HABIT
(Hand Arm Bimanual Intensive Therapy)
M.S.Rekha
SpR Paediatrics
Outline
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Cerebral palsy
Embryology and patho-physiology
Key issues affecting therapy
HABIT
Future
24/05/2010
North West CP Network Meeting
HABIT
Cerebral Palsy
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CP – incidence 1:500
36% Hemiplegic CP
UL > LL
Impairment
– Spasticity, Posturing, Sensation, Reduced
strength
• Intellectual capacity
• Impact
24/05/2010
North West CP Network Meeting
HABIT
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
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Synaptogenesis
Cortical Maps
Long term potentiation
Primary areas
Stem cells
North West CP Network Meeting
HABIT
Key issues
• Problems with bimanual coordination > unimanual deficit
• Restraining a child’s non-involved limb
– invasive
– frustrating
– de-motivating
• Children have never learned to use the affected
limb
24/05/2010
North West CP Network Meeting
HABIT
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
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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
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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
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
Taken from presentation by Charles &
Gordon on web
Intensity-based rehabilitation of the
upper extremity in children with
congenital hemiplegia
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North West CP Network Meeting
HABIT
HABIT (Charles & Gordon, 2006)
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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
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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):9316.
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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.
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Systematic Review and Meta-analysis of Therapeutic Management of UpperLimb Dysfunction, Sakzewski et al. Pediatrics.2009; 123: 1111-1122.
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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
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Neuroplasticity in Children, Mundkur N, Indian Journal of Paediatrics, 2005 72
(10): 855 - 7
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North West CP Network Meeting
HABIT
Thank you
Questions?
24/05/2010
North West CP Network Meeting
HABIT
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
• @15,000 (double the adult
size) at the age of 2yrs
• Apoptosis – Pruning
24/05/2010
North West CP Network Meeting
HABIT
Neuroplasticity
• Ability of the brain to constantly reorganise neural
pathways based on new experience and learning
• Ability of brain to change with learning
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Several processes involved
Different types of plasticity at different times
Developmental/Adaptive
Environmental
North West CP Network Meeting
HABIT
Neuroplasticity
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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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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
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• Primary areas not fixed
• Neurogenesis after
damage
North West CP Network Meeting
HABIT
Neuroplasticity
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North West CP Network Meeting
HABIT