Neuroscience outcomes in an RCT of constraint induced movement therapy versus bimanual training for children with congenital hemiplegia

Neuroscience outcomes in an RCT of constraint induced movement therapy versus bimanual training for children with congenital hemiplegia
R BOYD PHD MSC PT 1.2, R BADAWI2, D ABBOTT2,S LEAANE2,1,3, R GILMORE2, K PROVAN1, J ZIVIANI3,R MACDONNELL2, G JACKSON2.
1Queensland Cerebral Palsy and Rehabilitation Research Centre, University of Queensland, Brisbane, QLD;
2Neurosciences, Brain Research Institute, Melbourne, VIC;
3School of Rehabilitation Sciences, University of Queensland, Brisbane, QLD, Australia

Background/Objectives: To understand the neural mechanisms underlying response to constraint induced movement therapy (CIMT) compared with bimanual therapy (BIM).
Design: Single blind matched pairs randomized comparison trial.
Participants and Setting: Thirty children with congenital hemiplegia (15 pairs) matched for age (mean 10.2 years), gender (15 males) and side of hemiplegia (13 right) were randomly allocated.
Materials/Methods: Each intervention was delivered in a “day camp” for 6 hours/day over 10 days (60 hours). All groups received the same intensity/duration but differing methods. Main outcome measures: 27 children (15 CIMT, 12 BIM, MACs I=5, II=22) completed the structural MRI (including 18 PVL, 11 cortical/deep gray matter, one malformation and one other). On Transcranial magnetic stimulation (TMS) bilateral motor threshold and constructed recruitment curves at 100%, 110%, 120%, 130% and 140% of MT were measured. Whole-brain FMRI studies (3 T) were conducted. Function on Melbourne unilateral upper limb function (MUUL), assisting hand assessment (AHA) and jebsen taylor hand function test (JTHFT) was assessed. Statistical analysis: data were compared between groups at baseline and 3 weeks, 6 months using independent t-tests and within groups over time using paired t-tests (STATA 10.0).
Results: After random allocation, there was no difference between groups on any baseline measure. For BIM group on TMS there were no changes in cortical excitability in either side (impaired/unimpaired MD 0.14/0.7 at 3 weeks, 0.61/0.16 at 6 months, NS). In the CIMT group there were a significant increase in excitability on the impaired motor cortex at f/u compared to the baseline line at the 120%, 130% and 140% intensities (impaired/unimpaired MD 0.06/0.29 at 3 weeks, 0.24/0.38 at 6 months). There were no differences in the normal side . The CIMT group made greater gains on unimanual capacity (MUUL) at 3 weeks and 6 months (MD 4.8 (1.0-8.5; P=0.02). Both groups made significant gains in movement efficiency (JTHFT) by 6 months. Neither group demonstrated gains on bimanual performance (AHA) at 3 weeks or 6 months.
Conclusions/Significance: There is a clear difference between groups on cortical excitability of the impaired motor cortex following an equal dose of training, favouring CIMT. Both groups made significant improvements with movement efficiency (JTHFT) however the CIMT group demonstrated a significant improvement in unimanual capacity (MUUL). Our data suggest that clinicians may wish to tailor their treatment program according to the brain injury (unimanual or bimanual training).

 
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