HABIT (Hand Arm Bimanual Intensive Therapy)

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HABIT (Hand Arm Bimanual Intensive Therapy)

• M.S.Rekha
• SpR Paediatrics

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Outline

• Cerebral palsy
• Embryology and patho-physiology
• Key issues affecting therapy
• HABIT
• Future

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Cerebral Palsy

• CP incidence 1500
• 36 Hemiplegic CP
• UL gt LL
• Impairment
• Spasticity, Posturing, Sensation, Reduced
  strength
• Intellectual capacity
• Impact

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UL problems in CP

• Integrity of motor cortex and cortico-spinal
  tracts affected
• Precision grasping affected
• Fine control of hands and fingers affected
• Abnormal tone
• Abnormal posturing
• Tactile and proprioceptive disturbances

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Therapy - Pathophysiology

• How nervous system develops and functions
• Basis for the neural impairments
• Neurogenesis
• Neuroplasticity
• Synaptogenesis
• Cortical Maps
• Long term potentiation
• Primary areas
• Stem cells

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Key issues

• Problems with bimanual coordination gt uni-manual
  deficit
• Restraining a childs non-involved limb
• invasive
• frustrating
• de-motivating
• Children have never learned to use the affected
  limb

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CIMT

• Developed in adult to overcome learned non-use
  (children have to overcome developmental non-use)
• Invasive
  (it is practice
  not the restraint which helps)
• Uni-manual vs bimanual skills training
  (children compensate well with non-involved
  limb but not effectively)

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HABIT

• Motor learning
• Neuroplasticity
• Use of involved hand as a typically developing
  child uses non-dominant hand
• Practice Improvement in function
• Structured practice based on how CNS responds
• Ensure
• Optimum task response
• Gradually increase complexity
• Motivation, Rewards

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Evidence

• 1 Single blinded RCT (Gordon et al, 2007)
• Hemiplegic CP with Mild Moderate hand
  involvement
• 20 children (3.5 15.5 yrs)
• Randomized to intervention or delayed treatment
  control group
• Evaluation before and after and 1mth post
  intervention
• Assisting Hand Assessment
• Increased involved extremity use (Accelerometry
  Caregiver survey)
• Bimanual items of Bruiniknks-Oseretsky test of
  Motor proficiency
• Jebsen-Taylor test of hand function
• Simultaneity of completing a draw opening task
  with 2 hands (plt0.)5 in all cases)

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HABIT

• Select task Functional activities - bimanual
  hand use (based on individual child)
• Ground rules re use of non-involved limb
• Structured practice for 15 20 mins at a time
  (6 hours /day for 10 days)
• Gradually increasing in complexity (tailored to
  each child)
• Child friendly (goals, parental involvement)
• Home practice 1 hr/day during and 2hrs/day after
  intervention

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Taken from presentation by Charles Gordon on
web Intensity-based rehabilitation of the upper
extremity in children with congenital hemiplegia
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HABIT (Charles Gordon, 2006)
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Future

• Larger, robust, multi-centre RCTs would be needed
  comparing different strategies
• Boyd et al, 2010 conducting RCT comparing CIMT
  and BIM training

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References

• Development of hand-arm bimanual intensive
  training (HABIT) for improving bimanual
  coordination in children with hemiplegic cerebral
  palsy. Charles J Gordon A, Developmental
  Medicine Child Neurology, 2006
  Nov48(11)931-6.
• Efficacy of a hand-arm bimanual intensive therapy
  (HABIT) in children with hemiplegic cerebral
  palsy a randomized control trial, Gordon et al,
  Developmental Medicine Child Neurology, 2007
  Nov49(11)830-8.
• Systematic Review and Meta-analysis of
  Therapeutic Management of Upper-Limb Dysfunction,
  Sakzewski et al. Pediatrics.2009 123 1111-1122.
  
• INCITE A randomised trial comparing constraint
  induced movement therapy and bimanual training in
  children with congenital hemiplegia, Boyd et al.
  BMC Neurology 2010, 104 http//www.biomedcentral.
  com/1471-2377/10/4
• Neuroplasticity in Children, Mundkur N, Indian
  Journal of Paediatrics, 2005 72 (10) 855 - 7

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• Thank you
• Questions?

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Neurogenesis

• Prenatal
• Neurogenesis
• Neuronal proliferation
• Migration Aggregation
• Axonal growth synaptogenesis

• Postnatal
• Synaptogenesis and myelination till 2yrs
• Process continues at reduced rate
• Synaptic pruning
• Dynamic state
• Birth 2500 connections
• _at_15,000 (double the adult size) at the age of
  2yrs
• Apoptosis Pruning

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Neuroplasticity

• Ability of the brain to constantly reorganise
  neural pathways based on new experience and
  learning
• Ability of brain to change with learning
• Several processes involved
• Different types of plasticity at different times
• Developmental/Adaptive
• Environmental

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Neuroplasticity

• Individual connections - strengthened or removed
• Neurons that fire together wire together
• Neurons active together - synapses strengthened
  preserved
• Those not active are pruned (continues till
  16yrs)
• Activity between close neurons leads to
  cortical maps becoming
  one
• Neural development
• Gene expression
• Neurotransmitters
• Neurotrophins

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Adaptation

• Capacity to adapt and change connections in
  response to new information, stimulation, damage
• Reorganisation of cellular neural networks
• Synapses formed in response to stimulation
• Long term potentiation

• Primary areas not fixed
• Neurogenesis after damage

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Neuroplasticity