Efficacy of a web-based therapy program on occupational performance in children and adolescents with unilateral cerebral palsy

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Background Cerebral palsy (CP) is a group of non-progressive disorders of movement and posture resulting from disturbances to the developing central nervous system. Unilateral CP (UCP), or congenital hemiplegia, is the most prevalent subtype and is characterised by motor impairments lateralised to one side of the body. Due to the motor and associated impairments, individuals with UCP often experience difficulties in occupational performance. Activities of daily living (ADL) are necessary to support participation in occupational roles and enhancing ADL performance is a high priority for children with UCP and their caregivers. Current clinical practice affords children with UCP time-limited therapy, and for this reason interactive computer play has emerged as a feasible, child-active alternative to face-to-face therapy. Evidence to date however is limited to pilot studies and further studies with greater methodological rigour are required. Aim This doctoral program aimed to investigate the effectiveness of a novel, web-based therapy program, “Move it to improve it” (Mitii™), on improving occupational performance in children and adolescents with UCP. The primary objective was to evaluate the effectiveness of Mitii™ compared to standard care on enhancing ADL motor and processing skills, perceived occupational performance, upper limb function and visual perception. Secondary objectives were to (i) systematically review the psychometric properties of ADL measures for school aged children with CP; (ii) establish the reproducibility of the Assessment of Motor and Process Skills (AMPS) in children and adolescents with UCP; (iii) investigate relationships between ADL motor and processing skills, unimanual capacity, bimanual performance and visual perception; and (iv) understand engagement in Mitii™ from the perspective of children and their caregivers. Methods A matched-pairs waitlist control randomised controlled trial was conducted between April 2012 and March 2014 in Brisbane, Australia to investigate the effectiveness of Mitii™ compared to standard care over 20 weeks in children aged 8-18 years with UCP. Participants (n=102) were matched in pairs and randomised to intervention (Mitii™) or waitlist control (standard care). Mitii™ incorporates upper limb, cognitive, visual perception and physical activities and is delivered in the home environment via an internet-connected computer. Virtual therapists create individualised programs and modify modules weekly to provide incremental challenge. Outcomes were assessed at baseline and post-intervention (20 weeks). Primary outcomes were ADL motor and processing skills (AMPS), bimanual performance (Assisting Hand Assessment; AHA), unimanual speed and dexterity (Jebsen Taylor Test of Hand Function; JTTHF) and unimanual capacity (Melbourne Assessment of Unilateral Upper Limb Function; MUUL). Secondary outcomes were perceived occupational performance (Canadian Occupational Performance Model; COPM) and visual perception (Test of Visual Perceptual Skills (non-motor) 3rd edition; TVPS-3). Results A systematic review identified the AMPS as the best available measure of ADL performance for school-aged children with CP, however the test-retest reliability had not been established in this population. A reproducibility study of the AMPS found high test-rest reliability for children with UCP (AMPS motor scale ICC=0.93; AMPS process scale ICC=0.86). Analysis of cross-sectional data revealed that 57% of variance in AMPS motor scale scores were explained by bimanual performance and unimanual capacity of the dominant upper limb. Visual sequential memory, visual closure and dominant upper limb capacity together explained 35% of the variance in AMPS process scale scores. In the RCT, participants in the intervention group completed on average 32.4 hours of Mitii™ (range 3.7-74.7 hours). After 20 weeks, AMPS motor scale scores were 0.28 logits higher in the intervention group than in the control group after adjusting for baseline scores, (95%CI=0.17, 0.39; p=<0.001) and 0.30 logits higher on the AMPS process scale (95%CI=0.19, 0.41; p=<0.001). The Mitii™ group demonstrated statistically significantly higher scores on the JTTHF dominant upper limb, COPM performance and satisfaction scales and TVPS-3 compared to the control group. These differences did not exceed levels of clinical significance. There was no significant difference between groups on the AHA or MUUL, while there was a trend towards an improvement on the JTTHF impaired upper limb (p=0.058). A qualitative study identified key themes relating to client, intervention and service provider characteristics that influenced engagement in the Mitii™ program. The novelty of the program captured children’s interest initially however motivation declined over time. Caregivers desired programs to be ‘finely tuned’ to address individual needs and strong family support was necessary to facilitate engagement. Individual strategies Conclusion In an appropriately powered RCT, Mitii™ led to significant improvements in ADL motor and processing skills, perceived occupational performance and visual perception in children with UCP. Increased speed and dexterity of the dominant upper limb following Mitii™ may reflect improvements in motor planning abilities. Mitii™ offers a web-based multimodal therapy that has potential to increase the therapy dose received by children with UCP and supplement face-to-face therapy. Clinical implementation of Mitii™ will require therapists to consider children’s physical and cognitive abilities, interests, individual goals and available family support to identify suitable participants for this mode of therapy delivery.