EFFECT OF PARENT-DELIVERED ACTION OBSERVATION

THERAPY ON
UPPER LIMB FUNCTION IN UNILATERAL CEREBRAL PALSY:
A RANDOMIZED CONTROLLED TRIAL
Emma Kirkpatrick, Janice Pearse, Peter
James, Anna Basu

Presented by :
Novaria Puspita, M.D.

Supervised by :
Arnengsih, M.D., Physiatrist

4th Journal Reading

Wednesday, October 12,
2016

Introduction
Unilateral cerebral palsy (UCP) is the commonest
form of
cerebral palsy (CP), with a prevalence of 0.6 per
1000 live
births
Characteristic
features of hand function in UCP

include weak grasp, reduced speed, loss of fine

motor
skills, and spasticity
Insufficient therapy service provision
for children with disabilities is an internationally
recognized problem
Models of service delivery must
be explored, including family-centred, parentdelivered
approaches to supplement therapist input

Introduction
One such intervention which lends itself to a parent-delivered approach is action
observation (AO) therapy
Few Studies have assessed AO therapy in children with CP
The rationale was that AO primed brain regions involved in movement
production, enhancing the benefits of subsequent movement practice
Children could observe parents modelling the movements, potentially facilitating
motor learning

Objective
Assess the effectiveness of parent-delivered play-based
Action Observation therapy with repeated practice (AO+RP)
versus RP alone
The Author hypothesized that the AO+RP group would show greater
improvements in hand function than the RP group
Assess the overall effectiveness of the home-based playtherapy by combining the AO+RP and RP groups
The Author predicted an improvement between baseline and 3month follow-up, maintained at 6 months

A single-centre
Single-blinded (outcomes assessor) parallel-group
randomized controlled trial (RCT) with 1:1 allocation
The trial was registered and approved by Newcastle &
North Tyneside 2 Research Ethics Committee

Participants
Inclusion Criteria
Children aged 3 to 10 years
with
UCP
predominantly
affecting arm and hand
function were eligible for
inclusion

Exclusion Criteria
Children who were
registered visually impaired
Unable or unwilling to
understand or attempt the
tasks
Children with no active grasp
in the affected hand
Children who were expecting
another intervention or who
had
undergone
an
intervention in the preceding
3 months
Recruitment was through clinicians
based at 10 hospitals in northern
England

Interventions
The intervention was an individualized parent-delivered
home-based play therapy programme
Action Observation and Repeated (AO+RP) and
interventions based on repeated movement practice

RP

The patients were randomized in two groups :

1. The Control (RP) Group
Played independently (with parental supervision)
2. AO+RP Group
Watched a parent perform the movement each time before
attempting it

Interventions
The AO+RP group could observe parental hand movements from an egocentric
viewpoint
The parent was on the side of the child least likely to be affected by visual neglect
or field defects
In both groups parents sat next to the child, facing the same direction, and on
the side of the less-affected hand
Families were provided with :
o Materials for the activities along with individually tailored
o Illustrated instruction booklets emphasizing the desired movements
o The seating instructions and allocation-specific approach
AB explained the approach and demonstrated the activities to parents

Interventio
ns
The intervention lasted 3 months
Parents were asked to deliver five sessions per
week, each lasting 15 minutes
Parents received a therapy diary to document
session details and reward stickers for the children
To enhance compliance and treatment fidelity,
families were telephoned fortnightly for support
AB also undertook a home visit at 6 weeks,
delivering new activities to maintain interest and
motivation
Each child received around 12 tailored activities

OUTCOME MEASURES

Primary

Assisting Hand Assessment

(AHA) : Assessing spontaneous
use (performance) of the
affected hand in bimanual
activities

Secondary
1

Melbourne Assessment 2
(MA2) : Measuring unimanual
capacity

Secondary
2

ABILHAND-Kids questionnaire :
Measuring hand function in activities
of daily living

OUTCOME MEASURES
The Outcome Measure were completed at
baseline, 3 months to assess the effect of
the intervention, and 6 months to assess
maintenance of effects

Participant
Demographic
and Result of
Baseline

The Change in Outcome Measure Scores at 3- And 6Month Follow-up for The AO+RP and RP Groups

DISCUSSION
This Study did not
demonstrate a
significant improvement
in hand function with
AO+RP compared with
RP alone in children age
3 to 10 years with UCP

In contrast to Sgandurra
et al :
Between-group difference
in the changes for AHA
was significant (p=0.008)

Key differences between

these trials include the
setting, dose, and
duration of therapy
and sample size

DISCUSSION
Setting
This Research differs from those previously undertaken in using a parent-delivered, homebased therapy model
Sgandurra et al and Buccino et al : Rehabilitation sessions at Rehabilitation Clinic with
therapies
Monitoring of treatment fidelity is more challenging in this research setting (home-based)
than in a clinic-based environment with therapist delivery

DISCUSSION
Dose and Duration
In this research participants were asked to undertake activities for 15 minutes, five times
per week for 3 months
Novak et al demonstrated improvements on the Quality of Upper Extremity Skills Test
following 4 weeks of a home programme with 4.5 hours of intervention
This research aimed to provide around 15 hours of therapy though small compared
with doses used in intensive approaches such as CIMT and HABIT
HABIT : The intervention was provided on 2wks of weekdays (at least 15 to 20 minutes
per day) at their university then each child in the treatment group went home with an
exercise program that involved bimanual practice for 1 hour, which was extended to 2
hours per day for 1 month after the intervention
Sgandurra et al : duration treatment 60 minutes per session, 15 rehabilitation sessions

DISCUSSION
Sample size
This research sample size was large compared with many studies of interventions
for children with UCP
A post-hoc power calculation based on our collected data 322 participants would
be needed to detect a between-group change difference of five logit-based AHA
units (smallest detectable difference) with 80% power

DISCUSSION
Combined group improvements
This research showed that a low-intensity parent-delivered home
programme of play therapy improves hand function in children with UCP
There is small but significant improvements were observed in the combined
group data in all three outcome measures used
This research approach is accessible and the findings generalizable within
the age group studied

Limitation
This research did not have an additional group receiving no intervention for 6
months, but it would have been difficult to recruit to such a group in the context of
the trial
Need to adding a further baseline test to demonstrate lack of change in the 3
months preceding the intervention, but this would have increased attrition
This research sample was not large enough to analyze the effect of age in response
to therapy intervention in each group

Conclusion
There is no difference in upper limb outcomes between AO+RP therapy and RP
alone for children aged 3 to 10 years with UCP
Low-intensity upper limb therapy can be delivered at home by parents,
incorporated into play for as little as 1 hour per week with a small but sustained
benefit

15.6 %

Yes

Yes, they are, but still need

further research

Assisting Hand Assessment

The Assisting Hand Assessment (AHA) is a hand function evaluation instrument,
which measures and describes how children with an upper limb disability in one
hand use his/her affected hand (assisting hand) collaboratively with the nonaffected hand in bimanual play.
The test is developed for use with children who have a unilateral disability, i.e., who
have one well functioning and one less well functioning hand. Children with
hemiplegic Cerebral Palsy or sequale from obstetric brachial plexus palsy (OBPP)
are appropriate candidates for the AHA
The AHA has the unique perspective of assessing how the child use their two hands
together, in a fun and engaging situation where using two hands is natural. It is the
childs spontaneous and normal way of handling objects when playing that is
assessed, not their best capacity to grasp, release or manipulate objects when
prompted to use their affected hand. This makes the AHA a measure of usual
performance.

Why use the AHA?

The AHA describes how effectively a child actually uses his/her affected hand when it needs to be
used interactively with the well-functioning hand. This information is perhaps the most important
aspect of the child's hand function since this is how two hands need to be used in most day to day
activities. The AHA is the first hand function test with this focus.
The AHA description is twofold; Firstly, it consists of a score giving a measure reflecting how well
the hand is used as an assisting hand. The scale range from 22 points, meaning that the hand is
not used at all, to 88 points meaning that the hand is used effectively, like a normal non-dominant
hand. The score reflects the child's ability to use the affected hand in bimanual performance.
Secondly, the outcome of the AHA provides a textual description of how the child uses the affected
hand. For example, how does the child grasp objects; from the table or from the other hand? How
stably are objects in the hand; do they sometimes slip or are objects of different features
effectively stabilized? How quickly does the child initiate the use of the affected hand; as quickly
as the other hand or only after a delay or only on request? For each of the 22 test items there are
criteria describing object related hand actions. Thus, as well as providing a sum score the AHA also
provides a description, an ability profile, of how the individual child uses the affected hand.

Play is used as the basis for the observation and toys from the AHA test-kit are
presented playfully and without instructions as to which hand to grasp or hold with.
The AHA is performed as an enjoyable, approximately 15 minutes play-session. The
toys in the AHA test kit are attractive and elicit bimanual use. The session is video
recorded and the scoring is done as a second step from viewing the video. This
makes it possible for the play conductor to interact with the child and make the play
session a fun and pleasant experience. The play itself is the focus for the child, the
objects are interesting and exciting and the play conductor can assist, if needed, to
make the performance successful. This makes the test situation attractive to children
and parents, and also to therapists. It also promotes typical use of the two hands.
The AHA test kit consists of a number of specific toys gathered in a children's
suitcase. A detailed manual includes the rationale and the purpose of the test, test
procedures, psychometric properties, scoring criteria and score forms.

AHA
There are three versions of the test:
-Small Kids AHA: The test session consists of play involving handling and exploring
objects from the AHA test kit for children 18 months to 5 years of age.
-School Kids AHA: The same objects are used but in an age appropriate context
using board games for children 6-12 years of age.
-Adolescence AHA : The same objects are used but in an age appropriate context for
children 13-18 years of age

AHA

Melbourne Assessment 2

The Melbourne Assessment 2: a test of unilateral upper limb function is a

validated and reliable tool for evaluating quality of upper limb movement
in children with neurological conditions aged 2.5 to 15 years. For ease of
use the assessment's full title is simplified to The Melbourne Assessment
2 or MA2.
The MA2 is a criterion-referenced test that extends and refines the scale
properties of the original Melbourne Assessment. The MA2 measures four
elements of upper limb movement quality: movement range, accuracy,
dexterity and fluency. It comprises 14 test items of reaching to, grasping,
releasing and manipulating simple objects. Each child's test performance
is videorecorded for subsequent scoring.

Scoring is completed for the 30 item scores using a three, four or five point scale and the
individually defined scoring criteria. Item scores relating to each element of movement
measured are categorised into four corresponding sub-scales. Within each sub-scale item
scores are summed to provide a total score for each of the four elements of movement
quality measured. A child's final score on the MA2 is therefore reported as four separate
scores, one for each element of movement quality measured. Both the test items and scoring
criteria on the MA2 aim to be representative of the most important components of upper limb
function.

Play therapy

Neurophysiological evidence
the mirror-neuron system :
The mirror neuron system is the
system at the basis of imitation in
humans
When individuals observe an
action
done by another individual their
motor
Cortex becomes active, in the
absence of any overt motor
activity
The mirror neuron system is
bilateral
and
includes
large
portion of the parietal and
premotor cortex
Neurons
responding
to
the
observation is the cortex of the
superior temporal sulcus (STS)

Unilateral CP caused by the

damage to the developing
nervous system (motor area
and corticospinal tract)
Corticospinal
tract
motor
pathway from motor area,
notably primary motor cortex,
approaching the spinal cord by
the 20th week of gestation
Corticospinal tract :
Directly
innervates
hand
motorneurons, which provide
the capacity for selective upper
extremity movement control,
damage to this developing
system can permanently impair
manual dexterity