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Aims: To pilot efficacy of a tailored multifaceted implementation program to change clinical practice of occupational therapists (OTs) providing upper limb (UL) therapy for children with unilateral cerebral palsy (UCP). Methods: This before and after study piloted a multifaceted implementation program comprising audit/feedback, barrier identification, and education. Medical chart audits were conducted prior to and 12 months after the intervention. Primary process outcomes included proportion of children with UCP with (1) goals set; (2) goals measured; (3) received contemporary motor learning approach; (4) an adequate dose (30–40 hours); and (5) measured UL outcomes. Results: Three teams of OTs (n = 9) participated. Forty-three audits at baseline and 53 at 12 months postimplementation program were conducted. Average time to complete audits was 10 min and four out of the five evidence criteria had complete data extracted from files. Changes in clinical behavior included greater measurement of goals before (+17%) and after (+22%) therapy; use of constraint therapy (+38%), bimanual therapy (+26%), home programs (+14%); measurement of UL outcomes before (+29%) and after (+23%) therapy. Children receiving the target dose increased from 0 to 10%. Conclusions: A tailored multifaceted implementation program was feasible to implement and led to meaningful changes in clinical practice behavior.

© 2016 Elsevier Inc. Introduction Infants with asymmetric brain injury (asymBI) are at high risk of Unilateral Cerebral Palsy (UCP). The Grasp and Reach Assessment of Brisbane (GRAB) was developed to detect asymmetries in unimanual/bimanual upper limb (UL) reach and grasp behaviours in infants with asymBI. This study reports the development of the GRAB and evaluates its construct validity and internal consistency. Material and methods Prospective study of twenty four infants with asymBI and twenty typically developing (TD) infants at 18 weeks corrected age (C.A.) in a structured play session. Three different coloured toys were presented at the midline in a block design of six 30-s trials of toy presentation, separated by five 30-s trials of no toy presentation. The number and duration of: (i) unimanual contacts; (ii) unimanual grasps; (iii) bimanual midline grasps; and (iv) duration of other unimanual behaviours (e.g. prehensile movements and transport phase) were measured. An Asymmetry Index (AI) was calculated to determine asymmetries between ULs. Possible AI values ranged from 0 to 100%, indicating proportion of toy presentation time that unimanual behaviours were asymmetric between ULs. Internal consistency of both the Time Phase (TP) and Toy Colour Phase (TCP) test items were determined by calculating Cronbach's alpha coefficients. Each assessment occasion was split into six TPs and two TCPs; whereby one TP comprised one 30-s trial of one toy presentation and one TCP comprised two 30-s trials of the same toy presentation. Results For TP, seven out of nine unimanual behaviours and two out of three bimanual behaviours demonstrated strong internal consistency (Cronbach's alpha coefficients 0.72–0.89). No unimanual activity demonstrated the strongest IC (0.89). For TCP, six out of nine unimanual behaviours demonstrated strong IC (0.73–0.82). Number of unimanual contacts and duration of unimanual prehensile movements demonstrated the strongest IC (0.82). Duration of

Aims: To determine if mastery motivation at baseline predicts engagement in two goal-directed upper limb (UL) interventions for children with unilateral cerebral palsy (UCP). Methods: Participants were 44 children with UCP, mean age 7 years 10 months, Manual Ability Classification System level I (N = 23) or II (N = 21). Twenty-six children received intensive novel group-based intervention (Hybrid Constraint Induced Movement Therapy, hCIMT) and 18 received distributed individual occupational therapy (OT). Caregivers completed the Dimensions of Mastery Questionnaire (DMQ) parent-proxy report at baseline. Children's engagement was independently rated using the Pediatric Volitional Questionnaire (PVQ). Associations between children's mastery motivation and engagement were examined using linear regression. Results: Children who received hCIMT had lower DMQ persistence at baseline (p = .05) yet higher PVQ volitional (p = .04) and exploration (p = .001) scores. Among children who received hCIMT, greater object-oriented persistence was associated with task-directedness (β 0.25, p = .05), seeking challenges (β = 0.51, p = .02), exploration (β = 0.10, p = .03), and volitional scores (β = 0.23, p = .01). Conclusion: Despite having lower levels of persistence prior to engaging in UL interventions, children who received hCIMT demonstrated greater engagement in goal-directed tasks than children who received individual OT. Within hCIMT, children's motivational predisposition to persist with tasks manifested in their exploration and engagement in therapy.

© 2015 American Physical Therapy Association.Background: Despite the health benefits of regular physical activity, children with cerebral palsy (CP) are thought to participate in reduced levels of physical activity.Objective: The study objective was to assess physical activity and determine the proportion adhering to the recommended 60 minutes of moderate-to-vigorous physical activity (MVPA) daily in independently ambulant children and adolescents with unilateral CP.Design: This was a cross-sectional study.Method: Children (N=102; 52 boys, 50 girls; mean age=11 years 3 months, SD=2 years 4 months) with spastic hemiplegia classified at Gross Motor Function Classification System (GMFCS) levels I (n=44) and II (n=58) recorded physical activity over 4 days using an accelerometer. Activity counts were converted to daily and hourly time spent inactive and in light physical activity or MVPA using uniaxial cutpoints (inactive: =100 vertical counts=min-1, light: 101 to 2,295 vertical counts·min-1, MVPA: -2,296 vertical counts=min-1) and recorded step counts. Differences between groups were examined using t tests.Results: Of a potential 396 days, 341 days (86%) were recorded. The average wear time was 11:44 (SD=1:56) hours. On a typical day, participants recorded 438 (SD=234) counts=min-1, took 7,541 (SD=3,894) steps, spent 8:36 (SD=1:09) hours inactive, spent 2:38 (SD=0:51) hours in light activity, and spent 0:44 (SD=0:26) hours in MVPA. Only 25% of participants met the recommended level of MVPA on at least one day. Physical activity was highest in boys (versus girls), in children (versus adolescents), and on weekdays (versus weekends).Limitations: Participants were limited to children with unilateral spasticity who were classified at GMFCS levels I and II.Conclusions: The majority of independently ambulant children with unilateral CP did not perform sufficient physical activity to meet public health recommendations.

© 2015 Boyd et al. Background: Acquired brain injury (ABI) refers to multiple disabilities arising from damage to the brain acquired after birth. Children with an ABI may experience physical, cognitive, social and emotional-behavioural impairments which can impact their ability to participate in activities of daily living (ADL). Recent developments in technology have led to the emergence of internet-delivered therapy programs. "Move it to improve it" (Mitii™) is a web-based multi-modal therapy that comprises upper limb (UL) and cognitive training within the context of meaningful physical activity. The proposed study aims to compare the efficacy of Mitii™ to usual care to improve ADL motor and processing skills, gross motor capacity, UL and executive functioning in a randomised waitlist controlled trial. Methods/Design: Sixty independently ambulant children (30 in each group) at least 12 months post ABI will be recruited to participate in this trial. Children will be matched in pairs at baseline and randomly allocated to receive either 20 weeks of Mitii™ training (30 min per day, six days a week, with a potential total dose of 60 h) immediately, or be waitlisted for 20 weeks. Outcomes will be assessed at baseline, immediately post-intervention and at 20 weeks post-intervention. The primary outcomes will be the Assessment of Motor and Process Skills and 30 s repetition maximum of functional strength exercises (sit-to-stand, step-ups and half kneel to stand). Measures of body structure and functions, activity, participation and quality of life will assess the efficacy of Mitii™ across all domains of the International Classification of Functioning, Disability and Health framework. A subset of children will undertake three tesla (3T) magnetic resonance imaging scans to evaluate functional neurovascular changes, structural imaging, diffusion imaging and resting state functional connectivity before and after intervention. Discussion: Mitii™ provides an alternative approach

Copyright © 2014 by the American College of Sports Medicine. Introduction: This study aimed to establish the variability in the measurement of habitual physical activity using the ActiGraph® GT3X+ accelerometer in children with cerebral palsy (CP). Method: Repeated measures: Independently ambulant children with unilateral CP (n = 30; age, 11 yr 3 months (2 yr 4 months)) completed standardized tasks over two consecutive days, wearing an ActiGraph® GT3X+ accelerometer and HR monitor. Testing protocol comprised 5 min of seated rest (REST), walking at light, moderate, and vigorous pace, and rapid stepping on/off a step. Agreement was calculated between days using intraclass correlation coefficients (ICC) (two-factor mixed agreement model). Minimum detectable difference was calculated (minimum detectable difference = [SDv1 - ICC] × 1.96v2). Performance variability: Participants (n = 102) wore an ActiGraph® GT3X+ accelerometer for 4 d in the community. Activity counts were converted into activity intensity using uniaxial-derived cut points to classify the time spent in moderate-to-vigorous physical activity (MVPA). Between-day intraclass reliability coefficients (R) and Spearman-Brown prophecy formula ([ICCdesired/(1 - ICCdesired)][(1 - ICCestimated)]/ICCestimated]) were calculated. Results: Agreement between repeated measures was strong for light physical activity and MVPA (ICC, 0.80). For MVPA, the minimum detectable difference was 1412 counts per minute. In the community, 345 d (87%) were recorded. Three days of monitoring produced acceptable variability estimates of MVPA (R = 0.63-0.73). Spearman-Brown prophecy analysis estimated that 3 d would achieve a reliability coefficient of 0.7 and 11d would achieve 0.9. Conclusions: Measurement of habitual physical activity using the ActiGraph® GT3X+ accelerometer is reliable under controlled walking and stepping conditions as well as in a community environment in independently ambulant children and adolescents with CP.

BACKGROUND: Australia has joined a growing number of nations which have evaluated the physical activity and sedentary behaviour status of their children. Australia received a 'D minus' in the first Active Healthy Kids Australia Physical Activity Report Card. METHODS: An expert subgroup of the Australian Report Card Research Working Group iteratively reviewed available evidence to answer three questions: 1) What are the main sedentary behaviours of children?, 2) What are the potential mechanisms for sedentary behaviour to impact on child health and development? and, 3) What are the effects of different types of sedentary behaviours on child health and development? RESULTS: Neither sedentary time nor screen time are homogeneous activities likely to result in homogenous effects. There are several mechanisms by which various sedentary behaviours may positively or negatively affect cardiometabolic, neuro-musculoskeletal, and psycho-social health, though the strength of evidence varies. National surveillance systems, and mechanistic, longitudinal and experimental studies are needed for Australia and other nations to improve their grade. CONCLUSIONS: Despite limitations, available evidence is sufficiently convincing that the total exposure and pattern of exposure to sedentary behaviours are critical to the healthy growth, development and wellbeing of children. Nations therefore need strategies to address these common behaviours.

therapy (mCIMT) and bimanual therapy on upper limb and individualized outcomes for children with unilateral cerebral palsy. This secondary analysis included two separate randomized trials that compared equal doses (high or low) of mCIMT to bimanual therapy; Study 1 (full dose – 60 h) n = 64 and; Study 2 (half dose – 30 h) n = 18 for children aged five to 16 years with unilateral cerebral palsy. Outcomes for both studies included the Melbourne Assessment of Unilateral Upper Limb Function, Assisting Hand Assessment, Jebsen Taylor Test of Hand Function and Canadian Occupational Performance Measure which were administered at baseline, three and 26 weeks. Mixed linear modelling was used to compare between dose (e.g. “full dose” to “half dose” of either mCIMT or bimanual therapy) on outcomes at three and 26 weeks post-intervention. There were no significant differences between groups at baseline, however, on average the half dose mCIMT group was younger with better hand function compared to the other groups. The full compared to half dose mCIMT group achieved greater gains in bimanual performance at three weeks and dexterity and quality of movement at 26 weeks. There were no between group differences for bimanual therapy doses. Half dose groups receiving either mCIMT or bimanual therapy did not make significant within group gains on any upper limb motor outcome, however gains in occupational performance were clinically meaningful. These results suggest that a half dose (30 h) of either mCIMT or bimanual therapy may not be sufficient to impact upper limb outcomes, but made clinically meaningful gains in occupational performance for school aged children with UCP.

Aims: This study aimed to understand engagement of children in a home-based computer program, “Move it to improve it” (Mitii™), designed to enhance motor, cognitive and visual perceptual skills. Methods: Participants were 10 children with unilateral cerebral palsy involved in the 20-week Mitii™ program (mean age = 11 years; 5 males) and their caregivers. Semi-structured interviews were audio recorded, transcribed verbatim and analyzed independently by two researchers. Themes were identified using an inductive approach to identify themes, and mapped against an engagement framework. (King et al., 2014). Results: Key themes were: (1) Child/family characteristics: children's interest captured through novelty and technology, motivation declines as novelty wears off, children require “finely tuned” programs, strong family support facilitates engagement, and children develop confidence and ownership; (2) Intervention characteristics: increased therapy frequency with reduced caregiver involvement, Mitii™ “becomes therapy” and competes with other interests; convenience within family routine, lack of real-time feedback and technical issues, and therapist guidance is essential; and (3) Service provider characteristics: initial and ongoing therapist input, family-friendly therapy approach, and tailored strategies to sustain engagement. Conclusions: Therapists should be cognisant of factors that may impact on children's engagement in home-based computer programs and devise individual strategies with families to support sustained engagement.

© 2015 Taylor & Francis Group, LLC Aims: To examine test–retest reproducibility of the Assessment of Motor and Process Skills (AMPS) in children aged 8–16 years with unilateral cerebral palsy (UCP). Methods: Thirty children with mild to moderate UCP (mean age = 11y 7m, SD 2y 4m; males = 18; Manual Ability Classification System level I = 10, II = 20; Gross Motor Function Classification System level I = 9, II = 21) enrolled in a large randomized controlled trial were recruited via consecutive series sampling. Children carried out two AMPS tasks over two consecutive days according to standardized AMPS administration procedures. The standard error of measurement (SEM), smallest detectable change (SDC), 95% limits of agreement using the Bland–Altman method, and intraclass correlation coefficients (ICC; 2,1) were calculated. Results: The SDC was 0.23 logits for the AMPS motor scale and 0.30 logits for the AMPS process scale. Test–retest reliability was excellent for both the AMPS motor scale (ICC = 0.93) and the AMPS process scale (ICC = 0.86). Intra-rater reliability (n = 10) was excellent for AMPS motor scale (ICC = 0.96) and AMPS process scale (ICC = 0.98). Conclusions: The AMPS can be used by therapists with 8- to 16-year-old children with UCP as an outcome measure with changes in scores reflecting real changes in performance or capacity.

© 2015 Mac Keith Press. Aim: The study aimed to investigate the effectiveness of a web-based therapy programme, 'Move it to improve it' (Mitii™), in children with unilateral cerebral palsy (UCP) on occupational performance, upper limb function, and visual perception. Method: Participants (n=102) were matched in pairs and randomized to intervention (Mitii for 20wks; 26 males, mean age 11y 8mo [2y 4mo], Manual Ability Classification System level I=11, II=39, III=1) or control (standard care; 25 males, mean age 11y 10mo [2y 5mo], Manual Ability Classification System level I=13, II=37). Outcomes were the Assessment of Motor and Process Skills (AMPS), Assisting Hand Assessment, Jebsen-Taylor Test of Hand Function (JTTHF), Melbourne Assessment of Unilateral Upper Limb Function (MUUL), Canadian Occupational Performance Measure (COPM), and Test of Visual Perceptual Skills (TVPS-3). Results: Participants completed on average 32.4 hours of Mitii (range 3.7-74.7h). The Mitii group demonstrated significantly greater post-intervention scores than the comparison group on the AMPS, JTTHF dominant upper limb, COPM, and TVPS-3. The differences between groups were not clinically significant. There were no differences between groups on measures of impaired upper limb function. Interpretation: Mitii delivers individualized, web-based therapy at home and has potential to increase therapy dose. Mitii can be considered as an option to enhance occupational performance and visual perception for children with UCP.

© 2014 Informa UK Ltd. All rights reserved: reproduction in whole or part not permitted. Purpose: To investigate the impact of mastery motivation on occupational performance outcomes immediately following upper limb (UL) training and 6 months post-intervention for school-aged children with unilateral cerebral palsy. Method: This prediction study was a post-hoc analysis of a matched pairs randomized comparison trial (COMBiT Trial Registration: ACTRN12613000181707). The Canadian Occupational Performance Measure (COPM) was administered at baseline, 13 and 26 weeks post-intervention. Parents completed the Dimensions of Mastery Questionnaire (DMQ), Parenting Scale and a demographic questionnaire. Children's UL capacity and performance was assessed using the Melbourne Assessment of Unilateral UL Function and assisting hand assessment (AHA). Regression models were fitted using generalized estimating equations to baseline, 13 and 26 week measurements. Results: Forty-six children (7.78 years SD 2.27 years, 31 males, Manual Ability Classification System I=23, II=23) participated. Higher levels of bimanual performance (AHA: ß=0.03, p<0.001), greater object-oriented persistence (DMQ: ß=0.31, p=0.05), and treatment group allocation (Standard Care: ß=0.24, p=0.01) were positively associated with COPM performance scores post-intervention. Conclusions: Children's bimanual performance and persistence with object-oriented tasks significantly impact occupational performance outcomes following UL training. Predetermining children's mastery motivation along with bimanual ability may assist in tailoring of intervention strategies and models of service delivery to improve effectiveness.Implications for RehabilitationChildren's object persistence and bimanual performance both impact upper limb training outcomesWorking with children's motivational predispositions may optimize engagement and therapy outcomes.Supporting positive parenting styles may enhance a child's mastery motivation and

© 2015 Mac Keith Press. Aim: To determine whether short-term intensive group-based therapy combining modified constraint-induced movement therapy and bimanual therapy (hybrid-CIMT) is more effective than an equal total dose of distributed individualized occupational therapy (standard care) on upper limb motor and individualized outcomes. Method: Fifty-three children with unilateral cerebral palsy (69% males; mean age 7y 10mo, SD 2y 4mo; Manual Ability Classification System level I, n=24; level II, n=23) were randomly allocated, and 44 received either hybrid-CIMT (n=25) or standard care (n=19). Standard care comprised six weekly occupational therapy sessions and a 12-week home programme. Outcomes were assessed at baseline, 13 weeks, and 26 weeks after treatment. Results: Groups were equivalent at baseline. Standard care achieved greater gains on satisfaction with occupational performance after intervention (estimated mean difference -1.2, 95% CI -2.2 to -0.1; p=0.04) and Assisting Hand Assessment at 26 weeks (estimated mean difference 3.1, 95% CI 0.2-6.0; p=0.04). Both groups demonstrated significant improvements in dexterity of the impaired upper limb, and bimanual and occupational performance over time. The differences between groups were not clinically meaningful. Interpretation: There were no differences between the two models of therapy delivery. Group-based intensive camps may not be readily available; however, individualized standard care augmented with a home programme may offer an effective alternative but needs to be provided at a sufficient dose.

© 2015 Mac Keith Press. Aim: This study examined relationships between activities of daily living (ADL) motor and process skills, unimanual capacity, bimanual performance, and visual perception in children with unilateral cerebral palsy (CP). Method: Participants were 101 children with unilateral CP (51 males, 50 females; mean age 11y 9mo [SD 2y 5mo; range 8-17y]; Manual Ability Classification System [MACS] level I=24; level II=76; level III=1). Measures were (1) Assessment of Motor and Process Skills (AMPS), (2) Jebsen-Taylor Test of Hand Function (JTTHF), (3) Assisting Hand Assessment (AHA), and (4) Test of Visual Perceptual Skills, 3rd edition (TVPS-3). Regression models were constructed with the AMPS motor scale and AMPS process as the dependent variables. Results: The AHA and JTTHF dominant upper limb score together explained 57% of the variance in AMPS motor scale scores. TVPS-3 Visual Sequential Memory, TVPS-3 Visual Closure, and JTTHF dominant upper limb score together explained 35% of the variance in AMPS process scale scores. Interpretation: Bimanual performance and unimanual capacity of the dominant upper limb are significantly associated with ADL motor skills in children with unilateral CP. Process skills of ADL are related to visual perceptual ability and dominant upper limb unimanual capacity, which may reflect motor planning required to perform daily tasks. What this paper adds: Bimanual performance and unimanual capacity of the dominant upper limb are associated with activities of daily living (ADL) motor skills in children with unilateral cerebral palsy. Visual perception ability, most significantly sequential memory and visual closure, are associated with ADL process skills. There is 65% variance in the current model for ADL process skills which is not explained by visual perception and dominant upper limb capacity.

Aim: To examine internal consistency, test-retest reproducibility, and parent-child concordance of the Dimensions of Mastery Questionnaire 17.0 (DMQ) in school-Aged children with congenital hemiplegia. Method: Forty-two children (8.24 ± 2.38 years, Manual Ability Classification System (MACS) I = 23, MACS II = 19) and their parents completed the DMQ, and a subset on two occasions 2-30 days apart (n = 27). Cronbach's alpha (a), intraclass correlation coefficients (ICCs), standard error of measurement (SEM), and 95% limits of agreement were calculated. Results: Internal consistency for child self-report was variable (a = 0.57-0.90). Cronbach's alphas for parent proxy report were good (a = 0.69-0.86). Test-retest reproducibility for instrumental aspect (ICC = 0.86) and total motivation (ICC = 0.84) were excellent with subscales ranging from 0.70 to 0.91. The SEM for total motivation was 0.23 points. Parent-child concordance was poor across all scores (ICC = -0.04 to 0.42) with a large SEM (0.50-0.91). Interpretation: The DMQ parent report has good test-retest reproducibility for subscales, instrumental, and total motivation scores in school-Aged children with congenital hemiplegia. Parent-child concordance was low highlighting differences in individual and contextual perspectives. © 2014 Informa Healthcare USA, Inc.

The purpose of this systematical review was to appraise the clinimetric properties of measures of motivation in children aged 5-16 years with a physical disability or motor delay. Six electronic databases were searched. Studies were included if they reported measuring motivation in school-aged children across occupational performance areas. Two reviewers independently identified measures from included articles. Evaluation of measures was completed using the COSMIN (consensus-based standards for the selection of health measurement instruments) checklist. A total of 13,529 papers were retrieved, 15 reporting measurement of motivation in this population. Two measures met criteria: Dimensions of Mastery Questionnaire (DMQ) and Pediatric Volitional Questionnaire (PVQ). There was evidence of adequate validity for DMQ, and preliminary evidence of test-retest reliability. Psychometric evidence for PVQ was poor. Both measures demonstrated good clinical utility. The large number of retrieved papers highlights the importance being attributed to motivation in clinical studies, although measurement is seldom performed. Both identified measures show promise but further psychometric research is required.

This study aimed to identify barriers and enablers experienced by occupational therapists to delivering evidence-based upper limb intervention for children with unilateral cerebral palsy. Semistructured interviews informed by the Theoretical Domains Framework were conducted with nine occupational therapists from three teams to ascertain barriers and enablers to implementing five evidence criteria. A key barrier was lack of knowledge of current evidence for upper limb therapies for children with unilateral cerebral palsy. Therapists were confident in delivering goal-directed bimanual occupational therapy, but less knowledgeable and skilled, and hence confident in providing constraint therapy. Strategies to increase dose of therapy were identified as greater use of home programs and group-based interventions; however, therapists indicated the need for further education and skill development in these areas. In order to increase the uptake of research evidence into practice, findings from this study will be used to inform context-specific, individually targeted implementation strategies.

Aim: This study aimed to quantify the contribution of physical, personal and environmental characteristics to physical activity among independently ambulant children with unilateral cerebral palsy (CP). Method: One-hundred and two children with unilateral CP (52 males, 50 females; 52 right hemiplegia; mean age 11y 3mo, range 8–17y [SD 2y 4mo]) classified at Gross Motor Function Classification System (GMFCS) levels I = 44 and II = 58 participated. Physical activity was measured over 4 days using ActiGraph accelerometers recording as activity counts. GMFCS, functional strength, 6-minute walk test (6MWT), mobility limitations (MobQues28), age, sex, Assessment of Life-Habits recreation domain, Participation and Environment Measure for Children and Youth (PEM-CY) and environmental characteristics were considered for selection in a linear regression model. These served as independent variables which were determined using a backwards selection procedure. Results: Younger age, male sex, increased performance on the 6MWT, and increased participation in the home and community measured using the PEM-CY were significantly associated with activity counts (p<0.001). However, the model fit was somewhat weak (R2=0.32), indicating that much of the variation was unexplained. Older age and reduced community participation were associated with high inactivity (p<0.001). Interpretation: Physical activity interventions should primarily target adolescents and females. Walking endurance and participation in the home and community may represent modifiable characteristics to increase physical activity.

Background and objective: Children with unilateral cerebral palsy present with impaired upper limb (UL) function affecting independence, participation, and quality of life and require effective rehabilitation. This study aims to systematically review the efficacy of nonsurgical upper limb therapies for children with unilateral cerebral palsy. Methods: Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Embase, the Cochrane Central Register of Controlled Trials, and PubMed were searched to December 2012. Randomized controlled or comparison trials were included. Results: Forty-two studies evaluating 113 UL therapy approaches (N = 1454 subjects) met the inclusion criteria. Moderate to strong effects favoring intramuscular injections of botulinum toxin A and occupational therapy (OT) to improve UL and individualized outcomes compared with OT alone were identified. Constraint-induced movement therapy achieved modest to strong treatment effects on improving movement quality and efficiency of the impaired UL compared with usual care. There were weak treatment effects for most outcomes when constraint therapy was compared with an equal dose (amount) of bimanual OT; both yielded similar improved outcomes. Newer interventions such as action observation training and mirror therapy should be viewed as experimental.Conclusions: There is modest evidence that intensive activity-based, goal-directed interventions (eg, constraint-induced movement therapy, bimanual training) are more effective than standard care in improving UL and individualized outcomes. There is little evidence to support block therapy alone as the dose of intervention is unlikely to be sufficient to lead to sustained changes in UL outcomes. There is strong evidence that goal-directed OT home programs are effective and could supplement hands-on direct therapy to achieve increased dose of intervention.

Aim: This study aimed to systematically review the psychometric properties and clinical utility of measures of activities of daily living (ADL) for children with cerebral palsy (CP) aged 5 to 18 years. Method: Five electronic databases were searched to identify available ADL measures with published psychometric data for school-aged children with CP. Measures were included if at least 60% of the items addressed ADL in the full assessment or in an independent domain. A modified CanChild Outcome Rating Form was used to report the validity, reliability, responsiveness, and clinical utility of the measures. Results: Twenty-six measures were identified and eight met inclusion criteria. The Pediatric Evaluation of Disability Inventory (PEDI) had the strongest psychometric properties but was limited by its age range. The Assessment of Motor and Process Skills (AMPS) was the most comprehensive evaluation of underlying motor and cognitive abilities yet further psychometric testing is required for children with CP. Interpretation: The PEDI should be used to measure ADL capability in elementary school aged children. The AMPS is the best measure to evaluate ADL performance or capacity and is suitable for all ages. Future research should examine the reliability of the AMPS to determine its stability in children and adolescents with CP. What this paper adds Eight measures of ADL are appropriate for school-aged children with CP.

© 2014 Mac Keith Press. Aim: To determine the extent to which children's mastery motivation predicts occupational performance outcomes following upper limb intervention (ULI). Method: In this cohort study, participants received 45 hours of ULI, either in an intensive group-based or distributed individualized model. The Dimensions of Mastery Questionnaire (DMQ) measured mastery motivation at baseline. Occupational performance outcomes were assessed at baseline and 13 weeks' post-intervention using the Canadian Occupational Performance Measure (COPM). Multivariable models determined the contribution of mastery motivation to COPM outcome irrespective of group membership. Results: Forty-two children with congenital hemiplegia (29 males, 13 females; mean age 7y 8mo [SD 2y 2mo]; range 5y 1mo-12y 8mo; Manual Ability Classification System [MACS] I=20 and II=22; predominant motor type unilateral spastic n=41) participated in the study. Significant gains were seen in COPM performance and satisfaction scores (p<0.001) post-intervention with no between group differences. Children who had greater persistence with object-oriented tasks (p=0.02) and better manual ability (p=0.03) achieved higher COPM performance scores at 13 weeks. Children's persistence on object-oriented tasks was the strongest predictor of COPM satisfaction (p=0.01). Interpretation: Children's persistence with object-oriented tasks as well as manual abilities needs to be considered when undertaking ULI. Predetermining children's motivational predispositions can assist clinicians to tailor therapy sessions individually based on children's strengths, contributing to effective engagement in ULI.

Aim: The aim of this study was to examine the relationship between mastery motivation and individual and environmental characteristics in school-aged children with congenital hemiplegia. Method: Forty-eight child-caregiver dyads (children's mean age 7y 11mo, SD 2y 4mo; 33 males, 15 females; Manual Ability Classification System [MACS] level I, n=25, and level II, n=23; predominant motor type spastic hemiplegia, n=47) were recruited to this cross-sectional study. Children were assessed using the Melbourne Assessment of Unilateral Upper Limb Function (MUUL) and the Assisting Hand Assessment. Caregivers completed the Dimensions of Mastery Questionnaire, the Parenting Scale, and a demographic questionnaire. Results: Consistent and positive parental disciplinary practices were associated with higher total motivation (p=0.006) and instrumental aspect scores (p=0.009). Children with siblings and from single-parent families experienced greater negative reactions to failure (p=0.006). Children from two-parent families (p=0.018) and with better bimanual performance (p=0.015) demonstrated greater object-oriented persistence. Age, sex, limitations in manual ability (MACS), and movement and body function of the impaired limb (MUUL) did not contribute significantly to mastery motivation. Interpretation: Inconsistent, excessively lax, and verbose parenting practices may discourage children from persevering with challenging tasks. Functional parenting styles, positive discipline practices, and autonomy-supportive strategies for task engagement should be encouraged when intervening with children with cerebral palsy. Parents should be supported to engage in these practices in all aspects of daily activities. © 2013 Mac Keith Press.

BACKGROUND: Like many other countries, Australia is facing an inactivity epidemic. The purpose of the Australian 2014 Physical Activity Report Card initiative was to assess the behaviors, settings, and sources of influences and strategies and investments associated with the physical activity levels of Australian children and youth. METHODS: A Research Working Group (RWG) drawn from experts around Australia collaborated to determine key indicators, assess available datasets, and the metrics which should be used to inform grades for each indicator and factors to consider when weighting the data. The RWG then met to evaluate the synthesized data to assign a grade to each indicator. RESULTS: Overall Physical Activity Levels were assigned a grade of D-. Other physical activity behaviors were also graded as less than average (D to D-), while Organized Sport and Physical Activity Participation was assigned a grade of B-. The nation performed better for settings and sources of influence and Government Strategies and Investments (A- to a C). Four incompletes were assigned due to a lack of representative quality data. CONCLUSIONS: Evidence suggests that physical activity levels of Australian children remain very low, despite moderately supportive social, environmental and regulatory environments. There are clear gaps in the research which need to be filled and consistent data collection methods need to be put into place.

INTRODUCTION: Children with congenital hemiplegia often present with limitations in using their impaired upper limb which impacts on independence in activities of daily living, societal participation and quality of life. Traditional therapy has adopted a bimanual training approach (BIM) and more recently, modified constraint induced movement therapy (mCIMT) has emerged as a promising unimanual approach. Evidence of enhanced neuroplasticity following mCIMT suggests that the sequential application of mCIMT followed by bimanual training may optimise outcomes (Hybrid CIMT). It remains unclear whether more intensely delivered group based interventions (hCIMT) are superior to distributed models of individualised therapy. This study aims to determine the optimal density of upper limb training for children with congenital hemiplegia. METHODS AND ANALYSES: A total of 50 children (25 in each group) with congenital hemiplegia will be recruited to participate in this randomized comparison trial. Children will be matched in pairs at baseline and randomly allocated to receive an intensive block group hybrid model of combined mCIMT followed by intensive bimanual training delivered in a day camp model (COMBiT; total dose 45 hours direct, 10 hours of indirect therapy), or a distributed model of standard occupational therapy and physiotherapy care (SC) over 12 weeks (total 45 hours direct and indirect therapy). Outcomes will be assessed at 13 weeks after commencement, and retention of effects tested at 26 weeks. The primary outcomes will be bimanual coordination and unimanual upper-limb capacity. Secondary outcomes will be participation and quality of life. Advanced brain imaging will assess neurovascular changes in response to treatment. Analysis will follow standard principles for RCTs, using two-group comparisons on all participants on an intention-to-treat basis. Comparisons will be between treatment groups using generalized linear models. TRIAL REGISTRATION: ACTRN12613000181707.

Introduction: Children with congenital hemiplegia often present with limitations in using their impaired upper limb which impacts on independence in activities of daily living, societal participation and quality of life. Traditional therapy has adopted a bimanual training approach (BIM) and more recently, modified constraint induced movement therapy (mCIMT) has emerged as a promising unimanual approach. Evidence of enhanced neuroplasticity following mCIMT suggests that the sequential application of mCIMT followed by bimanual training may optimise outcomes (Hybrid CIMT). It remains unclear whether more intensely delivered group based interventions (hCIMT) are superior to distributed models of individualised therapy. This study aims to determine the optimal density of upper limb training for children with congenital hemiplegia.Methods and analyses: A total of 50 children (25 in each group) with congenital hemiplegia will be recruited to participate in this randomized comparison trial. Children will be matched in pairs at baseline and randomly allocated to receive an intensive block group hybrid model of combined mCIMT followed by intensive bimanual training delivered in a day camp model (COMBiT; total dose 45 hours direct, 10 hours of indirect therapy), or a distributed model of standard occupational therapy and physiotherapy care (SC) over 12 weeks (total 45 hours direct and indirect therapy). Outcomes will be assessed at 13 weeks after commencement, and retention of effects tested at 26 weeks. The primary outcomes will be bimanual coordination and unimanual upper-limb capacity. Secondary outcomes will be participation and quality of life. Advanced brain imaging will assess neurovascular changes in response to treatment. Analysis will follow standard principles for RCTs, using two-group comparisons on all participants on an intention-to-treat basis. Comparisons will be between treatment groups using generalized linear models.

Regular participation in physical activity is an important determinant of health for children and adolescents with cerebral palsy (CP). However, there is little consensus on the most valid or reliable method to measure physical activity in this population. This study aimed to systematically review the psychometric properties of habitual physical activity (HPA) measures in primary school-aged children with CP. Databases were systematically searched for measures assessing physical activity over more than one day and had evidence of validity, reliability and/or clinical utility in children aged 6-12 years with CP. Ten measures met inclusion criteria and their quality was assessed in twelve studies. Quality of the included studies was appraised using the consensus-based standards for the selection of health measurement instruments (COSMIN) checklist. Measures were moderately to strongly correlated to criterion measures, with study quality rated as Fair (+) to Poor (0). Only four measures had evidence of reliability. Accelerometers provide a valid measure of HPA with good clinical utility; however they do not have documented reliability in this population. No one measure appears ideal to record HPA in primary school-age children with CP and further research is necessary to determine the psychometric properties of HPA measurement instruments in this population.

Introduction: Persons with cerebral palsy require a lifetime of costly and resource intensive interventions which are often limited by equity of access. With increasing burden being placed on health systems, new methods to deliver intensive rehabilitation therapies are needed. Move it to improve it (Mitii) is an internet-based multimodal programme comprising upper-limb and cognitive training with physical activity. It can be accessed in the client's home at their convenience. The proposed study aims to test the efficacy of Mitii in improving upperlimb function and motor planning. Additionally, this study hopes to further our understanding of the central neurovascular mechanisms underlying the proposed changes and determine the cost effectiveness of Mitii. Methods and analysis: Children with congenital hemiplegia will be recruited to participate in this waitlist control, matched pairs, single-blind randomised trial. Children be matched at baseline and randomly allocated to receive 20 weeks of 30 min of daily Mitii training immediately, or waitlisted for 20 weeks before receiving the same Mitii training (potential total dose=70 h). Outcomes will be assessed at 20 weeks after the start of Mitii, and retention effects tested at 40 weeks. The primary outcomes will be the Assessment of Motor and Process Skills (AMPS), the Assisting Hand Assessment (AHA) and unimanual upper-limb capacity using the Jebsen-Taylor Test of Hand Function ( JTTHF). Advanced brain imaging will assess use-dependant neuroplasticity. Measures of body structure and functions, activity, participation and quality of life will be used to assess Mitii efficacy across all domains of the International Classification of Functioning, Disability and Health framework.

Introduction: Infants with asymmetric brain lesions are at high risk of developing congenital hemiplegia. Action-observation training (AOT) has been shown to effectively improve upper limb motor function in adults with chronic stroke. AOT is based on action observation, whereby new motor skills can be learnt by observing motor actions. This process is facilitated by the Mirror Neuron System, which matches observed and performed motor actions. This study aims to determine the efficacy of AOT in: (1) influencing the early development of reaching and grasping of typically developing infants and (2) improving the upper limb activity of infants with asymmetric brain lesions. Methods and analysis: This study design comprises two parallel randomised sham-controlled trials (RCTs) in: (1) typically developing infants (cohort I) and (2) infants with asymmetric brain lesions (eg, arterial stroke, venous infarction, intraventricular haemorrhage or periventricular leukomalacia; cohort II). Cohort II will be identified through a neonatal ultrasound or neonatal MRI. A sham control will be used for both RCTs, taking into consideration that it would be unethical to give no intervention to an at-risk population. Based on a two-tailed t test of two independent means, with a significance (a) level of 0.05, 80% power, predicted effect size of 0.8 and a 90% retention rate, we require 20 participants in each group (total sample of 40) for cohort I. The sample size for cohort II was based on the assumption that the effect size of the proposed training would be similar to that found by Heathcock et al in preterm born infants (n=26) with a mean effect size of 2.4. Given the high effect size, the calculation returned a sample of only four participants per group, on a two-tailed t test, with a significance (a) level of 0.05 and 80% power. As cohort II will consist of two subgroups of lesion type (ie, arterial stroke and venous infarction), we have quadrupled the sample to include 16 participan

Phenomenology enables researchers and clinicians to understand the lived experience of those affected by situations that are not easily measurable. This paper presents an example of the decision making undertaken to investigate the lived experience of adolescents with cerebral palsy in their transition to secondary school. The process engaged in undertaking this research is used as a means of highlighting key decision points when undertaking qualitative investigation of this kind. Hermeneutic phenomenologically orientated study: Eleven parent-adolescent dyads of youth with cerebral palsy (8 males, 2 females, ages 12-14 years; Gross Motor Function Classification System (GMFCS) I=3, II=4, III=3, IV=1; Manual Abilities Classification System (MACS) I=5, II=2, III=4, IV=1, V=5; spasticity=10, dystonia=1; rural=1, regional=3, metropolitan=7). A step-by-step qualitative decision making pathway, including Colaizzi's methods, to facilitate investigation of the lived experience of adolescents with cerebral palsy was developed. The paper presents four main phases in the decision making process required when designing or interpreting a qualitative research study, namely philosophy, methodology, research methods, and confirmation. A clear process in the construction of qualitative research has been developed. This should support researchers working in various fields of allied health and rehabilitation to investigate the experiences of service recipients where there is insufficient research to formulate hypotheses.

Aim The aim of this study was to determine whether constraint-induced movement therapy is more effective than bimanual training in improving the quality of life of children with unilateral cerebral palsy (CP). Method Sixty-three children (mean age 10y 2mo [SD 2y 6mo]; 33 males, 30 females) with CP of the spastic motor type (n=59) or with spasticity and dystonia (n=4) were randomly allocated to two groups. The children were assessed as Manual Ability Classification System level I (n=16), II (n=46), or III (n=1). Each group received 6hours of daily intervention (either constraint-induced movement therapy [CIMT] or bimanual training [BIM]) for 10days over a 2-week period (total intervention time 60h). Children aged 9years and older completed the Cerebral Palsy Quality of Life Questionnaire for Children (CPQOL-Child) and those aged 8years and older completed the KIDSCREEN-52. All parents completed proxy versions of each measure. Assessments were made at baseline and at 3, 26, and 52weeks after the end of the intervention. Results Thirty-five children completed the CPQOL-Child and 41 completed the KIDSCREEN-52. No changes in social or emotional well-being were reported by children in either group. Children and parents from both groups reported a significant improvement in their or their child's feelings about functioning as well as participation and physical health on the CPQOL-Child. The parents of children receiving CIMT reported positive and sustained changes in their child's social well-being (CPQOL-Child). The CIMT group showed significant improvements in physical well-being, psychological well-being, and moods and emotions (KIDSCREEN-52) at 3weeks post intervention, which were maintained over the study period. Interpretation Intensive goal-directed upper limb training programmes using either CIMT or BIM achieved domain-specific changes in quality of life relating to feelings about functioning and participation and physical health. A condition-specific quality of li

Aim: To determine if constraint-induced movement therapy (CIMT) is more effective than bimanual training (BIM) in improving upper limb activity outcomes for children with congenital hemiplegia in a matched-pairs randomized trial. Method: Sixty-three children (mean age 10.2, SD 2.7, range 5-16y; 33 males, 30 females), 16 in Manual Ability Classification System level I, 46 level II, and 1 level III and 16 in Gross Motor Function Classification level I, 47 level II) were randomly allocated to either CIMT or BIM group day camps (60hours over 10days). The Melbourne Assessment of Unilateral Upper Limb Function assessed unimanual capacity of the impaired limb and Assisting Hand Assessment evaluated bimanual coordination at baseline, 3 and 26weeks, scored by blinded raters. Results: After concealed random allocation, there was no baseline difference between groups. CIMT had superior outcomes compared with BIM for unimanual capacity at 26weeks (estimated mean difference [EMD] 4.4, 95% confidence interval [CI] 2.2-6.7; p<0.001). There was no other significant difference between groups post-intervention. Both groups demonstrated significant improvements in bimanual performance at 3weeks, with gains maintained by BIM at 26weeks (EMD 2.3; 95% CI 0.6-4.0; p=0.008). Interpretation: Overall, there were only small differences between the two training approaches. CIMT yielded greater changes in unimanual capacity of the impaired upper limb compared with BIM. Results: generally reflect specificity of practice, with CIMT improving unimanual capacity and BIM improving bimanual performance. Considerable inter-individual variation in response to either intervention was evident. Future research should consider serial sequencing unimanual then BIM approaches to optimize upper limb outcomes for children with congenital hemiplegia. © The Authors. Journal compilation © Mac Keith Press 2011.

Objectives. To determine retention of treatment outcomes at 52 weeks following a matched-pairs randomized comparison trial of constraint-induced movement therapy (CIMT) and bimanual training (BIM). Methods. Sixty-four children (mean age = 10.2 ± 2.7 years, 52% male) were included. The Melbourne Assessment of Unilateral Upper Limb Function (MUUL), Assisting Hand Assessment (AHA), and Canadian Occupational Performance Measure (COPM) were the primary outcome measures. Evaluations were at baseline and at 26 and 52 weeks. Results. There were no baseline differences between groups on any measure. No significant differences were found between groups on primary outcomes at 52 weeks. Both groups retained the significant gains made from baseline to 26 weeks at the 1-year follow-up assessment for unimanual capacity on the MUUL, for bimanual performance on the AHA, and on the COPM. Conclusion. Intensive unimanual and bimanual training can both lead to long-term significant improvements in unimanual capacity, bimanual performance, and individualized outcomes. Gains established at 26 weeks were maintained at 12 months postintervention despite most children receiving no direct therapy during that time. © 2011 The Author(s).

Objective: To delineate characteristics of best responders in a randomized trial comparing constraint-induced movement therapy (CIMT) to bimanual training for children with unilateral cerebral palsy. Design: Secondary analysis of a single-blind matched-pairs randomized comparison trial. Setting: Community sporting facilities in 2 Australian capital cities. Participants: Children (n=64; mean age, 10.2±2.7y; 52% boys), matched for age, sex, side of hemiplegia, and upper-limb function, were randomized within pairs to CIMT or bimanual training. Sixty-one children who completed CIMT (n=31) or bimanual training (n=30) were included in this study. Interventions: Each intervention was delivered in day camps (total 60h over 10d) using a novel circus theme with goal-directed training. Main Outcome Measures: Change between baseline, 3, and 26 weeks on the Melbourne Assessment of Unilateral Upper Limb Function (MUUL>7.4%), Assisting Hand Assessment (AHA>4 raw score points), and Canadian Occupational Performance Measure (COPM>2 points) defined best responders.Results: Poorer baseline hand function predicted a best response for unimanual capacity of the impaired upper limb (MUUL) immediately postintervention; however, at 26 weeks the odds of achieving a favorable outcome were 21 times greater for CIMT than bimanual training. A favorable response for bimanual performance (AHA) was predicted by immediate change in Jebsen-Taylor hand function test scores. Age (older), left-sided hemiplegia, and lower-baseline COPM performance scores significantly predicted favorable individualized outcomes. Conclusions: Secondary analysis of a randomized trial directly comparing 2 upper-limb training models, found children with poorer hand function benefited most. Favorable outcomes for bimanual performance were associated with gains in movement efficiency and older children with left-sided hemiplegia achieved more favorable gains in perceived occupational performance.

Objective: To determine if constraint-induced movement therapy (CIMT) is more effective than bimanual training to improve occupational performance and participation in children with congenital hemiplegia. Design: Single-blind randomized comparison trial with evaluations at baseline, 3, and 26 weeks. Setting: Community facilities in 2 Australian states. Participants: Referred sample of children (N=64; mean age ± SD, 10.2±2.7y, 52% boys) were matched for age, sex, side of hemiplegia, and upper-limb function and were randomized to CIMT or bimanual training. After random allocation, 100% of CIMT and 94% of the bimanual training group completed the intervention. Interventions: Each intervention was delivered in day camps (total 60h over 10d) using a circus theme with goal-directed training. Children receiving CIMT wore a tailor-made glove during the camp. Main Outcome Measures: The primary outcome was the Canadian Occupational Performance Measure (COPM). Secondary measures included the Assessment of Life Habits (LIFE-H), Children's Assessment of Participation and Enjoyment, and School Function Assessment. Results: There were no between-group differences at baseline. Both groups made significant changes for COPM performance at 3 weeks (estimated mean difference =2.9; 95% confidence interval [CI], 2.33.6; P<.001 for CIMT; estimated mean difference=2.8; 95% CI, 2.23.4; P<.001 for bimanual training) that were maintained at 26 weeks. Significant gains were made in the personal care LIFE-H domain following CIMT (estimated mean difference=0.5; 95% CI, 0.10.9; P=.01) and bimanual training (estimated mean difference=0.6; 95% CI, 0.21.1; P=.006). Conclusions: There were minimal differences between the 2 training approaches. Goal-directed, activity-based, upper-limb training, addressed through either CIMT or bimanual training achieved gains in occupational performance. Changes in participation on specific domains of participation assessments appear to correspond with identifi

BACKGROUND: Congenital hemiplegia is the most common form of cerebral palsy (CP) accounting for 1 in 1300 live births. These children have limitations in capacity to use the impaired upper limb and bimanual coordination deficits which impact on daily activities and participation in home, school and community life. There are currently two diverse intensive therapy approaches. Traditional therapy has adopted a bimanual approach (BIM training) and recently, constraint induced movement therapy (CIMT) has emerged as a promising unimanual approach. Uncertainty remains about the efficacy of these interventions and characteristics of best responders. This study aims to compare the efficacy of CIMT to BIM training to improve outcomes across the ICF for school children with congenital hemiplegia. METHODS/DESIGN: A matched pairs randomised comparison design will be used with children matched by age, gender, side of hemiplegia and level of upper limb function. Based on power calculations a sample size of 52 children (26 matched pairs) will be recruited. Children will be randomised within pairs to receive either CIMT or BIM training. Both interventions will use an intensive activity based day camp model, with groups receiving the same dosage of intervention delivered in the same environment (total 60 hours over 10 days). A novel circus theme will be used to enhance motivation. Groups will be compared at baseline, then at 3, 26 and 52 weeks following intervention. Severity of congenital hemiplegia will be classified according to brain structure (MRI and white matter fibre tracking), cortical excitability using Transcranial Magnetic Stimulation (TMS), functional use of the hand in everyday tasks (Manual Ability Classification System) and Gross Motor Function Classification System (GMFCS). Outcomes will address neurovascular changes (functional MRI, functional connectivity), and brain (re)organisation (TMS), body structure and function (range of motion, spasticity, strength and sen

Objective: This qualitative study explored the experiences of children participating in modified constraint-induced movement therapy (CIMT) within a circus-themed day camp. Methods: Individual semi-structured interviews were performed with 32 children (15 girls, 17 boys; mean age 10.1 years) to gain insights into their experience of CIMT. Interviews were audio recorded, transcribed verbatim and independently read by two authors to identify common themes. Results: Three themes emerged from the data: children's experience of wearing the glove employed in the modified CIMT, their reactions to the camp format and the gains they made during the camp. Conclusion: The results highlighted the need to achieve a balance between the frustration of participating in modified CIMT and what was seen as motivators to sustain involvement. Findings are interpreted in the context of self-determination theory and remind clinicians to ensure interventions consider autonomy, competence and relatedness. © 2010 Informa UK Ltd All rights reserved.

Background: Congenital hemiplegia is the most common form of cerebral palsy (CP) accounting for 1 in 1300 live births. These children have limitations in capacity to use the impaired upper limb and bimanual coordination deficits which impact on daily activities and participation in home, school and community life. There are currently two diverse intensive therapy approaches. Traditional therapy has adopted a bimanual approach (BIM training) and recently, constraint induced movement therapy (CIMT) has emerged as a promising unimanual approach. Uncertainty remains about the efficacy of these interventions and characteristics of best responders. This study aims to compare the efficacy of CIMT to BIM training to improve outcomes across the ICF for school children with congenital hemiplegia.Methods/Design: A matched pairs randomised comparison design will be used with children matched by age, gender, side of hemiplegia and level of upper limb function. Based on power calculations a sample size of 52 children (26 matched pairs) will be recruited. Children will be randomised within pairs to receive either CIMT or BIM training. Both interventions will use an intensive activity based day camp model, with groups receiving the same dosage of intervention delivered in the same environment (total 60 hours over 10 days). A novel circus theme will be used to enhance motivation. Groups will be compared at baseline, then at 3, 26 and 52 weeks following intervention. Severity of congenital hemiplegia will be classified according to brain structure (MRI and white matter fibre tracking), cortical excitability using Transcranial Magnetic Stimulation (TMS), functional use of the hand in everyday tasks (Manual Ability Classification System) and Gross Motor Function Classification System (GMFCS). Outcomes will address neurovascular changes (functional MRI, functional connectivity), and brain (re)organisation (TMS), body structure and function (range of motion, spasticity, strength and sens

Aim: This study explores the relationship between unimanual capacity and bimanual performance for children with congenital hemiplegia aged 5 to 16 years. It also examines the relationship between impairments and unimanual capacity and bimanual performance. Method: Participants in this cross-sectional study attended a screening assessment before participating in a large, randomized trial. They comprised 70 children with congenital hemiplegia (39 males, 31 females; mean age 10y 6mo, SD 3y); 18 were classified in the Manual Ability Classification System level I, 51 in level II, and one in level III. Eighteen were in Gross Motor Function Classification System, level I and 52 in level II. Sixty-five participants had spasticity and five had dystonia and spasticity. Fifteen typically developing children (7 males, 8 females; mean age 8y 8mo, SD 2y 7mo), matched to study participants for age and sex, were recruited as a comparison group for measures of sensation, grip strength, and movement efficiency. Outcome measures for unimanual capacity were the Melbourne Assessment of Unilateral Upper Limb Function (MUUL), and the Jebsen-Taylor Hand Function Test (JTHFT). The Assisting Hand Assessment (AHA) evaluated bimanual performance. Upper limb impairments were measured using assessments of stereognosis, moving two-point discrimination, spasticity, and grip strength. Results: There was a strong relationship between unimanual capacity (MUUL) and bimanual performance (AHA; r=0.83). Linear regression indicated MUUL and stereognosis accounted for 75% of the variance in AHA logit scores. Sensory measures were moderately correlated with unimanual capacity and bimanual performance. Age, sex, and grip strength did not significantly influence bimanual performance. There was no difference between children with right- and left-sided hemiplegia for motor performance. Interpretation: Findings of our study confirm a strong relationship between unimanual capacity and bimanual performance in a co

CONTEXT. Rehabilitation for children with congenital hemiplegia to improve function in the impaired upper limb and enhance participation may be time-consuming and costly. OBJECTIVES. To systematically review the efficacy of nonsurgical upper-limb therapeutic interventions for children with congenital hemiplegia. METHODS. The Cochrane Central Register of Controlled Trials, Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), AMED (Allied and Complementary Medicine), Embase, PsycINFO, and Web of Science were searched up to July 2008. Data sources were randomized or quasi-randomized trials and systematic reviews. RESULTS. Twelve studies and 7 systematic reviews met our criteria. Trials had strong methodologic quality (Physiotherapy Evidence Database [PEDro] scale = 5), and systematic reviews rated strongly (AMSTAR [Assessment of Multiple Systematic Reviews] score = 6). Four interventions were identified: intramuscular botulinum toxin A combined with upper-limb training; constraint-induced movement therapy; hand-arm bimanual intensive training; and neurodevelopmental therapy. Data were pooled for upper-limb, self-care, and individualized outcomes. There were small-to-medium treatment effects favoring intramuscular botulinum toxin A and occupational therapy, neurodevelopmental therapy and casting, constraint-induced movement therapy, and hand-arm bimanual intensive training on upper-limb outcomes. There were large treatment effects favoring intramuscular botulinum toxin A and upper-limb training for individualized outcomes. No studies reported participation outcomes. CONCLUSIONS. No one treatment approach seems to be superior; however, injections of botulinum toxin A provide a supplementary benefit to a variety of upper-limb-training approaches. Additional research is needed to justify more-intensive approaches such as constraint-induced movement therapy and hand-arm bimanual intensive training. Copyright © 2009 by the American Academy of Pediatric

Methodological criticisms of research undertaken in the area of paediatric burns are widespread. To date, quasi-experimental research designs have most frequently been used to examine the impact of impairments such as scarring and reduced range of motion on functional outcomes. Predominantly, these studies have utilised a narrow definition of functioning (e.g. school attendance) to determine a child's level of participation in activities post-burn injury. Until recently, there had been little attempt to develop and/or test a theoretical model of functional outcome with these children. Using a conceptual model of functional outcome based on the International Classification of Functioning, Disability and Health, this review paper outlines the current state of the research literature and presents explanatory case study methodology as an alternative research design to further advance the study of functional outcome post-burn injury.

The contribution of demographic, injury, pre-morbid, and parent factors to a child's functional outcome at 6 months post-burn injury was examined. Sixty-eight children, aged 5-14 years with percent total body surface area (%TBSA) burns ranging from <1 to 35%, and their primary caregivers participated in the study. It was expected that pre-morbid and parent factors but not injury factors would have a significant impact on the functional outcome of children at 6 months post-burn. Injury factors included the percent of total body surface area burned, number of operative procedures, and source of the burn (i.e. flame burn, scald burn). Pre-morbid child factors included the presence or absence of behaviour problems, psychological or psychiatric problems, learning difficulty or developmental delay. Parent factors included anxiety, depression, coping processes, and social support. Whilst investigating the contribution of these factors to functional outcome, the effect of demographic factors (i.e. age, gender, family socioeconomic status, and the number of previous hospitalizations) was controlled for and investigated. Analyses included two hierarchical multiple regression analyses that supported the expected results. R was significantly different from zero at the end of each step in both hierarchical regression analyses, indicating that each group of factors added significantly to the fit of the model. After step 4 in the final regression model with all independent variables in the equation, R=0.85, F(18,49)=6.89, P<0.001.