Upper-limb Therapy Research Articles

Barriers, Facilitators, and a Proposed Model of Care for Implementation of Upper Limb Distributed Practice Approaches for Children with Unilateral Cerebral Palsy

Background/Objectives: There is high-level research evidence supporting task-focused upper limb therapy models for children with unilateral cerebral palsy (CP). However, a knowledge gap exists in understanding how to effectively implement distributed practice approaches in clinical practice and the effect on the development of bimanual performance. This study aims to evaluate clinical outcomes, examine key considerations for implementation outcomes, and propose a Model of Care for children with unilateral CP. Methods: A mixed-methods approach was applied, including a retrospective case series with an observational descriptive design. A convenience sample of nine children (<5 years of age) with unilateral CP who received multiple blocks of distributed, evidence-based upper limb therapy approaches between 2014 and 2020 were included. Outcomes were evaluated using the Assisting Hand Assessment family of assessments. A Model of Care framework was informed by the Updated Consolidated Framework for Implementation Research and the Conceptual Model for Implementation Research. Results: A total of 59 blocks of upper limb therapy (10 mCIMT and 49 bimanual therapy) were delivered, ranging from two to nine blocks (mean = 6.6) for each child. All children demonstrated improved outcomes in bimanual performance with an average change of 14 AHA units (range 1–22). Barriers to implementation included complexity and cost. Facilitators included the evidence base and adaptability of the approaches that allowed clinicians to respond to an individual child and family’s needs. Informed by evidence-based protocols and visual analysis of data, and in consideration of the barriers and/or facilitators to implementation from this study, a Model of Care for implementation of upper limb distributed practice approaches for children with unilateral CP in clinical practice is proposed. Conclusions: Implementing repeated, distributed blocks of evidence-based upper limb therapy in a clinical setting for children with unilateral CP led to incremental improvements in bimanual performance. There are a range of barriers and facilitators to the implementation of distributed practice approaches in clinical practice. The Model of Care outlines best practice care and service delivery for children with unilateral CP and their families and aims to support clinical practice and the future examination of implementation-effectiveness in practice.

Early developmental trajectories of the impaired hand in infants with unilateral cerebral palsy.

To identify developmental trajectories of impaired hand function in infants aged 3 to 15 months with unilateral cerebral palsy (CP). Sixty-three infants (37 male; median gestational age 37 weeks [interquartile range 30-39.1 weeks]) recruited as part of a randomized trial with a confirmed diagnosis of unilateral CP were included. All infants received early upper limb therapy. The Hand Assessment for Infants (HAI) was completed at baseline and until 12 to 15 months corrected age. Group-based trajectory modelling identified groups with similar trajectories of development of impaired hand function. Multinomial logistic regression determined associations between demographic variables and trajectory membership. The three-group trajectory model comprised 'low' 29%, 'moderate' 35%, and 'high' 36% functioning groups. The relative risk ratio of being in the low or moderate relative to high group increased by 16% (95% confidence interval [CI] 1.02-1.32) and 14% (95% CI 1.01-1.29) respectively for each 1 week increase in gestational age. Males were more likely to be in the low relative to high group (relative risk ratio 7.22; 95% CI 1.6-32.5). Three distinct trajectories of development of the impaired hand were identified. Males and infants born closer to term age were at higher risk of being in a low group with little improvement over time, despite receiving early intervention.

Robot-assisted upper limb therapy for personalized rehabilitation in children with cerebral palsy: a systematic review.

Cerebral palsy (CP) is a group of permanent disorders of movement development that may cause activity limitations. In this context, robot-assisted therapy might play a key role in clinical management. This comprehensive systematic review aimed to investigate the efficacy of robotic systems in improving upper limb (UL) functions in children with CP. PubMed, EMBASE, Scopus, and PEDro were searched from inception to February 2024. The risk of bias was assessed with the Joanna Briggs Institute critical appraisal tools battery. Of 756 articles identified, 14 studies involving 193 children with CP with a judged to be of good methodological quality, but with a lack in the study design, were included in the final synthesis. In the included studies a wide range of devices was used, both exoskeletons and end-effectors, both wearable and non-wearable. The CP children who underwent robot-assisted therapy reported a significant overall increase in clinical assessment, specifically in UL movements and manual dexterity. The clinical improvement was often accompanied by a gain also in instrumental assessments (i.e., kinematic analysis, EMG). The present review suggested that robot-assisted therapy can improve UL motor functions in children with CP. Moreover, the availability of different devices with adjustable parameters can represent an important resource in proposing patient-centered-personalized rehabilitation protocols to enhance the efficacy of rehabilitation and integration into daily life. However, the limited sample size and lack of standardized and clearly reproducible protocols impose to recommend the use of robot-assisted therapy as an integration to usual rehabilitation and not as a replacement. https://osf.io/a78zb/.

Upper Limb Therapy for Infants and Young Children with Unilateral Cerebral Palsy: A Clinical Framework.

Early detection and rehabilitation interventions are essential to optimise motor function in infants and young children with unilateral cerebral palsy. In this paper we report a clinical framework aimed at enhancing upper limb therapy for infants and young children with unilateral cerebral palsy during a sensitive period of brain development. We describe two major therapeutic approaches based on motor learning principles and evidence: constraint-induced movement therapy and bimanual therapy. These two therapies have demonstrated efficacy in older children and emerging evidence is available for their application to infants younger than 2 years of age. To provide clinicians with guidance as to when to implement these therapies, we discuss the key consideration when undertaking upper limb therapy programs. In addition, we describe the factors to consider when choosing which approach may be suitable for an individual child and family. Detailed strategies for implementing these therapies in infants and young children of different ability levels are given.

Impact of Intensive Upper Limb Therapy on School Readiness Skills in Preschool Children With Unilateral Cerebral Palsy

Abstract Date Presented 03/23/24 Engagement in high-intensity, motor-based therapeutic activity is associated with improvements in school readiness for preschool-age children with unilateral cerebral palsy with or without the inclusion of cognitive development skill training. Primary Author and Speaker: Angela Shierk Additional Authors and Speakers: Heather Roberts Contributing Authors: Fabiola Reyes, Nancy Clegg, Mauricio R. Delgado, Emily Kirby, Lindsay Miles, Rebecca Dharamraj, Ariel Alexander, Joe De La Torre

Caregiver Perceptions & Ability to Implement an Intensive Upper Limb Therapy Program in the Home Environment

Abstract Date Presented 03/22/24 Intensive therapies may put an extra burden on caregivers. Participants who engaged in longer onsite sessions successfully completed the program hours leading to clinically significant differences in occupational performance. Primary Author and Speaker: Heather Roberts Additional Authors and Speakers: Angela Shierk, Brenna Merrilat Contributing Authors: Briana Arellano, Marcus Fagan, Nancy Clegg, Deborah Baldwin, Fabiola Reyes, Mauricio R. Delgado

Family expectations and demand for home-based videogaming therapy in children with cerebral palsy in Costa Rica: a mixed methods study

Purpose To understand the expectations and demand for a movement-tracking videogame (Bootle Blast) for home-based, upper limb (UL) rehabilitation among Costa Rican children with cerebral palsy (CP). Methods Data were collected via telephone screening (demand) and child-parent dyads Zoom interviews (expectations). Descriptive statistics and data transformation were used to report on demand success criteria (i.e., recruitment rate, having an appropriate screen and space to play, setting a weekly play time goal (PTG) ≥45 min, identifying one UL therapy goal). The DEPICT model for collaborative qualitative analysis was used in the thematic analysis of interview data. Results Fifteen dyads participated (1.6 ± 1 recruited/month). All had a flat-screen TV in a suitable location to play, were able to set a UL therapy goal, and established PTGs ranging from 45–120 min per week. Identified themes were: 1) Socio-cultural factors heighten demand, 2) Feelings of hope prevail for the intervention, and 3) Collaborative goal setting supports realistic expectations for Bootle Blast. Conclusions Dyads had positive and realistic expectations about implementing the proposed videogaming intervention. This study provides insights on tailoring a family-centered, therapy gaming intervention to improve access to motor rehabilitation for children with CP in rural/remote settings and low-middle income countries.

Music Upper Limb Therapy – Integrated (MULT-I) supports a positive transformation in sense of self post stroke: a thematic analysis

Purpose To understand how the experience of Music Upper Limb Therapy – Integrated (MULT-I) interconnects with the experience of stroke. Methods Thematic analysis of semi-structured interviews and video-recorded MULT-I sessions from a larger mixed-methods study. Thirty adults with post-stroke hemiparesis completed pre-intervention interviews, of whom fifteen participated in MULT-I. Thirteen of the participants in MULT-I completed post-intervention interviews. Results The experience of stroke was characterized by five themes: (1) sudden loss of functional abilities, (2) disrupted participation, (3) desire for independence, (4) emotional distress and the need for support, and (5) difficulty negotiating changes in sense of self. The experience of MULT-I was characterized by three themes: (1) MULT-I activated movement and empowered personal choice, (2) MULT-I created a safe place to process emotional distress and take on challenges, and (3) MULT-I fostered a sense of belonging and a positive transformation in sense of self. These themes combined create a framework which illustrates the process by which MULT-I addressed each challenge described by survivors of stroke, facilitating a positive transformation in sense of self. Conclusion MULT-I promotes physical, emotional, and social wellbeing following a stroke. This integrated approach supports a positive transformation in sense of self. These findings have implications for improving psychosocial well-being post stroke.

Does somatosensory discrimination therapy alter sensorimotor upper limb function differently compared to motor therapy in children and adolescents with unilateral cerebral palsy: study protocol for a randomized controlled trial

BackgroundBesides motor impairments, up to 90% of the children and adolescents with unilateral cerebral palsy (uCP) present with somatosensory impairments in the upper limb. As somatosensory information is of utmost importance for coordinated movements and motor learning, somatosensory impairments can further compromise the effective use of the impaired upper limb in daily life activities. Yet, intervention approaches specifically designated to target these somatosensory impairments are insufficiently investigated in children and adolescents with uCP. Therefore, the aim of this randomized controlled trial (RCT) is to compare the effectiveness of somatosensory discrimination therapy and dose-matched motor therapy to improve sensorimotor upper limb function in children and adolescents with uCP, who experience somatosensory impairments in the upper limb. We will further explore potential behavioral and neurological predictors of therapy response.MethodsA parallel group, evaluator-blinded, phase-II, single-center RCT will be conducted for which 50 children and adolescents with uCP, aged 7 to 15 years, will be recruited. Participants will be randomized to receive 3 weekly sessions of 45 minutes of either somatosensory discrimination therapy or upper limb motor therapy for a period of 8 weeks. Stratification will be performed based on age, manual ability, and severity of tactile impairment at baseline. Sensorimotor upper limb function will be evaluated at baseline, immediately after the intervention and after 6 months follow-up. The primary outcome measure will be bimanual performance as measured with the Assisting Hand Assessment. Secondary outcomes include a comprehensive test battery to objectify somatosensory function and measures of bimanual coordination, unimanual motor function, and goal attainment. Brain imaging will be performed at baseline to investigate structural brain lesion characteristics and structural connectivity of the white matter tracts.DiscussionThis protocol describes the design of an RCT comparing the effectiveness of somatosensory discrimination therapy and dose-matched motor therapy to improve sensorimotor upper limb function in children and adolescents with uCP. The results of this study may aid in the selection of the most effective upper limb therapy, specifically for children and adolescents with tactile impairments.Trial registrationClinicalTrials.gov (NCT06006065). Registered on August 8, 2023.

Development and content validation of the Upper Limb-Motor Learning Strategy Tool for cerebral palsy

Purpose To describe the development and content validation of the Upper Limb-Motor Learning Strategy Tool (UL-MLST) that aims to guide clinicians on how to implement and document the motor learning strategies used in the upper limb therapy approaches for children with cerebral palsy. Methods The study consists of two main stages (1) item generation and development and (2) content validation and refinement. The UL-MLST Online Training Program, Manual and Checklist were developed by the authorship group in stage one. In stage 2, two experts evaluated the UL-MLST regarding the Relevance, Coherence, and Significance of the individual strategies and whether the tool is Relevant, Comprehensive, and Clinically useful. Results Of sixty-two strategies included in the UL-MLST, 52 strategies were rated as being either “Moderately” or “Highly” Relevant, Coherent, and Significant. Ten strategies did not achieve mutual agreement; however, they did not meet the criteria for deletion and were revised according to expert feedback. Overall, the UL-MST was judged to be Relevant, Comprehensive, and Clinically useful. Conclusions The UL-MLST provides a valid tool to support clinicians in the implementation of the motor learning strategies for children with cerebral palsy. IMPLICATIONS FOR REHABILITATION The Upper Limb- Motor Learning Strategy Tool (UL-MLST) Online Training Program, Manual, and Checklist provide a comprehensive package of resources to support the application of motor learning strategies in upper limb therapy for children with cerebral palsy. The UL-MLST provides clinicians with a valid tool for self-appraising the implementation of motor learning-based therapies. The tool has the potential to improve fidelity, enhance the quality, and ensure consistency of evidence-based, task-focused approaches of therapy.

Impact of Visual Feedback Configurations in a Task-Oriented Immersive Virtual Reality Mirror Therapy.

Mirror Therapy is a form of upper limb therapy in stroke, which consists on showing the mirrored symmetric movement of the unimpaired side using a mirror placed in the medial sagittal plane. The illusion of movement corresponding to the impaired extremity could facilitate neuroplasticity, and assists patients in regaining certain lost motor functions. Recent studies have shown the potential and benefit of translating this effective therapy in an immersive virtual reality (VR) environment, using head mounted display and hand tracking systems. This work investigates the feasibility to use myoelectric control in an immersive VR environment for the mirror therapy to accomplish a funtional task. Surface electromyography sensors were used to measure muscle activation and detect user intention to perform grasping actions in two visual feedback configurations: unimanual and bimanual. Even though in both conditions the virtual mirrored hand is controlled by the healthy hand, the latter creates the illusion that two functional hands cooperate for grasping. A total of 18 healthy subjects participated in the evaluation of the environment, control method and a comparison between the two configurations. This includes self-rating surveys and performance metrics. Results from the Simulator Sickness Questionnaire showed negligible adverse symptoms related to the use of the VR-application proposed. Positive outcomes from the System Usability Scale and Presence Questionnaire affirmed its feasible as a form of therapy for the rehabilitation of hemiparetic stroke patients. Although the adapted Box and Blocks Test proved immediate training-induced learning, performance measures revealed no significant distinctions between visual feedback configurations.

Technology-Assisted Upper Limb Therapy (TAULT): Evaluation of Clinical Practice at a Specialised Centre for Spinal Cord Injury in Switzerland

(1) Improving upper limb function is essential for people with tetraplegia. Although promising, technology-assisted upper limb training is understudied in this population. This article describes its implementation in a Swiss spinal cord injury rehabilitation centre and reports on the observed changes. (2) A retrospective evaluation of clinical data from January 2018 to June 2020 examined patient characteristics, training parameters, goal-setting practices, goal achievement, and changes in muscle strength over the course of technology-assisted upper limb training. (3) Data analysis included 61 individuals, 68.9% of whom had a spinal cord injury. The ArmeoSpring was the most frequently used device. The typical treatment regimen was three 25 min sessions per week, with evaluations approximately every six weeks. The 1:1 sessions, delivered by specialised staff, focused primarily on improving shoulder movement and the ability to eat and drink. Functional goals were set using a grid. Performance on selected goals in the areas of ‘body functions’ and ‘activities & participation’ as well as muscle strength, increased over the course of training. (4) The ArmeoSpring has broad applicability. Despite the observed improvements, the isolated effect of technology-assisted upper limb training cannot be concluded due to the lack of a control group and various concurrent interventions.

304 Increasing the intensity of physiotherapy in a subacute stroke rehabilitation unit—results of audit and intervention

Abstract Background The National Clinical Guideline for Stroke (2023) recommend the delivery of high intensity therapy to optimise physical recovery post-stroke. Previous guidelines suggested 45 minutes but now suggest a total of 3 hours daily. The aim of this intervention was to review current practice and implement the stroke guidelines aiming to augment the dosage of therapy sessions. Methods Given the guidelines’ recommendation to improve the reporting of exercise prescription, a chart audit was completed comparing the dosage of physiotherapy from 2020–2022 on a random sample of 10 charts per year. Strategies to increase intensity included a restructure of the stroke exercise class, run twice weekly. The class structure moved towards a circuit class of 5x 6-minute stations followed by group outdoor mobility. Use of tally counters, increased semi-supervised practice and introduction of a ‘champions board’ to celebrate individuals’ achievements also contributed to a culture of high intensity therapy. Results The chart audit showed an improvement in the recording of repetitions each year. The average recorded repetitions per week for stroke survivors increased from 77.9 repetitions in 2020 to a weekly average of 1,043 in 2022 (2020 range 0–288 repetitions; 2022 range 245–2095 repetitions). The average repetitions in the stroke exercise class in 2022 was 462 and was previously not measured. A review of annual patient statistics from 2021 and 2022 showed that stroke survivors spent more time in physiotherapy in 2022. This was likely affected by variables such as staffing allocation and COVID-19 restrictions limiting the ability to provide gym-based therapy or group classes. Conclusion The measurement and recording of intensity has improved and increased in 2022 although this may have been affected by factors outside of this intervention. Future iterations of this project would be to increase dosage of upper limb therapy, and to increase physical activity outside therapy, such as use of pedometers outside therapy hours.

Continuous Theta-Burst Stimulation of the Contralesional Primary Motor Cortex for Promotion of Upper Limb Recovery After Stroke: A Randomized Controlled Trial.

Despite improvements in acute stroke therapies and rehabilitation strategies, many stroke patients are left with long-term upper limb motor impairment. We assessed whether an inhibitory repetitive transcranial magnetic stimulation treatment paradigm started within 3 weeks after stroke onset promotes upper limb motor recovery. We performed a single-center randomized, sham-controlled clinical trial. Patients with ischemic stroke or intracerebral hemorrhage and unilateral upper limb motor impairment were randomized to 10 daily sessions of active or sham continuous theta-burst stimulation (cTBS) of the contralesional primary motor cortex combined with standard upper limb therapy, started within 3 weeks after stroke onset. The primary outcome was the change in the Action Research Arm Test score from baseline (pretreatment) at 3 months after stroke. Secondary outcomes included the score on the modified Rankin Scale at 3 months and the length of stay at the rehabilitation center. Statistical analyses were performed using mixed models for repeated measures. We enrolled 60 patients between April 2017 and February 2021, of whom 29 were randomized to active cTBS and 31 to sham cTBS. One patient randomized to active cTBS withdrew consent before the intervention and was excluded from the analyses. The mean difference in the change in Action Research Arm Test score from baseline at 3 months poststroke was 9.6 points ([95% CI, 1.2-17.9]; P=0.0244) in favor of active cTBS. Active cTBS was associated with better scores on the modified Rankin Scale at 3 months (OR, 0.2 [95% CI, 0.1-0.8]; P=0.0225) and with an 18 days shorter length of stay at the rehabilitation center than sham cTBS ([95% CI, 0.0-36.4]; P=0.0494). There were no serious adverse events. Ten daily sessions of cTBS of the contralesional primary motor cortex combined with upper limb training, started within 3 weeks after stroke onset, promote recovery of the upper limb, reduce disability and dependence and leads to earlier discharge from the rehabilitation center. URL: https://trialsearch.who.int/; Unique identifier: NTR6133.

Comparative Effectiveness of Upper Limb Exercise Interventions in Individuals With Stroke: A Network Meta-Analysis.

Although numerous effective exercise interventions can treat upper limb motor impairments after stroke, it remains unknown as to which are the most effective. The objective of the present study was to investigate the comparative effectiveness of various exercise interventions of the upper limb for individuals with an acute or subacute stroke. For this systematic review with network meta-analysis, we searched PubMed/MEDLINE, Cochrane Library CENTRAL and Web of Science from database inception to September 2021 for randomized controlled trials examining individuals within 6 months of stroke onset, active upper limb exercise interventions, and any kind of control intervention. The primary outcome was upper limb motor function, secondary outcomes were activities of daily living and social participation, both assessed at post-intervention and follow-up. Nonspecific/multimodal active upper limb therapy was the standard comparator. Standardized mean differences, that is, Hedge's g, were the effect size estimators. We calculated Frequentist-based network meta-analysis for the comparative effectiveness calculations using the R package netmeta. Main analyses were network plotting to display the geometry of the network and P-scores to summarize the intervention hierarchy. Results were derived from direct within-study and indirect between-study evidence comparisons. The Cochrane risk-of-bias tool II assessed all risk of bias domains. This review involved 145 randomized controlled trial on 6432 participants and 45 different treatment categories. The network meta-analysis analyzed 119 randomized controlled trials on 5553 participants and 41 different treatment categories. Electrical stimulation combined with task-specific training (standardized mean difference, 1.03 [95% CI, 0.51-1.55]; P<0.0001, P-score=0.11), high-volume constraint-induced movement therapy (0.86 [0.4-1.32]; P=0.0003, P-score=0.18), and strength training (0.65 [0.17-1.13]; P=0.01, P-score=0.28) were the most effective interventions (each k=107). Electrical stimulation combined with task-specific training (low evidence), high-volume constraint-induced movement therapy (moderate evidence), and strength training (low evidence) were the most effective interventions in improving upper limb motor function in individuals with a stroke. As the results were sensitive against a high risk of bias, likewise, these interventions should receive more attention in research and practice. Due to the heterogeneous use, electrical stimulation in combination with task-specific training should be further investigated in well-designed studies alongside other successful interventions (eg, constraint-induced movement therapy). URL: https://www.crd.york.ac.uk/prospero/; Unique identifier: CRD42021284064.

Detecting Movement Changes in Children with Hemiparesis after Upper Limb Therapies: A Responsiveness Analysis of a 3D Bimanual Protocol.

The "Be an Airplane Pilot" (BE API) protocol was developed to evaluate upper limb (UL) kinematics in children with unilateral cerebral palsy (uCP) during bimanual tasks. The aim of this study was to investigate the responsiveness of this protocol to changes in kinematics and movement quality after UL therapies, using individual and group analyses, and to analyse the relationships between kinematic and functional changes in these children. Twenty children with uCP (5-15 years old) either participated in bimanual intensive therapy or received UL botulinum toxin injections. All the children performed the BE API protocol and functional assessments (Assisting Hand Assessment [AHA]) before and after the interventions. The individual analyses found kinematic changes in 100% of the children after therapy. The group analysis found significantly higher trunk and shoulder deviations after the intensive therapy. No significant changes were found for smoothness or trajectory straightness. The changes in the kinematic deviations were moderately correlated with the changes in the AHA scores. This study confirmed the responsiveness of the BE API protocol to change after therapy; therefore, the protocol is now fully validated and can be implemented in clinical practice. Its use should help in the accurate identification of impairments so that individualized treatments can be proposed.

Interpreting the CPASS Trial: Do Not Shift Motor Therapy to the Subacute Phase

The Critical Periods After Stroke Study (CPASS, n = 72) showed that, compared to controls, an additional 20 hours of intensive upper limb therapy led to variable gains on the Action Research Arm Test depending on when therapy was started post-stroke: the subacute group (2-3 months) improved beyond the minimal clinically important difference and the acute group (0-1 month) showed smaller but statistically significant improvement, but the chronic group (6-9 months) did not demonstrate improvement that reached significance. Some have misinterpreted CPASS results to indicate that all inpatient motor therapy should be shifted to outpatient therapy delivered 2 to 3 months post-stroke. Instead, however, CPASS argues for a large dose of motor therapy delivered continuously and cumulatively during the acute and subacute phases. When interpreting trials like CPASS, one must consider the substantial dose of early usual customary care (UCC) motor therapy that all participants received. CPASS participants averaged 27.9 hours of UCC occupational therapy (OT) during the first 2 months and 9.8 hours of UCC OT during the third and fourth months post-stroke. Any recovery experienced would therefore result not just from CPASS intensive motor therapy but the combined effects of experimental therapy plus UCC. Statistical limitations also did not allow direct comparisons of the acute and subacute group outcomes in CPASS. Instead of shifting inpatient therapy hours to the subacute phase, CPASS argues for preserving inpatient UCC. We also recommend conducting multi-site dosing trials to determine whether additional intensive motor therapy delivered in the first 2 to 3 months following inpatient rehabilitation can further improve outcomes.

Wrist-Worn devices to encourage affected upper limb movement in unilateral cerebral palsy: Participatory design workshops.

Unilateral (Hemiplegic) cerebral palsy (UCP) causes weakness and stiffness affecting one sided of the body, often impacting activities of daily living. Upper limb therapy at effective intensity is not accessible to most. To determine stakeholder views on design of an approach using wrist-worn devices and a smartphone application to encourage use of the affected upper limb for children with hemiplegia. Four participatory design workshops and one young people's advisory group workshop incorporating views of five young people with hemiplegia, 13 typically developing peers aged 8-18 years, four parents, three occupational therapists, one teacher and two paediatricians. Two special educational needs co-ordinators were consulted separately. Peers were included to explore a study design whereby each child with hemiplegia would have a participating "buddy". Topics included views on an acceptable wrist-worn device and smartphone application, participant age range, involvement of a buddy, and barriers to using the technology in a school setting. Ethical/welfare considerations included data security, and potential risks around providing smartphones to young children. Children wanted a comfortable, conventional-appearing wristband incorporating a watch face and a secure, well-fitting strap. They were prepared to wear a band on each wrist. They wanted support with explaining the study to schoolteachers. Most schools restricted smartphone use during the school day: the study design accommodated this. Children agreed with a game as reward but had different views on an acceptable game; direct access to feedback data was preferred by some. Parents commented on the lack of access to upper limb therapy for children with UCP; therapists concurred. The proposed participant age range was widened based on feedback. Typically developing children were prepared to be buddies to help a friend with CP. Stakeholders were reassured by data security explanations and plans to provide internet safety information to participants. The participatory design process informed plans for the proof-of-concept stage of the study, hopefully leading to an approach that will be fun, easy to integrate into everyday life, and have the capacity to increase use of the affected arm and hand.

A 3D bimanual protocol to detect changes induced by intensive upper limb therapy in children with unilateral cerebral palsy

A 3D bimanual protocol to detect changes induced by intensive upper limb therapy in children with unilateral cerebral palsy

Automatic and Personalized Adaptation of Therapy Parameters for Unsupervised Robot-Assisted Rehabilitation: a Pilot Evaluation.

Growing evidence shows that increasing the dose of upper limb therapy after stroke might improve functional outcomes and unsupervised robot-assisted therapy may be a solution to achieve such an increase without adding workload on therapists. However, most of existing robotic devices still need frequent supervision by trained personnel and are currently not designed or ready for unsupervised use. One reason for this is that most rehabilitation devices are not capable of delivering and adapting personalized therapy without external intervention. Here we present a set of clinically-inspired algorithms that automatically adapt therapy parameters in a personalized way and guide the course of robot-assisted therapy sessions. We implemented these algorithms on a robotic device for hand rehabilitation and tested them in a pilot study with 5 subacute stroke subjects over 10 robot-assisted therapy sessions, some of which unsupervised. Results show that our algorithms could adapt the therapy difficulty throughout the whole study without requiring external intervention, maintaining performance around a predefined 70% target value (mean performance for all the subjects over all the sessions: 64.5%). Moreover, the algorithms could guide patients through the therapy sessions, minimizing the number of actions that subjects had to learn and perform. These results open the door to the use of robotic devices in an unsupervised setting to increase therapy dose after stroke.