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HABIT (Hand Arm Bimanual Intensive Therapy)
M.S.RekhaSpR Paediatrics
Outline
• Cerebral palsy• Embryology and patho-physiology• Key issues affecting therapy• HABIT• Future
24/05/2010 North West CP Network Meeting HABIT
24/05/2010 North West CP Network Meeting HABIT
• CP – incidence 1:500• 36% Hemiplegic CP• UL > LL• Impairment
– Spasticity, Posturing, Sensation, Reduced strength
• Intellectual capacity• Impact
Cerebral Palsy
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
24/05/2010 North West CP Network Meeting HABIT
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
24/05/2010 North West CP Network Meeting HABIT
24/05/2010 North West CP Network Meeting HABIT
Key issues
• Problems with bimanual coordination > uni-manual deficit
• Restraining a child’s non-involved limb– invasive – frustrating– de-motivating
• Children have never learned to use the affected limb
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) 24/05/2010 North West CP Network Meeting HABIT
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
24/05/2010 North West CP Network Meeting HABIT
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 (p<0.)5
in all cases)24/05/2010 North West CP Network Meeting HABIT
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 24/05/2010 North West CP Network Meeting HABIT
24/05/2010 North West CP Network Meeting HABIT
Taken from presentation by Charles & Gordon on webIntensity-based rehabilitation of the upper extremity in children with congenital hemiplegia
HABIT (Charles & Gordon, 2006)
24/05/2010 North West CP Network Meeting HABIT
Future
• Larger, robust, multi-centre RCTs would be needed comparing different strategies
• Boyd et al, 2010 conducting RCT comparing CIMT and BIM training
24/05/2010 North West CP Network Meeting HABIT
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 Nov;48(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 Nov;49(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, 10:4 http://www.biomedcentral.com/1471-2377/10/4
• Neuroplasticity in Children, Mundkur N, Indian Journal of Paediatrics, 2005 72 (10): 855 - 7
24/05/2010 North West CP Network Meeting HABIT
Thank youQuestions?
24/05/2010 North West CP Network Meeting HABIT
NeurogenesisPrenatal• Neurogenesis • Neuronal proliferation • Migration & Aggregation • Axonal growth &
synaptogenesis
24/05/2010 North West CP Network Meeting HABIT
Postnatal• Synaptogenesis and
myelination till 2yrs
Process continues at reduced rate
Synaptic pruning• Dynamic state• Birth – 2500 connections• @15,000 (double the adult
size) at the age of 2yrs• Apoptosis – Pruning
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
24/05/2010 North West CP Network Meeting HABIT
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
24/05/2010 North West CP Network Meeting HABIT
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
24/05/2010 North West CP Network Meeting HABIT
Neuroplasticity
24/05/2010 North West CP Network Meeting HABIT