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Objective: To determine the feasibility and short-term efficacy of caregiver-directed constraint-induced movement therapy to improve upper limb function in young children with hemiplegic cerebral palsy., Design: Randomized controlled trial with masked assessment., Setting: Community paediatric therapy services., Subjects: Pre-school children with hemiplegic cerebral palsy., Interventions: Caregiver-directed constraint-induced movement therapy administered using either 24-hour short-arm restraint device (prolonged) or intermittent holding restraint during therapy (manual)., Main Measures: Primary measures include Assisting Hand Assessment (AHA) at 10 weeks. Secondary measures include adverse events, Quality of Upper Extremity Skills Test and Pediatric Quality of Life Inventory. Feasibility measures include recruitment, retention, data completeness and adherence., Results: About 62/81 (72%) of eligible patients in 16 centres were randomized (prolonged restraint n = 30; manual restraint n = 32) with 97% retention at 10 weeks. The mean change at 10 weeks on the AHA logit-based 0-100 unit was 9.0 (95% confidence interval (CI): 5.7, 12.4; P < 0.001) for prolonged restraint and 5.3 (95% CI: 1.3, 9.4; P = 0.01) for manual restraint with a mean group difference of 3.7 (95% CI: -1.5, 8.8; P = 0.156) (AHA smallest detectable difference = 5 units). No serious related adverse events were reported. There were no differences in secondary outcomes. More daily therapy was delivered with prolonged restraint (60 vs 30 minutes; P < 0.001). AHA data were complete at baseline and 10 weeks., Conclusion: Caregiver-directed constraint-induced movement therapy is feasible and associated with improvement in upper limb function at 10 weeks. More therapy was delivered with prolonged than with manual restraint, warranting further testing of this intervention in a longer term trial.

Mirror visual feedback has previously been found to reduce disproportionate interlimb variability and neuromuscular activity in the arm muscles in children with Spastic Hemiparetic Cerebral Palsy (SHCP). The aim of the current study was to determine whether these positive effects are generated by the mirror per se (i.e. the illusory perception of two symmetrically moving limbs, irrespective of which arm generates the mirror visual feedback) or by the visual illusion that the impaired arm has been substituted and appears to move with less jerk and in synchrony with the less-impaired arm (i.e. by mirror visual feedback of the less-impaired arm only). Therefore, we compared the effect of mirror visual feedback from the impaired and the less-impaired upper limb on the bimanual coupling and neuromuscular activity during a bimanual coordination task. Children with SHCP were asked to perform a bimanual symmetrical circular movement in three different visual feedback conditions (i.e. viewing the two arms, viewing only one arm, and viewing one arm and its mirror image), combined with two head orientation conditions (i.e. looking from the impaired and looking from the less-impaired body side). It was found that mirror visual feedback resulted in a reduction in the eccentric activity of the Biceps Brachii Brevis in the impaired limb compared to the condition with actual visual feedback from the two arms. More specifically, this effect was exclusive to mirror visual feedback from the less-impaired arm and absent when mirror visual feedback from the impaired arm was provided. Across conditions, the less-impaired arm was the leading limb, and the nature of this coupling was independent from visual condition or head orientation. Also, mirror visual feedback did not affect the intensity of the mean neuromuscular activity or the muscle activity of the Triceps Brachii Longus. It was concluded that the positive effects of mirror visual feedback in children with SHCP are not just the result of the perception of two symmetrically moving limbs. Instead, in order to induce a decrease in eccentric neuromuscular activity in the impaired limb, mirror visual feedback from the 'unaffected' less-impaired limb is required.

The study examined the effects of mirror feedback information on neuromuscular activation during bimanual coordination in eight children with spastic hemiparetic cerebral palsy (SHCP) and a matched control group. The 'mirror box' creates a visual illusion, which gives rise to a visual perception of a zero lag, symmetric movement between the two arms. The study incorporated two additional visual feedback conditions by placing a glass or opaque screen between the arms. During bilateral symmetric circular arm movements mirror visual feedback induced lower neuromuscular intensities in the shoulder muscles of the less impaired arm of children with SHCP compared to the other visual conditions. In addition, the mirror lead to shorter relative durations of eccentric and concentric activity in the elbow muscles of the more impaired arm, whereas no effects of visual feedback were found in a matched control group. These results suggest that replacing veridical visual information of the more impaired arm with a mirror reflection of the less impaired arm improves the motor control of children with SHCP during interlimb coupling. The effects of the availability of visual feedback in individuals with hemiparesis are discussed with reference to: (1) increase ipsilateral motor cortex excitability and (2) congruence between afferent (visual) feedback and the internal copy of the motor commands., (Crown Copyright © 2010. Published by Elsevier Ltd. All rights reserved.)

This study compared the intensity, co-activity and frequency content of the electromyography (EMG) signals recorded bilaterally from six muscles of the upper limbs in children with spastic hemiparetic cerebral palsy (SHCP) and typically developing (TD) children during a bilateral movement. It was found that children with SHCP executed the bimanual circular movement with higher intensities of mean neuromuscular activity in both arms compared to TD children. Furthermore, the movement was performed with longer phases of concentric and eccentric activity in children with SHCP, indicating more co-activation, especially in the more impaired arm. The EMG signals yielded a higher mean power frequency in all the muscles of the more impaired arm and the wrist and elbow flexors of the less impaired arm, which was interpreted as a relatively higher contribution of type II muscle fibres compared to TD children. These observations suggest that in children with SHCP bimanual coordination requires higher neuromuscular activation in the muscles of both arms. Furthermore, SHCP also seems to involve structural changes to the muscle properties, which differ between arms., ((c) 2009. Published by Elsevier Ltd. All rights reserved.)

The study examined symmetrical bimanual coordination of children with spastic hemiparetic cerebral palsy (SHCP) and a typically developing (TD) control group under conditions of visual feedback created by placing a glass screen, opaque screen or a mirror ("mirror box") between the arms. The "mirror box" creates a visual illusion, which gives rise to a visual perception of a zero lag, symmetric movement between the two arms. Children with SHCP exhibited a similar mean coordination pattern as the TD control group, but had greater movement variability between the arms. Furthermore, movement variability in children with SHCP was significantly greater in the screen condition compared with the glass and mirror condition, which were similar to each other. The effects of the availability of visual feedback in individuals with hemiparesis are discussed with reference to central and peripheral mechanisms.