RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
BANGALORE, KARNATAKA.
ANNEXURE II
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1 / Name of the Candidate
and Address / PINAKINI PATEL
K.T.G COLLEGE OF PHYSIOTHERAPY,
SUNKADAKATTE,
BANGALORE-560 091
2 / Name of the Institute / K.T.G COLLEGE OF PHYSIOTHERAPY,
SUNKADAKATTE,
BANGALORE-560 091
3 / Course of Study and
Subject / MASTER OF PHYSIOTHERAPY (MPT)
(Neurological and Psychosomatic Disorders)
4 / Date of Admission
To Course / 12/07/2012
5 / Title of the Topic
“EFFECTIVENESS OF CONSTRAINED INDUCED MOVEMENT THERAPY (CIMT) VS. HAND ARM BIMANUAL INTENSIVE THERAPY (HABIT) TO IMPROVE FINE AND GROSS MOTOR FUNCTION OF UPPER EXTREMITY IN CHILDREN WITH HEMIPLEGIC CEREBRAL PALSY.–A COMPARATIVE STUDY.”
6
7 / Brief resume of the intended work:
6.1 Introduction:
CEREBRAL PALSY (CP) is a neurodevelopmental disorder caused by nonprogressive lesion(s) in the immature brain. The early central nervous system (CNS) damage results in chronic physical disabilities and often includes sensory impairments. The prevalence of congenital CP is approximately 2 per 1000 births, with hemiplegia accounting for approximately 25% of all new cases worldwide.1,2,3
Hemiplegia characterized by a clinical pattern of unilateral motor impairment, is a common type of cerebral palsy. Reduced upper limb function may result from sensory abnormalities, weak grasp, loss of fine-sequenced movements of the fingers, loss of speed of movement, loss of fine motor skills, associated and mirror movements, retention of grasp reflex and spasticity.4,5
Children with hemiplegic cerebral palsy grow and develop they learn strategies and techniques to manage daily tasks (for example play) with one hand. Performance of tasks is discovered to be more efficient and effective using the non-affected hand, even if there is only mild impairment in the affected limb.6
Traditional Physiotherapy treatment carries out to improve muscle strength, local muscular endurance and over all joint range of motion 7 Recent evidence suggests that children with CP may improve motor performance if provided with sufficient opportunities to practice.8, 9
One treatment approach that provides those opportunities and that is becoming increasingly popular is forced use or constraint-induced movement therapy (CIMT). Forced use facilitates practice with the involved extremity by restraining the non-involved extremity; it can be used alone or along with conventional PT and OT.10
In contrast, CIMT involves intensive targeted practice with the involved extremity coordination above and beyond their unilateral impairments. Recently it has been developed along with the restraint.11, 12
As children with hemiplegic cerebral palsy (CP) have impairments in bimanual coordination above and beyond their unilateral impairments one recent treatment approach providing a bimanual intervention Hand–Arm Bimanual Intensive Therapy (HABIT) has been developed, using the principles of motor learning, and neuroplasticity, to address these bimanual impairments.13,14,15
Beyond their involved upper extremity impairments, and these impairments may underlie some of the functional limitations that decrease their independence. There is some Children with hemiplegic cerebral palsy (CP) have impairments in bimanual suggestion that initial unimanual practice can transfer to
improvements in bimanual coordination. 16, 17
A bimanual intervention ‘Hand–arm bimanual intensive therapy’ (HABIT), addresses specific upper extremity impairments in congenital hemiplegia. HABIT is a form of functional training that takes advantage of the key ingredient of CIMT (intensive practice), but focuses on improving coordination of the two hands using structured task practice. It uses principles of motor learning.18
Need for the study:
Impaired hand function is a major disability in children with hemiplegic cerebral palsy (CP). As a result, children with hemiplegic CP often fail to use the involved upper extremity and learn to perform most tasks exclusively with their uninvolved upper extremity (i.e., developmental disuse).
The need of the study is to prescribe beneficial and proper exercise to individual to improve fine and gross motor function of upper extremity in children with hemiplegic cerebral palsy.
So, this study has been designed to determine the effectiveness of CIMT and HABIT to improve fine and gross motor function of upper extremity in children with hemiplegic cerebral palsy.
6.2 Review of Literature
Aimee P. Reiss, Steven L. Wolf, Elizabeth A.,et al(2012) have conducted a study of Constraint-Induced Movement Therapy (CIMT): Current Perspectives and Future Directions and resulted that Constraint-induced movement therapy (CIMT) has gained considerable popularity as a treatment technique for upper extremity rehabilitation among patients with mild-to-moderate stroke.19
Wuang YP, Su CY(2009) examined the internal consistency, test-retest reliability, and the responsiveness of the Bruininks-Oseretsky Test of Motor Proficiency-Second Edition (BOT-2) with One hundred children with intellectual disabilities (ID) and found that the test-retest reliability and internal consistency of the total scale were excellent.20
Gordon A; Schneider J; Chinnan A ;( 2007) performed a study on Hand–Arm Bimanual Intensive Therapy (HABIT) for hemiplegic cerebral palsy children. 20 subjects (age range 3y 6mo–15y 6mo) were randomized to two groups and as a result they found that for carefully selected subgroup of children with hemiplegic CP, HABIT appears to be efficacious in improving bimanual hand use.21
Hoare B, Imms C et al.,(2007) conducted a study of Constraint-induced movement therapy in the treatment of the upper limb in children with hemiplegic cerebral palsy and resulted positive treatment effect favouring CIMT using the Dissociated Movement subscale of the Quality of Upper Extremity Skills Test.32
Lena Krumlinde-Sundholm; Marie Holmefur; Anders Kottorp; Ann-Christin Eliasson(2007) prepared a report for validity reliability and responsiveness for AHA measures with 18 months to 12 years of age with 303 subjects .Their results were positive & indicates that the AHA can be useful for research.22
Taipei(2007) did one randomized controlled study to check effects of modified constraint-induced movement therapy on reach-to-grasp movements and functional performance after chronic stroke, they have taken thirty-two chronic stroke patients. Functional outcomes were evaluated using the Motor Activity Log and Functional Independence Measure. As a result there were moderate and significant effects of modified constraint-induced movement therapy. To improve functional use of the affected arm and daily functioning and gave a conclusion that modified constraint-induced movement therapy improves motor control strategy during goal-directed reaching.23
Charles J and Gordon A(2006) did one study as CI therapy has several important limitations. Children with hemiplegia have impairments in bimanual coordination beyond their unilateral impairments. They used an intervention approach to increase functional independence during activities of daily living by using both hands in cooperation. They introduced a new intervention for children with hemiplegia, hand–arm bimanual intensive training (HABIT), to address the limitations of CI therapy and to improve bimanual coordination.24
Stewarta K, Cauraugha J, Summers J(2006) had done a systematic review and meta-analysis for bilateral movement training and stroke rehabilitation. They used 11 stroke rehabilitation studies qualified for their systematic review. These meta-analysis findings indicate that bilateral movements alone or in combination with auxiliary sensory feedback are effective stroke rehabilitation protocols during the sub-acute and chronic phases of recovery.25
Cauraugh H, Summers JJ (2005) studied a rehabilitation approach for neuralplasticity and bilateral movements in for chronic stroke. This review proposed that noteworthy upper extremity gains toward motor recovery evolve from activity- dependent intervention based on theoretical motor control constructs and inter limb coordination principles. Planning and executing bilateral movements post-stroke may facilitate cortical neural plasticity by three mechanisms: (a) motor cortex disinhibition that allows increased use of the spared pathways of the damaged hemisphere, (b) increased recruitment of the ipsilateral pathways from the contralesional or contralateral hemisphere to supplement the damaged crossed corticospinal pathways, and (c) up regulation of descending premotorneuron commands onto propriospinal neurons.26
Gordon A, Charles J, Wolf S (April 2005) studied whether CIMT is a child- friendly intervention for improving upper-extremity function. 38 children with hemiplegic CP who were between the ages of 4 and 14 years. And found that modified
therapy is tolerated by most children and modifications on the specific components of
the intervention that are most effective to who are most likely to benefit.27
Rose DK, Winstein CJ. (2004) studied bimanual training after Stroke to enhance recovery of upper extremity function. They have suggested a set of prerequisite task features and patient characteristics for consideration in the application of bimanual training protocols for post stroke rehabilitation.28
T JH Bovend'Eerdt ,H Dawes,H Johansen-Berg(2004) had done a study to examine the concurrent validity and test–retest reliability of the Jebsen Test of Hand Function (JT) and the University of Maryland Arm Questionnaire for Stroke (UMAQS), Twenty-six individuals with acquired neurological disorders. As a result their study supports the use of the MJT as a measure of gross functional dexterity.29
Lena Krumlinde-sundholm and Ann-christin Eliasson(2003) reported on the first step in the development of a new instrument, the Assisting Hand Assessment (AHA), that measure the effectiveness with which a child with unilateral impairment makes use of his/her affected hand in bimanual activity performance. The AHA is conducted through observations of performance skills exposed during play where toys requiring bimanual handling are used. The validity and reliability of the measures were explored using a Rasch measurement model for analysis. Their results were potential for the AHA to become a useful tool for both clinical practice and research.30
Duger T, Bumin G, Uyanik M, Aki E, Kayihan H(1999) did one research for the assessment of Bruininks-Oseretsky test of motor proficiency in One hundred and twenty children. They assessed the gross motor skills and fine motor skills. The scores of motor abilities were better in successful children than unsuccessful children. As an outcome they revealed that the Bruininks-Oseretsky test can be useful to investigate unexplored aspects of motor development.31
6.3  Objective of the study:
·  To measures the improvement in Fine and Gross Motor Function of Upper Extremity in Children with Hemiplegic Cerebral Palsy after CIMT.
·  To measures the improvement in Fine and Gross Motor Function of Upper Extremity in Children with Hemiplegic Cerebral Palsy after HABIT.
·  To compare the improvement in fine and gross motor function of Upper Extremity in Children with Hemiplegic Cerebral Palsy after both CIMT and HABIT.
6.4 Hypothesis:
Null hypothesis
The Constraint Induced Movement Therapy is more effective than Hand Arm
Bimanual Intensive Therapy in Improving Fine and Gross Motor Function of Upper Extremity in Children with Hemiplegic Cerebral Palsy.
Alternate hypothesis
The Hand Arm Bimanual Intensive Therapy is more effective than Constraint Induced Movement Therapy in Improving Fine and Gross Motor Function of Upper Extremity in Children with Hemiplegic Cerebral Palsy.
Material and methods:
7.1 Source of data:
The study will be conducted on 30 subjects with hemiplegic cerebral palsy. Subjects will be taken from K.T.G Hospital from Bangalore on the basis of controlled clinical trial.
7.2 Method of collection of data:
The study will be consisting of 30 subjects with hemiplegic cerebral palsy. Prior to the participation all subjects will be explained briefly about the aims and objectives of the study, health benefits of the exercises and about the procedure of measuring Upper extremity fine and gross motor function. All subjects will be screened and a detail medical history will be taken to exclude any serious illness. Physical activity readiness questionnaire will be used to identify the serious illness in the subject. Informed consent will be signed by the subjects for their voluntary participation. Subjects will be requested to continue their normal activities and avoid any other form of exercises for the duration of the study.
Sampling :
Simple Random sampling.
7.3 Measurement procedure:
TOOLS USED FOR THE STUDY:-
Assisting Hand Assessment (AHA)21,29
Bruininks Oseretsky Test of Motor Proficiency (BOTMP)19,30
PROCEDURE:
Subjects who fulfill the selection criteria will be selected for the study and informed consent (Annexure-1) will be obtained from their parent or caregiver. All the subjects will be randomly divided into Group A (Experimental group) and Group B (Experimental group).
Group A (Experimental group) subjects will receive only Constraint Induced Movement therapy for upper extremity (UE). It includes Repetitive task practice is the
performance of functional tasks continuously for 15 to 20 minutes but no longer than one hour. It is targeted movement that is embedded in a functional activity. Fine motor
and manipulative gross motor activities that elicit the general movement behaviours of
interest and include a range of functional and play activities in which children might typically participate on a given day. The activities are appropriate for the age of the child and all can be performed unimanually. Specific activities are selected by considering:
(1)  Joint movements with pronounced deficits; (2) joint movements that physiotherapists believe have the greatest potential for improvement; and (3) child preference for activities that have similar potential for improving identified movements. The task is made progressively more difficult as the child improves in performance by requiring greater speed or accuracy, increased movement repetition, or performance-sensitive adaptations.27
Group B (Experimental group) subjects will receive the a list of age-appropriate fine motor and manipulative gross motor activities that required the use of both hands. Specific activities were selected by considering the role of the involved limb in the activity (e.g. stabilizer, manipulator, active/passive assist). Activities were performed continuously for at least 15 to 20 minutes but no longer than 1 hour.
Directions were given to the child before the start of each task in order to specify how each hand would be used during the activity and to avoid use of compensatory strategies (performing the task unimanually with the non-involved extremity.21
All the subjects will be treated in study setting for 30 days and outcome will be assessed for pre and post treatment sessions for each sitting by using Assisting Hand Assessment (AHA) and Bruininks Oseretsky Test of Motor Proficiency (BOMP) to know the effectiveness before and after one month of study intervention.
Materials to be used:
Ball, stick, paper, pencil, blocks, pen, consent form etc.
Inclusion Criteria:
(1)  Age group 4 to 14 years.
(2)  Sex – both male and female
(3)  Ability to extend the wrist greater than 20° and the fingers at the etacarpophalangeal joints greater than 10° from full flexion.
(4) Greater than 50% difference between the involved and non-involved hand on the
Jebsen–Taylor Test of Hand Function provided during screening.
(5) The ability to lift the involved arm from the table surface to a surface six inches