Title: Efficacy of Home-based Intensive Bimanual Training for Children with Unilateral Spastic Cerebral Palsy
Description: Neuroplasticity research suggests intervention at early developmental stages is optimal for maximizing recovery of function in children with unilateral spastic cerebral palsy (USCP). Intensive bimanual training is an effective method for improving upper-extremity function in children with USCP when provided in massed-practice day camps. Given the challenges young children face sustaining attention and their susceptibility to fatigue, adapted models using distributed practice are required. The aim of this study was to perform a randomized trial comparing home-based hand-arm bimanual intensive training (H-HABIT) with a control group receiving an intervention of equal duration, intensity, and social interaction. Twenty-four children with USCP (age range 2 yr., 6 mos. - 10 yr. 1 mos.) were randomized to participate in either 90 hours of H-HABIT (n=12) or an equivalent dose of functional lower-limb training (FLL-control; n=12). Caregivers were trained by experienced interventionists to administer either H-HABIT or FLL-control.

Caregivers then performed activities with children in their own home 2 hrs./day, 5 days/week for 9 weeks (90 hrs. total). Caregivers were supervised remotely once a week for one hour using telerehabilitation. Dexterity was assessed using the Box and Blocks test. Bimanual hand function was measured using the Assisting Hand Assessment (AHA). Canadian Occupational Performance Measure (COPM) was used to assess caregiver perception (performance and satisfaction) of functional goals. All measures were assessed immediately prior to (pretest) and immediately after (posttest) the intervention and analyzed with a 2(group) x 2(session) repeated measures ANOVA. There were no statistical differences between the two groups at baseline. Children in H-HABIT showed greater improvement (pretest=9.0±5.8; posttest=14.5±7.8) than children in FLL-control (pretest=10.6±7.2; posttest=11.9±6.1) on the Box and Blocks test (for interaction, F(1,20)=18.53, p<.001). Neither group demonstrated change on the AHA (F(1,22)=0.89, p>.05) (H-HABIT=60.5 AHA units±10.1; FLL-Control=52.8 AHA units±17.1).

COPM data revealed a significant test session by group interaction (F(1,22)=10.82, p<.01) with caregivers of children in H-HABIT rating higher goal performance (pretest=2.9±1.0; posttest=6.8±1.3) relative to FLL-control (pretest=2.7±1.0; posttest=4.5±1.7). Caregivers in both groups showed equal improvement between the two sessions (F(1,22)=115.63, p<.001) in ratings of satisfaction of goal performance (pretest=3.8±1.8; posttest=7.3±1.1 for H-HABIT and pretest=2.3±1.0; posttest=4.7±1.8 for FLL-control). Children in H-HABIT made greater improvements in dexterity and parent-rated goal performance. This is the first randomized trial to examine the efficacy of intensive bimanual training with caregivers as interventionists—a model which permits intervention at younger ages when there may be greater potential for improving hand function. Using caregivers as a way to implement intensive interventions provides a cost-effective alternative to expensive clinic-based interventions. Home-based models provide a valuable intervention approach to add to the repertoire of options clinicians have to chose from when developing individualized treatment programs for children and their families.