I Fit, UFIT, We All Fit Together: Advances in Pediatric Neurorehabilitation

Tonya Rich, MA, OTR/L

Gillette Children’s Specialty Healthcare

University of Minnesota

Objectives

• Learning Objective #1: Integrate the knowledge of CP related classification tools and models of care. Learn who’s appropriate, how much therapy to provide and how to engage patients and families.

• Learning Objective #2: Explore motor learning approaches for children through the use of constraint induced movement therapy and intensive bimanual training.

Considerations and Types of Decisions Made by Therapists

• Who needs intervention and why?

• What are the expected outcomes of the intervention?

• How do we document the outcomes?

• How many visits will it take to achieve the outcomes?

• Evaluation of overall clinical program

MOTOR CONTROL THEORIES

Frameworks to Guide Practice

• Rehabilitation theories have evolved over time to match the understanding of motor recovery, executive functioning development, and interplay of the child in the context of family.

• Motor Developmental Theories – NDT

– Dynamic System’s Theory

– Neuronal Group Selection Theory

Promotion of function as a goal of therapy intervention

In the past, goals of therapy were to normalize movement patterns, reduce neurological signs, and minimize the development of secondary

impairments

“From a functional perspective, therapy for children with motor impairments should aim at enabling the children to master tasks and

participate in activities that are important to the child and family” (Ostensjo et al, 2003)

Dynamic Systems Approach

• Adaptation of the environment and/or the task is considered acceptable as a solution to a motor problem rather than focusing on changing the abilities of the child

• In a task/context-focused approach, the child’s interest in motor-based tasks is identified as are the constraining factors, and treatment focuses on modifying the identified constraints

Theoretical Shift

• Philosophical and practical shift from previously held tenets is driven by factors including models of health status, family-centered principles, and improved theories of motor control and motor learning

FACTORS THAT IMPACT HAND SKILL DEVELOPMENT

CLASSIFICATION SYSTEMS IN CP

http://www.canchild.ca/en/measures/gmfcs.asp

Gross Motor Function Classification System (GMFCS)

Manual Abilities Classification System

I. Handles objects easily and successfully

II. Handles most objects with reduced quality and/or

speed of achievement.

III. Handles objects with difficulty; needs help to

prepare and/or modify activities.

IV. Handles a limited selection of easily managed

objects in adapted situations.

V. Does not handle objects and has severely limited

ability to perform even simple actions.

http://www.macs.nu

Pediatric Neurorehabilitation

• There are a multitude of factors to consider for successful hand use for daily activities.

• Neuroscience Factors focus on corticospinal tract integrity and excitability of the motor cortex.

• Disruption in any of these systems, greatly impacts the individual’s ability to succeed and can contribute to developmental disregard.

Eliasson (2005)

MOTOR LEARNING PRINCIPLES

Motor Learning Assumptions

• Motor learning assumes a degree of brain plasticity and expects reorganization or recovery potential.

• Retraining must be applied strategically and skillfully to maximize engagement, learning, and generalization to function (Dobkin & Dorsch, 2013).

The Challenges to Developmental and Motor Theories

Runaway Train of Development Individual Differences

Variability Across All Children

Pediatric Challenges

• The influence of:

– Maturation

– Limited processing skills

• Balancing the core belief that play and exploration drive movement and skill acquisition.

• Harnessing development potential

Specific Motor Learning Techniques

• Session structure and context,

• Teaching techniques,

• Distribution and practice structure,

• Whole vs. part practice, and

• Task specificity and executive functioning

Approaches to Therapy

vs.

What is the evidence for our interventions?

Grades of Evidence—

Traffic Alert Action

(Novak et al., 2013)

Note: SI was evaluated in

the context of children with

CP only. Refer to article for

discussion on NDT. (Novak et al., 2013)

UFIT—UPPER EXTREMITY INTENSIVE THERAPY FRAMING THERAPY CARE PLANS

Present Day Challenges to Intensives

• Competing therapy and educational needs

• Limited resources

• Chronic care needs

• Financial challenges for funding therapy and caregiver support

Framing Therapy Intensives

• Create intensity through caregiver engagement and empowerment

• Utilize episodes of care to meet chronic needs

• Equip families with knowledge. Dispel the “expert therapist” myth!

Successful Transitions to Episodic Care

• Parental confidence in:

– Red flags of concern

– Knowledge of the follow up plan

– Comfort level with carrying over concepts to the home and community setting

• How do you get there?

• Treatment fidelity matters

• Sharing this knowledge with families (while monitoring for information overload) benefits all.

• Leverage families efforts and contributions to best benefit all during more intensive bursts of care

CONSTRAINT INDUCED MOVEMENT THERAPY

Gillette’s 3-Phase Approach to CIMT… It’s a marathon, not a sprint.

• Preparation—4 weeks

• Casting—4 weeks

• Bimanual Practice—4 weeks+

Given it’s a marathon…how do we make it engaging, worthwhile, and

more importantly…uber cool?

Trea

tmen

t In

gred

ien

ts

Functional, Individualized

Therapy

WB’ing

ROM

Strength

Sensory Input

High Reps

Shaping

(T. Rich, 2013)

Creative Curriculums

• Differentiates this therapy from standard, developmental therapy

• Engages the child at a new level

• Positively impact self-esteem and a success-based intervention

But…Are two hands better than one?

• Bimanual Intensive Training-

– Gordon, 1997

• Benefits of each treatment modality

• Utilizing both approaches

BIMANUAL TRAINING

Hand-Arm Bimanual Intensive Training (HABIT)

• Developed out of Columbia University

• Focuses on delineating the roles of the hands with one as a stabilizer and one as active

• Developed with the same principles that have been associated with strong outcomes in CIMT

• Periods of intensive bimanual training often follows CIMT

WHAT NEXT?

What intervention do you choose?

• Is CIMT the best?

• Is HABIT more functional?

• Should traditional therapy morph to be more inclusive of intensive therapy techniques and approaches?

• What is the role of internal motivation in pediatrics?

Thoughts for Consideration

Gordon, 2011

Treatment Components of CIMT and HABIT

Motivation

Mass Practice

High Intensity

Graded Constraints (Shaping)

Active Problem Solving

(T. Rich, 2013)

• There are a variety of options. What is your goal?

• Individualized therapy based on client based goals takes advantage of all systems—motivation, functional activities, and arm use.

• Instill a sense of accomplishment and success which contributes to overall resiliency.

• Creativity is key!

Concluding Thoughts

• Pediatric neurorehabilitation is ever evolving and EXCITING!

• Collaborative interventions provide holistic views of the child and meet complex therapy needs.

• Creativity wins you engagement and sustained results.

Any Questions?

Tonya Rich, MA, OTR/L tlrich@gillettechildrens.com 952-223-3435

Acknowledgements

• A portion of the slides were previously presented with Sue Murr, DPT, PCS at the AACPDM Annual Meeting (2012).

• The Episodic Care original presentation was developed with Robin McDonald, PT and Heather Bracken, MA, CCC-SLP (2010).

References

• Classification Tools:

– Gross Motor Function Classification System: http://www.canchild.ca/en/measures/gmfcs.asp

– Manual Abilities Classification System: http://www.macs.nu

• Texts:

– Physiotherapy and Occupational Therapy for People with Cerebral Palsy: A Problem Based Approach to Assessment and Management. Edited By: Karen J. Dodd, Christine Imms, and Nicholas F. Taylor (2010). Mac Keith Press.

– Improving hand function in children with cerebral palsy: theory evidence and intervention. Edited By: Eliasson, A. C. & Burtner, P. A. (2008). (1st ed.). Mac Keith Press

References

• Aarts, P. B., Jongerius, P. H., Geerdink, Y. a, Van Limbeek, J., & Geurts, A. C. (2011). Modified constraint-induced movement therapy combined with bimanual training (mCIMT-BiT) in children with unilateral spastic cerebral palsy: How are improvements in arm-hand use established? Research in Developmental Disabilities, 32(1), 271–279. doi:10.1016/j.ridd.2010.10.008

• Bailes, Reder, Burch. Development of Guidelines for Determining Frequency of Therapy Services in a Pediatric Medical Setting: Pediatric Physical Therapy: Summer 2008 - Volume 20 - Issue 2 - pp 194-198

• Butler, C., & Darrah, J. (2001). Effects of neurodevelopmental treatment (NDT) for cerebral palsy: An AACPDM evidence report. Developmental Medicine and Child Neurology, 43(11), 778–90. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/11730153

• De Brito Brandão, M., Gordon, A. M., & Mancini, M. C. (2012). Functional impact of constraint therapy and bimanual training in children with cerebral palsy: a randomized controlled trial. The American Journal of Occupational Therapy, 66(6), 672–81. doi:10.5014/ajot.2012.004622

• Eliasson, A. C. (2005). Improving the use of hands in daily activities: Aspects of the treatment of children with cerebral palsy. Physical & Occupational Therapy in Pediatrics, 25(3), 37-60.

• Eliasson, A.C., Krumlinde-Sundholm, L., Gordon, A.M., Feys, H., Klingels, K., Aarts, P.B., Rameckers, E., Autti-Ramo, I., Hoare, B., European network for health technology Assessment (EUnetHTA). (2014). Guidelines for future research in constraint induced movement therapy for children with unilateral cerebral palsy: An expert consensus. Dev Med Child Neurol, 56(2):125-37.

References

• Gillick, B.T., Krach, L.E., Feyma, T., Rich, T.L., Moberg, K., Thomas, W., Cassidy, J.M., Menk, J., Carey, J.R. (2014). Primed low-frequency repetitive transcranial magnetic stimulation and constraint-induced movement therapy in pediatric hemiparesis: a randomized controlled trial. Dev Med Child Neurol; 56(1):44-52.

• Gordon, A. (2010). Two hands are better than one: Bimanual skill development in children with hemiplegic cerebral palsy. Dev Med Child Neurol, 52(4):315-6.

• Gordon, A.M., Schneider, J.A., Chinnan, A., & Charles, J.R. (2007). Efficacy of hand-arm bimanual intensive therapy (HABIT) in children with hemiplegic cerebral palsy: A randomized control trial. Dev Med Child Neurol; 49(11):830-8.

• Gordon, A. M., Charles, J., & Wolf, S. L. (2006). Efficacy of constraint-induced movement therapy on involved upper-extremity use in children with hemiplegic cerebral palsy is not age-dependent. Pediatrics, 117(3), e363–73. doi:10.1542/peds.2005-1009

• Hubbard, I. J., Parsons, M. W., Neilson, C., & Carey, L. M. (2009). Task-specific training: Evidence for and translation to clinical practice. Occupational Therapy International, 16(3-4), 175–89. doi:10.1002/oti.275

• Holmefur, M., Krumlinde-Sundholm, L., Bergstrom, J., & Eliasson, A.C. (2010). Longitudinal development of hand function in children with unilateral cerebral palsy. Dev Med Child Neurol, 52(4): 352-7.

• Metzler, M. J., & Metz, G. A. (2010). Translating knowledge to practice: An occupational therapy perspective. Australian Occupational Therapy Journal, 57(6), 373–9. doi:10.1111/j.1440-1630.2010.00873.x

• Novak, I., McIntyre, S., Morgan, C., Campbell, L., Dark, L., Morton, N., Stumbles, E., Wilson, S.A., Goldsmith, S. (2013). A systematic review of interventions for children with cerebral palsy: State of the evidence. Dev Med Child Neurol, 55(10):885-910.

• Sakzewski, L., Gordon, A.M., & Eliasson, A.C. (2014). The state of the evidence for intensive upper limb therapy approaches for children with unilateral cerebral palsy. J Child Neurol; 11;29(8):1077-1090.

• Sterling, C., Taub, E., Davis, D., Rickards, T., Gauthier, L. V, Griffin, A., & Uswatte, G. (2013). Structural Neuroplastic Change After Constraint-Induced Movement Therapy in Children With Cerebral Palsy. Pediatrics. doi:10.1542/peds.2012-2051