HABIT (Hand Arm Bimanual Intensive Therapy)

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 North West CP Network Meeting

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

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 North West CP Network Meeting

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 North West CP Network Meeting

6. 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 North West CP Network Meeting

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) North West CP Network Meeting

8. 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 North West CP Network Meeting

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) North West CP Network Meeting

10. 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 North West CP Network Meeting

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

12. HABIT (Charles & Gordon, 2006) North West CP Network Meeting

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

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/1471-2377/10/4 • Neuroplasticity in Children, Mundkur N, Indian Journal of Paediatrics, 2005 72 (10): 855 - 7 North West CP Network Meeting

15. Thank you Questions? North West CP Network Meeting

16. Neurogenesis 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 Prenatal • Neurogenesis • Neuronal proliferation • Migration & Aggregation • Axonal growth & synaptogenesis North West CP Network Meeting

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 North West CP Network Meeting

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 North West CP Network Meeting

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 North West CP Network Meeting

20. Neuroplasticity North West CP Network Meeting