ACQUIREc The Effective Application of Pediatric CI Therapy

1
ACQUIREcThe Effective Application of Pediatric
CI Therapy

• Stephanie DeLuca, Ph.D.
• Karen Echols, P.T., Ph.D., P.C.S.
• Sharon Ramey, Ph.D.
• Mary Rebekah Trucks, O.T.R./L.
• Dorie Ainsworth, O.T.R./L.
• Sarah Gillis, O.T.R./L.

2
What is ACQUIREc Therapy

• Acquisition of new motor skills
• Continuous practice with shaping to
  produce
• Quality movement of the
• Upper Extremity through
• Intensive therapy and
• Reinforcement in
• Everyday patterns and places
• C Casting

3
ACQUIREcA Three-Phase Treatment Protocol

• Phase One
• Casting of the stronger arm and hand
• Phase Two
• Providing INTENSIVE therapy for the weaker arm
  and hand in NATURAL settings
• Phase Three
• Post-therapy Planning including a home program
  that involves a life-style change to included the
  weaker arm and hand in the daily life of the
  child

4

• Professional demands for a science of Pediatric
  Therapy
• Traditional Physical and Occupational Therapy
• Given 2-hours per week on average (based on data
  from control children in our research)
• Very little scientific evidence for efficacy
• Leading professionals and groups have called for
  therapeutic approaches to become more
  standardized and scientifically evaluated

5

• Need to develop and provide efficacious therapies
  
• Importance of systematic diagnostic evaluations
  and assessment of developmental stages
• Urgency of objective documentation of treatment
  effects and developmental consequences of
  alternative therapies

6
What is ACQUIREc Therapy

• Acquisition of new motor skills
• Continuous practice with shaping to
  produce
• Quality movement of the
• Upper Extremity through
• Intensive therapy and
• Reinforcement in
• Everyday patterns and places
• C Casting

7
ACQUIREcA Three-Phase Treatment Protocol

• Phase One
• Casting of the stronger arm and hand
• Phase Two
• INTENSIVE therapy for the weaker arm and hand in
  NATURAL settings
• Phase Three
• Post-therapy Planning including a home program
  that involves a life-style change to included the
  weaker arm and hand in the daily life of the
  child

8
ACQUIREc

• Developed and tested by an interdisciplinary team
  at UAB
• Based on theory and research about Pediatric CI
  Therapy
• Constraint-Induced Movement Therapy

9
Constraint-Induced Movement Therapy

• Rehabilitation treatment for adults with
  hemiparesis
• Primarily applied to adults with CVA
• Informed by
• experimental neuroscience research with non-human
  primates
• basic principles of learning theory (established
  in the 1940s 1960s)

10
CI Therapy

• CI Therapy is considered a new set of
  rehabilitation techniques
• CI Therapy combines two techniques
• Restraint of unaffected arm
• Intensive forced use of affected arm through
  operant training techniques

11
CI Therapy

• Based on scientific findings of change in adults
  which include
• Large changes in self-reported functional
  abilities after 2 to 3 weeks of therapy
• Self-report of long-term maintenance (2 yrs)
• Improvement in accuracy and speed in lab tests
• Evidence of cortical reorganization

12
Learned Nonuse Theory

• CI therapy is based a theory called Learned
  Nonuse (LNU)
• After an injury, the central nervous system (CNS)
  goes into an acute state of shock
• affecting the lesioned and non-lesioned areas
• resulting in a chronic conditioned suppression of
  movement

13
Mechanisms for Effectiveness

• Behavioral
• Cortical reorganization which is theorized to be
  use dependent
• The size of cortical representations of a body
  part depends, in part, on the amount of use of
  that part.

14
We have proposed principles important for
effective treatments for impairments due to CNS
damage

• Minimum Therapy Thresholds
• Below-threshold dosages of the same approach may
  not produce measurable or lasting changes
• Multiple Therapeutic Approaches to Recovery
• Recognition that there are likely to be multiple
  therapeutic approaches that may produce
  measurable and sustainable gains

15
Early Childhood CNS Injury

• Theoretical basis for movement disorder is
  somewhat different for children than for adults
  because
• Underlying neural framework may not have
  developed
• Most children are not merely recovering
  previous function
• Many children display what we have termed
  developmental disregard for impaired extremity

16
Developmental Disregardin the Weaker Upper
Extremity
Injury early in life prior to development of
full movement repertoire
Child develops a disregard for many potential
movements and functions of other (unused) side
Repertoire limited by input from only one-side
17
Developmental Disregard

• Time-distributed feature
• Differences between the two sides of the body
  become greater as the child develops plus
• Compensatory movements or accommodations for
  hemiparesis occur (these are the norm for
  children with hp)

18
How ACQUIREc Therapy can alter Developmental
Disregard

• Decreasing the attention to the stronger
  extremity
• Re-directing the childs attention to the
  impaired extremity
• Experiencing repeated positive reinforcement with
  functional use of the impaired extremity
• Increasing the childs natural motivation to use
  the impaired extremity
• Increasing the expectations of family members
  about the childs abilities with the impaired
  extremity
• Reducing the aversions and negative sensitivity
  associated with moving the impaired extremity

19
ACQUIREc Therapy

• Similarities with CI Therapy
• - Restraint
• Operant Training Techniques
• Massed Practice (repetition)
• Strength building
• Focus on developing new movement

• Differences with CI Therapy
• Type and amount of restraint
• Setting(s) for therapy
• Treatment schedule length and daily amounts
• Involvement of ADLs
• Explicit bilateral training

20
Key Components of Daily ACQUIREc (Pediatric CI)
Therapy Treatment Protocol
21
Essential features of ACQUIREc

• Constraint (for full course of therapy)
• Long-arm cast
• Intensive therapeutic shaping
• Many hours each day for intensive treatment
  periods
• 3. Conducted in natural settings
• Focus on functional and play activities

22
Constraint

• Long-arm fiberglass cast
• Focused Rigidity Splinting
• Axillary area to fingertips
• Elbow in 90o flexion, wrist and fingers in
  neutral
• Wrapped in Co-Ban
• Bi (uni)-valved for weekly removal
• Check skin integrity and allow active range of
  motion for a few minutes.

23
Intensive Treatment

• Therapeutic Shaping
• Success oriented
• Positive reinforcement
• Progressive levels of difficulty

24

• Facilitation techniques used in activities and
  tasks
• Verbal cues
• Modeling
• Hand over hand facilitation
• Fading

25

• Many tasks are also used to increase sensory
  awareness
• Sensory tolerance
• Sensory stimulation
• Sensory processing

26

• Tasks are also goal-oriented
• Goals determined by all participants
• Child
• Family
• Therapist
• Teachers
• Goals are evaluated throughout course of therapy
• Shaped

27

• Family Centered
• Treatment includes available family members and
  caregivers
• Parents
• Siblings
• Grandparents
• Daycare workers
• Teachers
• Babysitters

28
Research Background of ACQUIREc Therapy
29
Libbys History

• Prematurity
• IVH Shunt
• Spastic quadriplegic cerebral palsy (RgtL)

30

• Since 4 months of age, participated in EIP that
  included weekly services of
• Special Ed
• Speech
• Nursing
• OT
• PT
• Nutrition

31
Protocol

• Bi-valved cast worn 24-hours
• Treatment 6 hours each day for many consecutive
  days.
• Treatment given in the childs natural
  environment.
• Weekdays 3 weeks
• Total of 15 treatment days

32
Measures of Libbys progress

• Peabody Developmental Motor Scales
• Denver Developmental Screening Tool
• Pediatric Motor Activity Log
• Toddler Arm Use Test
• Clinical diaries

33
Pretreatment

• Age at initiation 15 months
• 12 months when corrected for prematurity
• Skill Level
• Developmental Delays
• Globally delayed in all areas of development
• Severe motoric delays

34
Motor Accomplishments during Therapy for Libby

• Day 3 Initiated voluntary reaching
• Day 4 1st voluntary grasp
• Day 5 Bares weight on R arm in quadruped
• Days 6-8 Tone ? progressed in sitting
  balance, control, endurance, rolling
  transitions supination
  emerged
• Days 9-10 Gross grasping more spontaneous
• Days 14-15 1st demo of understanding that 2
  arms can function together

35
Peabody Developmental Motor Scales (Libby)
36
Denver Developmental Screening Tool (Libby)
37
Pretreatment 2

• Age at initiation 21 months
• Duration of treatment 21 straight days (included
  weekends)
• Motor skill level
• Gross arm use on request
• Independent in floor mobility

38
Measures

• Pediatric Motor Activity Log
• Toddler Arm Use Test
• Developmental Activities Screening Inventory

39
Pediatric Motor Activity Log
40
Toddler Arm Use Test
Voluntary Arm Selection on First Attempts
41
Toddler Arm Use Test
Functional Amount of Use
42
Randomized Controlled Trial of Pediatric CI
Therapy

• PI Sharon Ramey
• Co-PIs Stephanie DeLuca
• And Karen Echols

43
Subjects

• 18 children
• Randomly assigned to either receive Pediatric CI
  Therapy or Traditional Therapeutic Services
• Average age was 41.5 months
• 13 males and 5 females
• No between group differences on age or gender

44
QUEST Dissociated Movement
45
PMAL Frequency of Use
46
PMAL Quality of Movement
47
Emerging Behaviors Scale
48
PMAL QOM(6 month Follow-up)
49
PMAL - Frequency (6 month Follow-up)
50

• Clinical Implementation and Clinical Results of
  Pediatric CI Therapy

51
PMAL Quality Clinical Sample
Pre Post
52
PMAL Frequency Clinical Sample
Pre Post
53
Emerging Behaviors ScaleClinical Study (n46)
54
Change Scores
55
Pediatric Neuromotor Research Clinic

• 96 Children
• 9 with multiple treatment sessions
• 10 children scheduled for the next year who will
  be going through second of third treatment
  sessions
• We see 2-4 children per month
• Average 3 children per month
• This fiscal year we will have 37 treatment
  sessions

56
Spillover Effects

• Improved communication skills
• Decreased sensory aversion to touch/textures
• Improved gross motor and mobility skills
• Increased self-confidence and independence
• Reduced behavioral problems

57
Ongoing Research and Important Unanswered
Questions
58

• Clinical dissemination
• Need to disseminate the entire protocol
• Replication Studies
• Multi-site RCT with expanded measures and
  additional controls

59

• Policy Changes
• Insurance coverage
• Treatment delivery systems
• Increased research training and mentoring for
  practitioners

60

• Additional Areas of Study
• Dosage Curve analysis
• Cost-benefit analysis
• Longitudinal Studies
• Understanding of the contribution of the
  individual components of ACQUIREc Therapy