of the patient. 2. Asking clinical questions about the patient problem. 3. Acquiring the best available evidence that answers these questions. 4. Appraisal of evidence for its validity and usefulness. 5. Applying the results of the appraised evidence to the patient.


E B M C ycle √

Assess your patient

Fig. (1): Steps of Evidence based medicine (Shaheen, 2009).

Asking clinical question means to convert the patient's problem into clinical question in a specific format as shown in figure (2), (PICO) represents these particular components(Guidance of EFSA, 2010) where: (P) is the patient problem or population of interest. (I) is the intervention, independent variable or exposure. (C) is the comparison intervention or exposure or reference intervention. (O) is the outcome that patients look for (patient oriented outcome).

PICO question according to Moher and Tricco(2008) may be:  Therapy Question: Concerning the effectiveness of a treatment  Prognosis Question: Concerning outcome of a patient with a particular condition.  Diagnosis Question: Concerning the ability of a test to predict the likelihood of a disease.  Harm Question: Concerning the likelihood of a therapeutic intervention or exposure to cause harm. 12

Fig. (2): PICO question (Shaheen, 2009).

Decision making is the process by which evidence is (or is not) applied to practice. The statement "evidence alone does not make decisions, people do" according to Haynes et al., (2002) reflects the integral role of the therapist in translation of evidence to practice. Evidence is applied within the context of values and preferences of individual patients, clinical expertise of the practitioner, and health care resources (Guyatt et al., 2000). Components of evidence-based decision making Evidence Based Practice is a problem solving approach in which solutions are sought for questions that arise during clinical practice. It is defined as the integration of best research evidence with clinical expertise and patient values as shown in figure (3) (Oxford Centre for evidence – based medicine, 2009).


Fig. (3): Components of Evidence-Based Decision (Haynes and Haines, 1998).

(1) Research evidence It involves tracking down the best and latest evidence from research articles that critically appraised for its validity and usefulness before applying their results to the patient care (Richardson, 2000). Evidence Based Practice help clinicians to keep their practice up to date and to explain satisfactory the rationale behind their decisions. In this way, they will ultimately provide the best care to their patients. Because evidence relies on well-designed research studies to demonstrate the efficacy and effectiveness of diagnostic tests, treatment strategies, new materials, and products, the scientific literature is an essential component for evidence-based practice (Straus et al., 2005). The best evidence for intervention can be drawn from randomized controlled trials (RCT) and systematic reviews of such trials. Randomized controlled trials (RCTs) are the “gold standard” for providing evidence on the effects of interventions (Anttila, 2008).


(2) Clinical expertise It refers to the clinician's cumulated experience, education and clinical skills. It is important to rapidly identify each patient's unique health state and diagnosis, their individual risks and benefits of potential interventions, and their personal values and expectations. It is important to emphasize that EBM complement experience and does not replace it (Sackett et al., 2000). (3) Patient value The patient value mean the unique preferences, concerns and expectations each patient brings to a clinical encounter and which must be integrated into clinical decisions if they are to serve the patient (Sackett et al., 2000). The Hierarchy of Evidence Evidence based practice clinician must know the strength of the evidence found and therefore the accompanying degree of uncertainty to make decisions about whether evidence should be applied to practice, Figure (4) presents the classic hierarchy of evidence triangle. With each descending level on the pyramid, the chance for bias increases (Bhandari, 2003). Evidence-based clinical guidelines and systematic reviews (SRs) are at the top of the hierarchy, providing the richest source of best evidence. Evidence obtained from at least one well-designed randomized controlled trial (RCT) is next followed by evidence obtained from welldesigned controlled trials without randomization and from well-designed cohort studies and case-controlled studies. Descriptive studies, evaluation studies, and qualitative studies are generally positioned at the base of the pyramid. Evidence generated from research is not all the same. Some 15

evidence is better than others are. Whenever one searches for evidence, he should start looking for the best available one that is obtained from the following types of research as seen in figure (4) (Sackett et al., 2000). 1- Systematic reviews and meta-analysis. 2- Randomized controlled studies. 3- Non-randomized controlled studies. 4- Cohort studies. 5- Case control studies. 6- Case series. 7- Case reports. 8- Opinions of experts. 9- Animal research and in vitro studies.

S.Rs& metaanalysis

R.C.T. s

Non RCT Cohort studies

Case control studies

Case series Case reports Opinions of Animal research and in virtro studies

Fig. (4): Levels of Evidence. (Sackett et al., 2000). exp expee xxexperts EXPERTSEXe xperts 16

The amount of evidence supporting or failing to support the effectiveness of physical therapy for children with cerebral palsy has increased exponentially in each of the past two decades. Reasons for this include (1) academic progress within the physical therapy profession, including a greater number of PhD-trained therapists and elevation of the basic education level for therapists from a bachelor’s to a doctoral degree and (2) factors outside of the profession, such as a greater focus on evidence-based practice in all medical and allied health fields (Damiano, 2009).

Requirements for evidence-based physical therapy according to Jewell (2008): • A willingness to challenge one's assumptions. • The ability to develop relevant clinical questions about a patient/client. • Access to evidence. • Knowledge regarding evidence appraisal. • The time to make it all happen.

II) Systematic review A systematic review (SR) is an overview of existing evidence pertinent to a clearly formulated question, which uses pre-specified and standardized methods to identify and critically appraise relevant research, and to collect, report and analyze data from the studies that are included in the review (Guidance of EFSA, 2010).


Why systematic reviews are needed? The explosion in medical, nursing and allied healthcare professional publishing within the latter half of the 20th century (perhaps 20,000 journals and upwards of two million articles per year), which continues well into the new millennium, makes keeping up with primary research evidence an impossible feat (Mckibbon et al., 2004). For many, this need conflicts with their busy clinical or professional workload. For consumers, the amount of information can be overwhelming, and a lack of expert knowledge can potentially lead to false belief in unreliable information, which in turn may raise health professional workload and patient safety issues (Higgins and Green, 2011). Systematic Reviews help overcoming limitations of primary research by testing its findings for consistency and whether they can be generalized across populations or not. Meta-analysis in particular increases the power and precision of estimates and treatment effects and exposure risks. Besides the explicit methods used in SR, it limits bias and improves reliability and accuracy in conclusions. In this way, SR and meta-analysis can help physicians, physical therapists, health care providers and policy makers to make informed decisions in health care (Akobeng, 2005). Importance of a systematic review: The importance of systematic review is concluded for that, for busy healthcare providers and decision makers, systematic reviews are important as they summarize the overwhelming amount of research – based healthcare information that is available to be read and synthesized (Clarke, 2005).


Systematic reviews overcome some of the bias associated with small single trials where results may not be robust against chance variation if the effects being investigated are small. Under Guyatt’s leadership, the Evidence-Based Medicine Work Group published a series of articles for the Journal of the American Medical Association between 1993 and 2000 that outlined the criteria for evaluating current evidence to support clinical decisions. These articles formed the basis of most existing critical appraisal tools. Acceptance for EBM has grown substantially over the past fifteen years among nurses and other health professionals including public health practitioners (Glasziou et al., 2004). Advantages of a systematic review: There are multiple advantages of systematic reviews according to Jessani and Reid (2009): Condensed: allowing the reader to access consolidated results of huge volume of information. Objective: reducing (though not eliminating) the risk of bias and error. Balanced: studies which are identified via a thorough and systematic search strategy. Verifiable: incorporating transparent processes that allow the reader to know exactly how the conclusions were reached. Flexible: can be updated on a regular basis. Dynamic: in identifying under-researched areas or new research questions. Readable: presented in a format that is easy to read and understand.


Steps of a systematic review according to Handoll and Smith( 2003): 1. The title - framing the review question. 2. Forming the review team. 3. The protocol - deciding on and defining inclusion and exclusion criteria, and methods. 4. Exhaustive search for material. 5. Appraisal and quality assessment of material. 6. Data extraction. 7. Summarizing and synthesis (combining the results). 8. Interpretation Briefly, developing a SR requires the following steps as illustrated in figure (5) according to Davies and Crombie (2006): 1. Defining an appropriate healthcare question This requires a clear statement of the objectives of the review, intervention or phenomena of interest, relevant patient groups and subpopulations (and sometimes the settings where the intervention is administered), the types of evidence or studies that will help answer the question, as well as appropriate outcomes. These details are rigorously used to select studies for inclusion in the review.

Fig. (5): Steps for conduction of systematic reviews (Attia et al., 2007).


2. Searching the literature The published and unpublished literature is carefully searched for the required studies relating to an intervention or activity (on the right patients, reporting the right outcomes and so on). For an unbiased assessment, this search must seek to cover all the literature (not just MEDLINE where, for example, typically less than half of all trials will be found), including non-English sources. In reality, a designated number of databases are searched using a standardized or customized search filter. Furthermore, the grey literature (material that is not formally published, such as institutional or technical reports, working papers, conference proceedings, or other documents not normally subject to editorial control or peer review) is searched using specialized search engines, databases or websites. Expert opinion on where appropriate data may be located is sought and key authors are contacted for clarification. Selected journals are hand-searched when necessary and the references of full-text papers are also searched. Potential biases within this search are publication bias, selection bias and language bias. 3. Assessing the studies Once all possible studies have been identified, they should be assessed in the following ways, each study needs to be assessed for eligibility against inclusion criteria and full text papers are retrieved for those that meet the inclusion criteria. Following a full-text selection stage, the remaining studies are assessed for methodological quality (e.g. Pedro scale) using a critical appraisal framework. Poor quality studies are excluded but are usually discussed in the review report. Of the remaining studies, reported findings are extracted onto a data extraction form. Some studies will be excluded 21

even at this late stage. A list of included studies is then created. Assessment should ideally be conducted by two independent reviewers. Trials could be rated with a checklist more specific for physical therapy intervention studies (called the Pedro scale). The Pedro scale considers two aspects of trial quality, namely the “believability” (or internal validity) of the trial and whether the trial contains sufficient statistical information to make it interpretable. It does not rate the “meaningfulness” (generalizability or external validity) of the trial, or the size of the treatment effect. To assess believability we look for confirmation of a number of criteria, including random allocation, concealment of allocation, comparability of groups at baseline, blinding of patients, therapists and assessors, analysis by intention to treat and adequacy of follow-up. To assess interpretability we look for between-group statistical comparisons and reports of both point estimates and measures of variability. This gives a total of 10 scale items. Trials are rated on the basis of what they report. If a trial does not report that a particular criterion was met, we score it as if the criterion was not met (guilty until proven innocent). All but two of the Pedro scale items are based on the Delphi list, developed by Verhagen and colleagues. The Delphi list is a list of trial characteristics that was thought to be related to trial “quality” by a group of clinical trial experts. The Pedro scale contains additional items on adequacy of follow-up and between-group statistical comparisons. One item on the Delphi list (the item on eligibility criteria) is related to external validity, so it does not reflect the dimensions of quality assessed by the Pedro scale. This item is not used to calculate the method score that is displayed in the search results (which is why the 11 item scale gives a score out of 10). This item has, nevertheless, been retained so that 22

all Delphi list items are represented on the Pedro scale (Sherrington et al., 2000). 4. Combining the results If appropriate, the findings from the individual included studies can then be aggregated to produce a summary estimate of the overall effect of the intervention. Sometimes this aggregation is qualitative (i.e., individual descriptions of the included studies), but more usually it is a quantitative assessment using meta-analysis. Meta-analysis should only be performed when the studies are similar with respect to population, outcome and intervention. 5. Placing the findings in context The findings from this aggregation of an unbiased selection of studies then need to be discussed to put them into context. This will address issues such as the quality and heterogeneity of the included studies, the likely impact of bias, as well as the chance and the applicability of the findings. The reliability of the results of a randomized trial depends on the extent to which potential sources of bias have been avoided. A key part of a review is to consider the risk of bias in the results of each of the eligible studies. A useful classification of biases is into selection bias, performance bias, attrition bias, detection bias and reporting bias as shown in table (1). Selection bias refers to Systematic differences between baseline characteristics of the groups that are compared. Performance bias refers to Systematic differences between groups in the care that is provided, or in exposure to factors other than the interventions of interest. Attrition bias refers to Systematic differences between groups in withdrawals from a study. Detection bias refers to Systematic 23

differences between groups in how outcomes are determined. Reporting bias refers to Systematic differences between reported and unreported findings. (Higgins and Green, 2011).

Table (1): A common classification scheme for bias (Adapted from Higgins and Green, 2011). Relevant domains in the Collaboration’s ‘Risk of bias’ tool

Type of bias


Selection bias

Systematic differences between baseline characteristics of the groups that are compared.

Sequence generation.

Allocation concealment.

Systematic differences between groups in the care that is provided, or in exposure to factors other than the interventions of interest.

Blinding of participants and personnel.

Other potential threats to validity.

Detection bias Systematic differences between groups in how outcomes are determined.

Blinding of outcome assessment.

Other potential threats to validity.

Systematic differences between groups in withdrawals from a study.

Incomplete outcome data

Reporting bias Systematic differences between reported and unreported findings.

Selective outcome reporting

Performance bias

Attrition bias


Method of heterogeneity in study design and quality affect the ability to perform a meta-analysis. When study heterogeneity precludes metaanalysis, the authors of SR need to summarize findings based on the strength of the individual studies and reach conclusions if indicated (Wright et al., 2007). Heterogeneity Studies brought together in a SR will differ; any kind of variability among studies in a SR may be termed heterogeneity. It can be helpful to distinguish between different types of heterogeneity. Variability in the participants, interventions and outcomes studied may be described as clinical heterogeneity, and variability in trial design and quality may be described as methodological heterogeneity. Variability in the treatment effects being evaluated in the different trials is known as statistical heterogeneity, and this is a consequence of clinical and/or methodological diversity among the studies. Meta-analysis should only be considered when a group of trials is sufficiently homogeneous in terms of participants, interventions and outcomes to provide a meaningful summary (Higgins and Green, 2011). Meta-analysis Meta-analysis is the use of statistical methods to summarize the results of independent studies, it can provide more precise estimates of the effects of healthcare than those derived from the individual studies included in a review and allows decisions that are based on the available evidence. It is a powerful tool for deriving meaningful conclusions from data. However, there are situations in which meta-analysis can be more of a hindrance than a help. Meta-analysis of poor quality studies may be seriously misleading. If bias is present in each or some of the individual studies, meta-analysis will simply compound the errors, and produce a 25

‘wrong’ result that may be interpreted as having more credibility. Reasons for considering including a meta-analysis in a review according to Higgins and Green (2011) are: To increase power: Power is the chance of detecting a real effect as statistically significant if it exists. Many individual studies are too small to detect small effects, but when several are combined there is a higher chance of detecting an effect. To improve precision: The estimation of a treatment effect can be improved when it is based on more information. To answer questions: not posed by the individual studies. Primary studies often involve a specific type of patient and explicitly defined interventions. A selection of studies in which these characteristics differ can allow investigation of the consistency of effect and, if relevant, allow reasons for differences in effect estimates to be investigated. To settle controversies: arising from apparently conflicting studies or to generate new hypotheses. Statistical analysis of findings allows the degree of conflict to be formally assessed, and reasons for different results to be explored and quantified. Limitations of traditional reviews Traditional reviews may, for instance, be called literature reviews, narrative reviews, critical reviews or commentaries within the literature. Although often very useful background reading, they differ from a SR in that they are not led via a peer-reviewed protocol and so, it is not often possible to replicate the findings. In addition, such attempts at synthesis have not always been as rigorous as might have been hoped (Antman et al., 1992).Traditional reviews are rarely explicit about how studies are selected, assessed and integrated. Thus, the reader is generally unable to


assess the likelihood of prior beliefs or of selection or publication biases clouding the review process (Torgerson, 2003).

III) Cerebral palsy Definition: Cerebral palsy (CP) describes a group of disorders of the development of movement and posture, causing activity limitation, that are attributed to non-progressive disturbances that occurred in the developing fetal or infant brain. The motor disorders of cerebral palsy are often







communication, perception, and/or behavior, and/or by a seizure disorder (Rosenbaum et al., 2007). Incidence: Cerebral palsy is a chronic disabling condition of childhood. It occurs in 1.5/1,000 to 3/1,000 live births with spasticity as a prevalent disabling clinical symptom. The incidence is higher in males than in females (Volpe, 2008). The survival of infants has improved over time but the prevalence of cerebral palsy has remained the same with little change over the past 40 years this is thought to be due to increase in cerebral palsy within the population of preterm and very preterm infants (Reddihiugh


Collins, 2003). Etiology Cerebral palsy is a static neurologic condition resulting from brain injury that occurs before cerebral development is complete. Because brain development continues during the first two years of life, CP can result from brain injury occurring during the prenatal, perinatal, or postnatal periods (Bass ,2000 and United Cerebral Palsy, 2005). 27

Seventy to 80 percent of CP cases are acquired prenatally and from largely unknown causes. Birth complications, including asphyxia, are currently estimated to account for about six percent of patients with congenital CP, neonatal risk factors for cerebral palsy include birth weight of less than (2,500 g), intrauterine growth retardation, intracranial hemorrhage, and trauma. In about 10 to 20 percent of patients, CP is acquired postnatally, mainly because of brain damage from bacterial meningitis,






collisions, falls, or child abuse (Taylor, 2005). Classification








Hicks(2011): Topographical classification: • Tetraplegia (quadriplegia): Involvement of all limbs. Arms are equally or more affected than the legs. Many are asymmetrical (one side more affected) and called double hemiplegia. • Diplegia: Involvement of limbs, with arms much less affected than legs. • Hemiplegia: Limbs on one side affected. Classification of types of cerebral palsy: There are several different types of CP. While some patients are severely affected, others have only minor disruption, depending on which parts of the brain have been damaged. The main types of CP are: • Spastic cerebral palsy: Some of the muscles in the body are tight, stiff and weak, making control of movement difficult. • Athetoid (dyskinetic) cerebral palsy: Control of muscles is disrupted by spontaneous and unwanted movements. Control of posture is also disrupted.


• Ataxic cerebral palsy: Problems include difficulty with balance, shaky movements of hands or feet, and difficulty with speech. • Mixed cerebral palsy : A combination of two or more of them . Symptoms of cerebral palsy: Diagnosing CP during the earliest months of life is often unreliable. Early warning signs include poor suck, persistent fisting, delayed motor milestones, decrease rate of head circumference growth, seizures, irritability, toe walking and scissoring of the lower extremities (Murphy and Such-Neibar,2003). Children with CP present with three types of motor problems .The primary impairments of muscle tone, balance and strength are directly related to damage in the CNS. Secondary impairments of muscle contracture and deformities develop over time in response to the primary problems and musculoskeletal growth. Tertiary impairments are adaptive mechanisms and coping responses that the child develops to adapt to the primary and secondary problems (Nadir and Selim,2005) . Treatment of cerebral palsy according to Wikipedia(2010): There is no cure for CP, however, various forms of therapy can reduce the impact of the condition by easing symptoms such as spasticity, improving communication skills and finding other ways to do things. Treatment may include one or more of the following: physical therapy, occupational therapy, orthoses, speech therapy, drugs, hyperbaric oxygen, biofeedback, surgery to correct anatomical abnormalities or release tight muscles and botulinum toxin A.


- Physical therapy (PT): programs are designed to encourage the patient to build a strength base for improved gait and volitional movement, together with stretching programs to limit contractures. - Occupational therapy: Helps adults and children maximize their function, adapt to their limitations and live as independently as possible. - Orthotic devices: Are often prescribed to minimize gait irregularities, control spasticity, tightness and deformities. - Speech therapy: Helps control the muscles of the mouth and jaw, and improve communication. - Hyperbaric oxygen therapy: Significant enhancements were documented showing improved vision, hearing and speech as well as a reduction of spasticity. - Biofeedback: Is an alternative therapy in which people with CP learn how to control their affected muscles. - Surgery: Usually involves one or a combination of: o Loosening tight muscles and releasing fixed joints. o Straightening abnormal twists of the leg bones. o Cutting nerves on the limbs most affected by movements and spasms.

IV) Hemiplegia Definition: Hemiplegia is a condition involving paralysis or partial paralysis of one side of the body. In child or infant hemiplegic CP, there is damage to part of the brain and this may occur in utero, at birth, or later, as a result of accident or illness. Hemiplegia is sometimes known as hemiparesis, meaning partial paralysis of one side of the body (CHASA, 2009).


The affection in Spastic hemiplegia includes the limbs, trunk and the neck. The upper limbs are more severely affected than the lower limbs, although this is partly because the less affected proximal part of the body makes walking look relatively normal. The involvement of the lower limb often becomes more apparent with ambulation. Impairment in hand functions appears because pincer grasp of thumb, extension of wrist and supination of the forearm are affected. Bony undergrowth of the affected limb, when present, occurs in the first two years of life (and beyond) and if not suitably managed, may play a part in the development of contractures of the tendo-Achilles. Seizures occur in more than 50%, visual field defects as homonymous hemianopia and cranial nerve abnormalities most commonly facial nerve palsy are seen. It is seen in 56% of term infant and 17% of preterm infants (Bax et al., 2005). Types of Hemiplegia: With respect to CP, a distinction is made between a congenital form of hemiplegia, when the lesion occurs before the end of the neonatal period (within the first four weeks of life), and an acquired form, when the lesion provoking hemiplegia occurs later, within the first three years of life (Aicardi and Bax, 2009). Incidence of Hemiplegia: The prevalence of spastic hemiplegia accounted for about 0.6 per 1000 live births and it did not change significantly over time (KrägelohMann and Cans, 2009). Hemiplegic forms are the most common expression of CP (more than 38 % of cases) and the second in terms of frequency, after diplegia, in premature infants (around 20% of cases) (Himmelmann et al., 2005). Congenital forms amount to 70-90% of childhood hemiplegia, while acquired forms only amount to 10-30% (Hagberg and Hagberg , 2000). 31

Signs of hemiparesis or hemiplegic cerebral palsy according to Menkes and Sarnat (2000) may include: - Unilateral paresis or paralysis with upper limbs more severely affected than the lower limbs. -Voluntary movements are impaired with hand functions being most affected. Pincer grasp of the thumb, extension of the wrist and supination of the forearm are affected. -In the lower limb, dorsiflexion and eversion of the foot are most impaired. -There is increased flexor tone with hemiparetic posture, flexion at the elbow and wrist and equines position of the foot. - Palmer grasp may persist for many years. - Sensory abnormalities in the affected limbs are common; sterognosis is impaired most frequently, two point discrimination and position sense are also affected. These children generally have very few associated problems as seizures, learning and behavioral problems, while communications is almost unimpaired. Functional prognosis is good compared to other types because one side of the body is normal. All hemiplegic children learn to walk by the age of three. They become independent in the activities of daily living. Seizures, mild mental retardation, learning difficulties and behavioral disturbances may complicate the management and integration into the society. The most common musculoskeletal problems found is shoulder adduction and internal rotation, the elbow is flexed and pronated, the wrist and fingers are flexed, the thumb is in the palm. The hip is extended and internally rotated, the knee is flexed or extended, and 32

the ankle is in planter flexion. The foot is generally in varus, although valgus deformity may also be seen. The hemiplegic side may be short and atrophied depending on the severity of the involvement (Gordon et al., 2003). During symmetrical bimanual movements, there is coupling of movements of the two extremities. With one or both of the movements being affected, This coupling may be either advantageous or detrimental depending on the task constraints. In tasks which involve simple non functional symmetrical (mirror) movements of the two hands, the non involved hand slowed down and mimicked the movement of the involved hand, as a result, the two hands accomplished their goal together as long as the tasks were not too complicated (Utely and Steenbergen, 2006). Obviously for asymmetrical movements of the two hands, coupling (such as in mirror movements) can greatly interfere with task performance.






movement (e.g. opening a drawer and manipulating its contents) are performed sequentially in children with CP; i.e. there is poor temporal coordination (because of the complexity and asymmetrical components of this task, the non involved hand could not simply slow down as a compensatory strategy) so, asymmetrical movements were disturbed more than the symmetrical movements (Hung et al., 2004). Unlike unilateral impairments, these bimanual coordination problems may underlie some of the functional limitations these children experience in activities such as dressing, eating, and playing sports, and this logic forms the basis for new bimanual assessments (Skold et al., 2010).


V) Bimanual performance Occupations can simply be described as “what we do”. “What we do” can however be viewed from several perspectives, showing a complex construct. From one view, occupational performance is essential to humans as a carrier of meaningful experiences (Jonsson and Josephsson, 2005). However, another view is that the performance of occupations can be described as a concrete execution of tasks; “getting something done”. The routinely performance of daily activities may require low attention and may become more or less automatic. What we do and how we do it depends on individual interests, values, sense of competence and effectiveness. Further, “what we do” is also dependent on function in bodily systems and mental and cognitive abilities as well as physical and social environment including cultural and political structures. Thus, human occupation and "what we do" is a complex interplay between individual and environment and when being in focus in research, this complexity needs attention (Kielhofner, 2008). Hand skills are critical for interaction with the environment. Hands allow us to act on our world through contact with our own and others bodies and through contact with objects. The child who has a disability affecting hand skills has less opportunity to take in sensory information from the environment and to experience the effect of his or her actions on the world (Exner, 2005). Bimanual activity performance varies with activity, person and environment: Hand use and performance of bimanual activities is varying depending on variables in the three aspects; activity, person and environment. It can be assumed that a dynamical interaction between these three aspects form the activity performance: 34

1) Activity Guiard (1987) describes bimanual performance from the perspective of activities. Guiard categorizes bimanual activities into three categories: unimanual (e.g., dart throwing), bimanual asymmetric (e.g., playing the violin), and bimanual symmetric, in which the two hands play the same role, either in phase (e.g., rope skipping) or out of phase (e.g., rope climbing). This classification has since been used in various contexts. However, Guiard suggests that no activity can be proven to be truly unimanual; for example, in dart throwing, the other hand may contribute to postural function, influencing the performance. Thus, some activities obviously demand the use of both hands, while in others, hand use varies and is not always obvious. 2) Person A person can choose how to perform an activity, based on personal preferences and in relation to the activity itself and the environment. Values and interests, as well as belief in what one can achieve, influence the choices made in activity performance (Kielhofner, 2008). It can be assumed that this is true for bimanual activities as well as other activities. However, no literature has been found as regards how the persons own values influence hand use. However, much knowledge has been generated as regards the neural control of the hand. Neural control of the hand involves several areas in the brain, working together in neural networks, selecting and planning movement performance (Pehoski, 2006). Without having to pay attention to and plan every movement in a task, a person performs well known tasks in an efficient way. For example, when opening a drawer with one hand and manipulating something in the drawer with the other, the first hand starts, reaching out towards the drawer, preshaping the hand in relation to the size of the handle, and the 35

second hand is starting before the first hand is finished, creating a temporal overlap between the movements of the two hands (Hung et al., 2004). Thus, whereas the general performance of the activity is influenced by values and personal preferences, humans are generally not making conscious choices about how to use the hands in well known activities, rather it is automatically formed by neural control so, if the neural control is impaired, hand use may not be automatic in the same way and the way of using the hands may become an issue which demand that the person make more conscious choices. Further, the functions of the musculoskeletal and somatosensory systems in the arm and hand, including range of motion, strength, and sensibility, are also crucial for how activity performance takes form (Eliasson, 2006). 3) Environment The environment influences activity performance in various ways, as it may both demand particular behaviours and discourage or disallow others (Kielhofner, 2008). The environment includes both factors that influence all of society, such as cultural and political factors, and factors specific to the situation in which the person performs an activity, such as social and physical environments and the object to be handled .Social aspects include the universal need for social acceptance as well as the need for practical, informational, and emotional support (Christiansen and Baum, 2005). Objects are defined by Kielhofner (2008) as “naturally occurring or fabricated things with which people interact and whose properties influence what they do with them”. Handling objects demands various degrees of hand function; the physical properties of objects, such as their size, friction, and weight, require forces of various strengths, and the grasping and lifting actions must be adjusted in relation to the object to produce smooth movement . Previous experiences of handling objects 36

are used to estimate what movements and forces are needed, new information rapidly contributing to updating the information base and adjusting the feed-forward strategy (Eliasson et al., 1995 and Forssberg et al., 1995) . In the personal element of the activity–person–environment interplay, the prerequisites for hand use on the part of children with unilateral CP differ from those of children with no dysfunction, though the activities that they are expected to perform are largely the same as those of children with no dysfunction. To a certain degree, children with unilateral CP are restricted in the performance of daily activities and in social participation, although less so than children with more severe CP. However, little is known about how the dynamic activity–person– environment interplay manifests itself in the presence of CP, nor are there any studies of how people with CP view this matter (Skold et al., 2010 ). Mandich and Rodger (2006) describe children’s activities as possibilities to develop abilities and to become social beings. Occupational skills can only be learned and mastered by doing. Successful doing can help children develop a healthy sense of who they are and what they can become. Therefore, the enabling of doing is important. The activity performance of children differs from that of adults. Play is central in children’s lives, though the type of play differs according to age. In the ages of middle childhood (age 6–10 years), structured games and organized play predominate. Interacting with peers and following rules becomes more important. By eight to nine years children become more interested in crafts and hobbies as well as organized sports, it becomes more important to achieve something with the play. Social play increases in importance, e.g., belonging to groups and talking to friends (Case-Smith, 2005). Where as earlier in life, play is 37

more characterized by the qualities of exploring, participating, and imitating, the play of middle childhood is more characterized by expectations of certain behaviors. However, in the presence of restricted mobility, play can be different, children mostly played alone or with adults. Play with friends – either interactive or as an onlooker – was less common. During adolescence, the child takes on increased responsibility in activities of daily life and independence becomes more important. It is also an important aspect to fit in with peers and to be successful in obtaining a job (Shepherd, 2005). Children with hemiplegic CP primarily have one well-functioning side ‘less affected’ side of their body and one ‘more affected’ side, evaluation of the upper limb often targets the more affected limb using unimanual assessments. Yet clinical experience shows that children with hemiplegic CP rarely use their impaired hand for unimanual tasks. This hand is typically used when they need it, i.e. during bimanual task performance. Bimanual actions are more complicated than unimanual actions as many children with hemiplegia present with deficits in bimanual coordination which is problematic as the movements of both arms and hands must be coordinated temporally and spatially to complete a task or achieve a desired goal. Independence in these tasks is achieved using adaptive strategies to compensate for poor bimanual skills (Utely and Steenbergen, 2006). Unimanual impairments do not greatly impact functional independence and quality of life because tasks such as hair combing, teeth brushing, and drinking may effectively be performed with the noninvolved extremity. Children with hemiplegic CP are also remarkably adept at using their non-involved extremity alone in a compensatory manner during tasks that typically developing children or adults would 38

normally perform bimanually. However, these compensations are highly inefficient and take longer than performing the same tasks with two hands. Furthermore, such compensations may be reinforced over time and make rehabilitation more difficult therefore, rather than defining increased unimanual use of the involved extremity as the therapeutic goal, the goal of upper extremity intervention should be to increase functional independence by improving use of both hands in cooperation (Charles and Gordon, 2006). The scales designed for the assessment of upper extremity function in children are very few. Most of them aim to assess hand function on request and only two; Besta scale and Assisting Hand Assessment (AHA) are designed to directly assess spontaneous hand use. This represents a strong limitation for assessors because, in children, performance on request is different from spontaneous use in a natural context. Besta Scale assess the differences between the grasp function on request (capacity) and the spontaneous bimanual use in play and activities of daily living (bimanual performance) and AHA is a useful tool for the assessment of spontaneous bimanual use, but it is unable to evaluate the use of the hands in self-care activities (Fedrizzi et al., 2012). The discrepancy between unimanual capacity and bimanual performance is of key interest to therapists aiming to improve functional use of the impaired limb and enhance performance of daily activities. A greater understanding of the relationship between unimanual capacity (i.e. what children can do with their upper limb when asked) and bimanual performance (i.e. how children spontaneously use their impaired upper limb in bimanual tasks) may assist clinicians in optimizing interventions (Sakzewski et al., 2010).


With many everyday tasks requiring cooperative use of both hands, poor bimanual performance is often the greatest functional impairment for children with hemiplegia. Careful evaluation of bimanual ability should be an integral component of an upper limb assessment as Careful evaluation of bimanual abilities and their progression could provide valuable information for clinicians and researchers about how these skills are affected by the evolving impairment. Evaluation could also assist in determining whether the infants’ skills are different to those of older children whose motor patterns have become established. Carefully collected information about bimanual performance could then be used to guide and⁄ or evaluate the effectiveness of intervention programs (Greaves et al., 2010).

VI) Bimanual training Bimanual training in children with unilateral CP is not new. Historically, therapists have used a bimanual approach called bimanual occupational therapy (BOT) in the management of motor dysfunction in children with hemiplegia. One of the traditional therapeutic intervention aims is to improve the hemiplegic children’s ability to use their hands together. Previously, little research has focused exclusively on investigating the effectiveness of bimanual interventions, or identified specific intervention strategies and training practices that promote bimanual hand function however, practice of activities and tasks requiring bilateral hand use is a routine element of therapy (Eliasson, 2007). Bimanual occupational therapy focuses on improving child’s occupational performance (the performance of self-care, productivity, and leisure activities) in the context of motivating, meaningful, and purposeful bimanual activities. This has been well supported by the 40

advances in the areas of neuroscience, basic mechanisms of hand function and more specifically, motor control and motor learning theories (Hoare et al., 2010 and Eliasson, 2005). Charles and Gordon (2006) developed a bimanual intervention for children with hemiplegia named Hand Arm Bimanual Intensive Training (HABIT), which was developed in response to the limitations of constraint induced movement therapy (CIMT), as it is a form of functional training that takes the advantage of the key ingredient of CIMT (intensive practice), but focuses on improving coordination of the two hands by introducing bimanual training activities using structured task practice embedded in bimanual play and functional activities with intensive practice (6h per day for 10-15 days) . It uses principles of motor learning (practice specificity) which suggest that the most functional way to balance the cortical activity and improve bimanual control would be to practice bimanual activities directly, and principles of neuroplasticity (practice-induced brain changes arising from repetition, increasing movement complexity, motivation, and reward) (Schmidt and Lee, 2005 & Nudo, 2003) . Gordon(2011) stated that researchers in the past decade have started to compare the effectiveness of these two approaches. The focus has mainly been on two key questions, namely ‘what are the strengths and weaknesses of each?’ and ‘is the successful treatment factor is the intensity or the

constraint?’. Fedrizzi et al., (2012) compared three

groups of children with hemiplegic cerebral palsy, treated for 10 weeks (three hours per day,

seven days per week ; first with unimanual

modified constraint-induced movement therapy (mCIMT), second with intensive bimanual training), and the last with standard treatment to determine if the efficacy of mCIMT is due to the restriction of the non 41

affected arm or due to the intensity of treatment and also to find whether similar intensive practice elicited with bimanual training without the restraint of the unaffected hand - and using the same schedule - would result in similar functional results gained by mCIMT. Despite the considerable attention CI therapy has received, there are several conceptual problems in applying it to children. First, CI therapy was developed to overcome learned non-use in adults with hemiplegia. However, children with hemiplegia must overcome ‘developmental nonuse’, because they may never have effectively learned to use their involved extremity. Therefore, the approach must be modified to be developmentally focused (Gordon et al., 2005). Second, restraining a child’s non-involved extremity (especially with casts) is potentially invasive. Finally, constraint-induced (CI) therapies are frequently conducted without regard for realistic expected functional outcomes (Sunderland and Tuke, 2005).








Occupational Therapy: Despite similarities with BOT, there are specific differences between the therapies, including the high intensity of treatment used in hand arm bimanual intensive therapy (6h per day for 10-15 days), use of behavioural shaping theory; and sole reliance on environmental adaptation for grading of activities in HABIT, rather than physical assistance or handling of the child which are used in BOT (Hoare et al., 2010).


Hand Arm Bimanual Intensive Training versus Constraint Induced Movement Therapy: Different approaches to training have been appeared in the last decade such as HABIT and CIMT. All of these approaches are based on the advances in understanding of motor control, motor learning, brain plasticity, and development and they are intended to meet different purposes. The intention when using HABIT is to improve the frequency and quality of bimanual hand use. By practicing bimanual activities, children will be more successful and thereby recognize the benefit of using the two hands. CI therapy was developed to overcome learned nonuse in adults with hemiplegia, but, children with hemiplegia do not need to relearn to use the hand, they need to learn what the hand can do. It is important to remember that it is the elicited practice, rather than restraint, that is responsible for the improved motor performance (Eliasson, 2007). Impaired bimanual coordination might be amenable to treatment. During bimanual movements, the non-involved hand could provide a template for the involved hand when movements are either performed sequentially or simultaneously (Utley et al., 2004). Although there is some suggestion that initial unimanual practice with the involved hand can transfer to improvements in bimanual coordination, principles of motor learning emphasize the importance of task specificity in practice to maximize learning. Thus, improved bimanual coordination might be best accomplished by practicing bimanual skills directly (Schmidt and Lee, 2005). Although HABIT is potentially less invasive than CIMT because there is an absence of restraint, administering it is often more difficult for the interventionists. Children with hemiplegia are strikingly adept at 43

using only their non-involved extremity to perform tasks for which their typically developing peers require both hands, even if it is at the cost of efficiency (e.g. performing tasks sequentially or using body parts as a brace). During CIMT, the restraint forces the participant to use the involved extremity to accomplish the task, with the drawback that the tasks must be unimanual. HABIT tasks must be bimanual to train specific coordination skills. In many instances, spatial and temporal discoordination associated with using the two extremities together was observed. Often their natural tendency would be to over-compensate with their non-involved extremity (e.g. reach into the involved extremity’s hemi space). Although the interventionist could simply remind the child to use the involved extremity, this strategy is less effective than desirable as children quickly attenuate. Thus, far more attention must be provided to the choice of activities and structuring the environment. Providing rules before an activity, with occasional reminders of the rules (rather than direct prompts), are far more effective because the child is asked to verbally agree before participation. Thus, the interventionist must use these rules and the environment as a new type of restraint (Gordon et al., 2007).

Development of HABIT by Charles and Gordon (2006): 1) OVERVIEW HABIT methodology focuses on: (1) Provision of structured practice increasing in complexity. (2) Provision of functional activities that necessitate bimanual hand use. (3) Remaining a child-friendly intervention protocol that takes into account children’s goals and parental involvement. 44

2) TASK SELECTION A large bank of age-appropriate fine motor and manipulative gross motor activities that require use of both hands was established. The intervention is conducted in groups to provide an environment of peer support and social interaction. Specific activities are selected by considering the role of the involved limb in the activity. Although task demands are graded to allow for success, children are asked to use the involved limb in the same manner as that of the non-dominant limb of a typically developing child. During these activities the children receive instructions from the interventionist but also must engage in their own active problem-solving. Task performance is recorded and both positive reinforcement and knowledge of performance are used for motivation and to reinforce target movements. 3) PRACTICE Because the goal is to provide sufficient practice intensity in performing bimanual activities, the choice of specific activities is less important than the movements the child elicits. By engaging the child in these activities for six hours per day, both part and whole-task practice were elicited. The use of skilled, repetitive, structured practice as a means of inducing neuroplastic changes in the motor cortex was viewed (Nudo, 2003 and Kleim et al., 2004). Movement deficits of the involved upper extremity and bimanual coordination problems are determined during the pre-intervention evaluation. Bimanual activities are selected that will improve these movement deficits and engage the child in activities of increasingly complex bimanual coordination. Directions specifying how each hand will be used are provided to the child before the start of each task to prevent use of compensatory strategies (e.g. performing the task unimanually). For example in playing with Lego bricks, the pieces are 45

placed in two piles. The child is asked to use the appropriate hand for grasping and using each piece. If the child attempts to use the noninvolved hand inappropriately, the task is paused and the child is reminded of the task rules. Interventionists are instructed to avoid using physical or verbal restraint (such as consistently urging the child to use his/her involved hand). During performance of whole-task practice, the activities are performed continuously for at least 15 to 20 minutes. Targeted movements and spatial and temporal coordination are practiced within the context of completing a task. For example, during drawing, the objective is to complete a picture using different colored markers. The motor components include grasping the marker, removing the cap, positioning and stabilizing the paper all with the involved hand, and drawing on the paper with the non-involved hand. Part-task practice involves practicing a targeted movement exclusive of other movements. It is analogous to ‘shaping’ in psychology and CI therapy literature (Gordon et al.,2005). Specifically, symmetrical bimanual movements that elicit a targeted movement are used. For example, after completing a game with Lego bricks, children pick up pieces from the table using each hand and place them back in a box as fast as possible. The interventionist records the number of pieces the child can place in the box in 30 seconds. The symmetrical task allows children to practice targeted movements (i.e. manipulation and wrist extension) with augmented neural input from the non-involved side (Stinear and Byblow, 2004). 4) GRADING TASK DIFFICULTY Task difficulty is graded as performance improves by requiring greater speed or accuracy, or by providing tasks that require more skilled use of the involved hand and arm (e.g. moving from activities in which the involved limb acts as a stabilizer to activities that require 46

manipulation). The progressive challenge always takes into consideration the child’s abilities (tasks should never exceed a child’s abilities). Interventionists alter constraints to grade tasks according to desired target movements. For example, during the drawing (whole practice) task described above, the number of colors to be used can be incremented and cap removal difficulty can be graded depending on the child’s motor capabilities and the designated target movements. Likewise, the interventionist can ask the child to frequently change the paper orientation. During the game of Lego (part-practice) task, spatial constraints can be added by repositioning the box. Temporal and spatial constraints are added by asking the child to drop the pieces into the box individually or simultaneously. Accuracy is manipulated by decreasing the box opening. 5) HOME PRACTICE Parental involvement is extremely important. Parents are asked to engage children in home practice of bimanual activities for one hour daily during the intervention and two hours daily after the intervention. HABIT provides a window of opportunity whereby children begin a routine of involved-hand use in which parents/caregivers can problem solve with staff members, with the hope that this interface with the child will continue. Who is this intervention suitable for? Children must be old enough and cognizant to understand directions and understand why they are participating. Although HABIT is designed for children with hemiplegia, it could potentially be applied to other populations where bimanual control is also impaired. Likewise, if it were modified in intensity, it may be suitable for younger children


without the potential psychological and physical risks of CIMT (Martin et al., 2004). Hand arm bimanual intensive training is complementary to (rather than a substitute for) other treatments of the upper extremity as it only occurs during a short period. Thus even a small to moderate effect size for such a short treatment duration represents a success. Nevertheless, HABIT may need to be performed over a longer period or repeated during childhood and adolescence (Gordon et al., 2007) . To motivate children, participation must be fun. Thus, HABIT is consistent with the emphasis on functional training and practicing predefined goals in therapeutic environments. HABIT’s emphasis on functional activity performance also directly addresses the modification of the definition of CP, whereby it is considered a ‘disorder of movement and posture causing activity limitation’ (Ahl et al., 2005 and Bax et al., 2005).


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