Comparative Evaluation of Hand-Arm Bimanual Intensive Therapy and Mental Imagery in Cerebral Palsy: A Study of Efficacy in Clinic-Based and Telerehabilitation Settings

INTRODUCTION

Cerebral palsy (CP) is the most common motor disability in children.^[1] It is one of the leading causes of disability in children worldwide.^[2] Research has shown that deficits in motor behaviour cause activity limitations in CP, leading to slow, inefficient, and sequential behaviour.^[3,4] Rehabilitation programmes that target motor behaviour and provide functional task settings can benefit CP individuals.^[5,6] Therapy involving bimanual extremity involvement can facilitate motor planning and involve the upper extremity from the non-involved limb.^[7,8]

Hand-arm bimanual intensive therapy (HABIT) involves training of bilateral hands, which helps in improving bimanual coordination, functional independence, and the ability to perform activities of daily living.^[9] HABIT prioritises hand-bimanual coordination skills while maintaining the focused effectiveness of constraint therapy based on the principles of motor learning and neuroplasticity. The practice involving bimanual activities is divided into two parts, i.e., part-task and whole-task. The whole-task practice involves performing continuously for 15-20 minutes, while part-task practice involves focusing on targeted movements exclusive of other movements. It is similar to “shaping” in psychology. For example, in flipping a card, the movement will be focused on pronation and supination.^[9] Many daily activities necessitate the hands to perform multiple movements in a coordinated manner at the same time.

Mental imagery (MI) is concerned with the presentation of self in action. It involves experiencing oneself performing a specific action, whether involving the entire body or only a portion of it.^[10] The use of MI training with arm immobilisation may help in limiting the negative effects of arm disuse.^[10]

Telehealth is an alternative approach to rehabilitation models that incorporates modern tools such as digital practice. It includes telerehabilitation, which is a system that utilises telecommunication to monitor and support remote rehabilitation, aiming to improve access and adherence to treatment.^[11]

This article discusses the results of an experimental study that investigated the use of telerehabilitation for individuals with CP who underwent HABIT and MI training. The study compared the outcomes of telerehabilitation with in-person clinic-based rehabilitation, focusing on enhancing hand function, attention, and memory.

MATERIAL AND METHODS

The study was designed as an experiment type involving unilateral spastic cerebral palsy (USCP) patients between the age of 5-15 years, including both males and females. Data were collected from clinics in New Delhi, India. Using a convenient sampling method, 40 patients were selected and divided randomly into two groups of n=20 each, using a coin method (coin method of randomisation used through flipping a coin, i.e. heads for HABIT group and tails for MI group) and all the participants have an equal chance of participating in HABIT and MI groups, as shown in Figure 1. Each group was further divided into two sub-groups of, telerehabilitation and clinical-based, with n=10 patients in each.

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Figure 1:

Enrolment of participants. HABIT: Hand arm bimanual intensive therapy.

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Inclusion criteria were limited to hemiplegic CP children/ USCP, aged 5-15 years, with gross motor function classification system (GMFCS) Level II to IV, manual ability classification system (MACS) Level II to III, both males and females, ability to follow verbal and visual instructions, normal working memory, using digit span test, and who gives informed consent from parents. Participants were excluded if they had quadriplegic, diplegic, and paraplegic CP, auditory or non-corrected visual problems, orthopaedic surgery, botulinum neurotoxin in the upper limb in the last 6 months, other associated disorders, such as hydrocephalus, autism, microcephalus, severe mental retardation, or were unable to follow instructions.

As such, 48 children were assessed for eligibility, of which 8 were excluded. Five of them did not have the internet access required for the telerehabilitation protocol, and three were unable to fulfil the inclusion criteria, as shown in Figure 1. Children with hemiplegic CP were recruited from a paediatric clinical rehabilitation set-up located in New Delhi, India. MI was assessed using the Mental Rotation task. The task includes pictures of rotated hands shown on a screen, and participants make a laterality judgment by telling if it is a right hand or left hand, as quickly as possible, as shown in Figure 2. The ability to correctly answer the mental rotation task assessed their eligibility to be a part of the MI group.^[12]

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Figure 2:

Different positions of hand for the mental rotation task.

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This study was approved by the NTCC ethical committee of Amity Institute of Physiotherapy, Amity University, before patient recruitment. The trial has been registered in the Clinical Trial Registry of India (CTRI), with registration number- CTRI/2022/02/040105.

Procedure

A total of 40 subjects were recruited for the study. An informed consent form was given to all the parents, and the purpose of the study was explained. Participants were divided into two groups. Group A (n=20) HABIT training, Group B (n=20) MI training. Two subgroups were created under both groups A and B, i.e., Group Ai (n=10) Telerehabilitation and Aii (n=10) clinic-based training, Group Bi (n=10) Telerehabilitation and Bii (n=10) clinic-based training. These tasks are based on the physical execution and sensorial feedback of practice, activating different neural networks involved in executed and imagined movement.^[14] Participants allocated in both groups received training thrice a week for four consecutive weeks with an average of 50-55 minutes per session. Baseline data were collected before the treatment was initiated in the clinic for all the groups.

For telerehabilitation training, children in telerehabilitation groups, i.e., Ai (HABIT) and Bi (MI), received training sitting comfortably at their homes. Tele-rehabilitation was conducted on an online platform, either on Zoom or Google Meet, whichever was more suitable for the participants.

In Group Ai: HABIT via Telerehabilitation: The HABIT protocol was set as per the MACS level, with whole task and part task activities. Children were taught to use both hands while performing activities, and hence, the use of bilateral upper extremities was encouraged.^[15] Parents/caregivers were attentive throughout the session and helped children with the performance of activities. The therapist was online during the session with the participants and guided them throughout the session.

Activities provided to children included reaching with both hands, followed by bringing each hand towards the midline presented with objects, reaching first with 45 degrees and then 90 degrees of shoulder flexion, elbow extension and forearm supination and pronation, use of bilateral hands to push, lift and carry large objects/toys to encourage elbow extension, throwing and catching ball using both hands, releasing toys/objects in a container, passing onto objects from one hand to another, using the vestibular ball, prone on ball and performing reaching activities, weight bearing on textured surfaces, examples sand, grass, and small pebble. Children were taught object manipulation, like opening and closing a nut and bolt, spoon handling and transferring, tying and untying a rope, stacking coins, and flipping cards. Hand manipulation activities also included clapping and tapping, folding clothes, buttoning and unbuttoning, opening and closing the zip, twisting the lid of the jar, and using a lock and key.

Group Bi: MI via Telerehabilitation: MI in children was assessed using a mental rotation task on the first day of baseline recordings. For telerehabilitation, the screen was shared online, showing a model performing activities, which was recorded in the department under the therapist’s supervision. The participants were instructed to watch the videos attentively, concentrating on the activities. In the video, the model performed activities related to the upper extremities similar to activities provided in group A, such as picking up objects, drinking water, colouring, writing, and wearing a mask. No other therapeutic intervention was provided after that.^[12] After this observation period, the participants were asked to repeat the activity mentally. The actions were presented in a fixed order according to their complexity.^[16] Each mental trial was repeated five times.

For Clinical-Based Training: Group Aii HABIT via Clinic-based training: Protocol was similar to group Ai, with the only difference being of mode of delivery of the intervention. The therapist helped the child with the required instructions at every stage. Activities were similar in both groups, as shown in Figure 3a, b, and c.

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Figure 3:

(a), (b), and (c) show the bilateral task of the HABIT intervention in the clinical settings. HABIT: Hand-Arm Bimanual Intensive Therapy.

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Group Bii MI training group: Throughout the training, children receiving MI in the clinic were comfortably seated on a chair or a mat at a distance of 50 cm from the laptop/tab screen. The same video was used as in the telerehabilitation, and the procedure was repeated similarly.

RESULTS

The results of interventions aimed at improving hand function, attention, and working memory in children with CP. The interventions were performed either through clinical-based training or telerehabilitation, and they included HABIT and MI.

Clinic-based HABIT training showed significant improvement in working memory (p=0.001) and attention (p=0.000) after practised an average of 50-55 minutes per session, thrice a week, for four consecutive weeks, as described in Table 1.

Clinic-based HABIT training also showed significant changes in page-turning with both dominant (0.002) and non-dominant hands (0.03), lifting of small and large objects with both hands, feeding, and stacking checkers with non-dominant hands (p<0.05), as shown in Figure 4.

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Figure 4:

Mean and SD of JTHFT of HABIT+C Group. SD: Standard deviation, JTHFT: Jebsen-Taylor hand function test. HABIT+C: Hand-arm bimanual intensive therapy (Clinical-based)

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MI clinic-based intervention resulted in significant improvements in the total score of attention (p=0.000) as shown in Table 2, and no significant changes were seen in the impact score of attention and working memory.

Clinical-based MI also shows significant changes in writing, page-turning with both dominant, lifting of small and large objects, feeding, and stacking checkers with both hands (p<0.05), as shown in Figure 5.

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Figure 5:

Mean and SD of JTHFT of MI+C Group. SD: Standard deviation, JTHFT: Jebsen-Taylor hand function test, MI: Mental imagery.

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Tele-rehabilitation-based HABIT intervention resulted in significant improvements in the total score of attention (p=0.013), as shown in Table 3, and no significant changes were seen in the impact score of attention and working memory.

Telerehabilitation HABIT training also showed significant changes in page-turning with both dominant (0.002) and non-dominant hands (0.03), lifting of small and large objects with both hands, feeding, and stacking checker with non-dominant hands (p<0.05) as shown in Figure 6.

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Figure 6:

Mean and SD of JTHFT of HABIT + T Group. SD: Standard deviation, HABIT+T: Hand-arm bimanual intensive therapy (Telerehabilitation), JTHFT: Jebsen-Taylor hand function test.

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Telerehabilitation-based MI training showed significant improvements in total score of attention (p=0.003), page-turning with both hands, lifting small objects with the dominant hand, feeding with both hands, stacking checkers with the dominant hand, and lifting large light and heavy objects with both hands, as shown in Figure 7.

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Figure 7:

Mean and SD of JTHFT of MI+ T Group. SD: Standard deviation, MI+ T: Mental imagery (Telerehabilitation), JTHFT: Jebsen-Taylor hand function test.

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Based on the results, it was concluded that clinic-based HABIT training is the only intervention that improved working memory in addition to attention and other hand functions. Telerehabilitation-based HABIT intervention improved attention and writing, along with other hand functions. Clinic-based MI training improved writing, attention, and other hand functions, mainly of the non-dominant hand. Finally, the results suggest that all four interventions can be used to improve attention, working memory, and hand function in children with CP.

DISCUSSION

This study aimed to determine whether HABIT and MI training are effective in improving hand function, working memory, and attention in CP patients. The study compared the effectiveness of these interventions in a clinical setting versus through telerehabilitation. The study found that both HABIT and MI training were effective in improving hand function and cognitive abilities in CP patients. The results also indicated that tele-rehabilitation-based interventions were as effective as clinic-based ones. This study was the first to investigate the effects of telerehabilitation on attention and working memory in CP patients and to compare the effects of HABIT and MI training provided in both settings.

According to motor learning principles, the repetitive practice of bimanual goal-directed tasks maximises improvement in the use of two hands together.^[16] Because the development of motor control is modelled on the effective use of the dominant hand, early bimanual use of both hands is thought to be important for the development of the assisting hand or non-dominant hand.^[15] This could be one of the reasons why the hand function of the non-dominant hand has improved in tasks like page-turning, lifting small objects, stacking checkers, and lifting large, light and heavy objects.^[15]

Surkar et al. investigated the efficacy of HABIT in improving pre-frontal cortex (PFC) activation in children with hemiplegic CP.^[17] The findings of this study suggest that HABIT has the potential to increase PFC activity while children with HCP perform action planning of motor tasks. The decrease in PFC activation after HABIT suggests that the children’s attentional resources were better allocated for simultaneously processing cognitive (attention, memory, and information processing) and motor demands.^[17] The findings were similar to our results of how HABIT improves cognitive function in CP patients. HABIT provided in the clinical set-up has improved working memory and attention, while HABIT provided via tele-rehabilitation has improved attention in hemiplegic CP.

In a mini-review by Fabrizio Stasolla and colleagues, the effects of telerehabilitation on improving clinical and health conditions in children with CP have been discussed.^[18] Seven studies have been reviewed in this research that highlight hand function training provided through online training, i.e., telerehabilitation.^[18] In one of the studies, a protocol similar to HABIT has been discussed that involves training of the bilateral hands.^[18] The result of the study is consistent with ours, which is that training in hand function through telerehabilitation is effective in improving hand functions that involve daily activities, for example, feeding, lifting objects, etc.

Cognitive telerehabilitation training has been provided to adults with intellectual disability in a pilot study by Javier and his colleagues in 2020. It is worth noting that the study’s participants are in their fifth decade. The brain plasticity mechanisms are not as effective at this age as at younger ages. In addition to this, in our study, we saw that attention, a component of cognition, has been improved via telerehabilitation in CP patients between the ages of 7 to 15 years. As it is concluded in the aforementioned study, neural plasticity is effective at a younger age; therefore, through task-oriented motor rehabilitation, changes were noticed in children’s attention.^[19]

Previous research has found that imagined movements have similar neural substrates to actual movements and induce brain plasticity similar to that obtained through physical practice.^[10,11]

Our results were consistent with other research. MI, when provided in a clinic, has been proven beneficial in improving attention and hand function, including writing, page-turning, feeding with both dominant and non-dominant hands, and lifting objects.

In an RCT conducted on multiple sclerosis patients, physical, cognitive, and psychosocial effects of tele-rehabilitation-based motor imagery training were studied. Their result suggests, similar to our study, that tele-MIT (MI training) is beneficial in improving motor and cognitive abilities. In our study, tele-MI training has improved attention and hand function in CP patients.^[20] As a result, the MI method can be considered a learning strategy, as well as a foundation for many children and adolescents’ therapeutic interventions aimed at improving new skills, including motor skills.^[10,11]

Limitations: It is important to note that this study has certain limitations. Firstly, the sample size was relatively small. Therefore, future studies should be conducted on a larger sample size to increase the accuracy of the results. Additionally, the follow-up period of only 4 weeks may not be sufficient to draw definitive conclusions. Secondly, the study only investigated the efficacy of these interventions on hemiplegic CP patients with lower dosages of 50-55 minutes per day. Future studies could explore the effectiveness of these interventions for other neuro-developmental disorders.

Future scope: The present study has revealed new possibilities for future research. For instance, future studies could investigate the use of these interventions on other types of neurodevelopmental disorders. Moreover, the use of MI to improve other cognitive functions can also be explored. Finally, the use of bilateral movements for lower limbs could be a promising area for further investigation.

CONCLUSION

In our study, we found that both HABIT and MI can be equally effective in improving the hand functions and attention of CP patients. Our research also suggests that training provided in a clinic or via telerehabilitation can be beneficial. However, we found that only HABIT provided in a clinic can improve working memory in hemiplegic CP patients.