1. HABIT (Hand Arm Bimanual Intensive Therapy) M.S.Rekha SpR Paediatrics

2. Outline Cerebral palsy Embryology and patho-physiology Key issues affecting therapy HABIT Future 24/05/2010North West CP Network MeetingHABIT

3. 24/05/2010North West CP Network MeetingHABIT CP – incidence 1:500 36% Hemiplegic CP UL > LL Impairment – Spasticity, Posturing, Sensation, Reduced strength Intellectual capacity Impact Cerebral Palsy

4. 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 24/05/2010North West CP Network MeetingHABIT

5. 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 24/05/2010North West CP Network MeetingHABIT

6. 24/05/2010North West CP Network MeetingHABIT 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

7. 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) 24/05/2010North West CP Network MeetingHABIT

8. 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 24/05/2010North West CP Network MeetingHABIT

9. 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) 24/05/2010North West CP Network MeetingHABIT

10. 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 24/05/2010North West CP Network MeetingHABIT

11. 24/05/2010North West CP Network MeetingHABIT Taken from presentation by Charles & Gordon on web Intensity-based rehabilitation of the upper extremity in children with congenital hemiplegia

12. HABIT (Charles & Gordon, 2006) 24/05/2010North West CP Network MeetingHABIT

13. Future Larger, robust, multi-centre RCTs would be needed comparing different strategies Boyd et al, 2010 conducting RCT comparing CIMT and BIM training 24/05/2010North West CP Network MeetingHABIT

14. 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/1471-2377/10/4http://www.biomedcentral.com/1471-2377/10/4 Neuroplasticity in Children, Mundkur N, Indian Journal of Paediatrics, 2005 72 (10): 855 - 7 24/05/2010North West CP Network MeetingHABIT

15. Thank you Questions? 24/05/2010North West CP Network MeetingHABIT

16. Neurogenesis Prenatal Neurogenesis Neuronal proliferation Migration & Aggregation Axonal growth & synaptogenesis 24/05/2010North West CP Network MeetingHABIT 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

17. 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 24/05/2010North West CP Network MeetingHABIT

18. 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 24/05/2010North West CP Network MeetingHABIT

19. 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 24/05/2010North West CP Network MeetingHABIT

20. Neuroplasticity 24/05/2010North West CP Network MeetingHABIT