Critically appraised paper: Hand-arm bimanual intensive therapy including lower extremities (HABIT-ILE) improves bimanual performance and gross motor function in pre-school children with unilateral cerebral palsy [commentary].Journal of physiotherapy • February 06, 2024
Functional task-specific training of client-chosen goals is considered best practice for children with cerebral palsy.1 Both modified constraint-induced movement therapy and bimanual therapy are well-established and intensive options to improve the upper limb function of young children with unilateral cerebral palsy. There is a comparative dearth of evidence for improving gross motor function in this age group.2
Hand-arm bimanual intensive therapy including lower extremities (HABIT-ILE) builds on bimanual therapy to target both upper limb and gross motor function.1 This randomised controlled trial of pre-school children is likely to add strength and increased certainty of evidence for HABIT-ILE, which is already among a small number of currently recommended interventions in clinical practice guidelines for improving function.1
The dose of 50 hours/2 weeks of therapist-led practice is substantially higher than typically offered.2 However, the use of inertial sensors in this study cleverly demonstrated that it is not simply increased movement that is responsible for improved function, but movement that is highly structured and goal-directed. While improvements were generally large and sustained at follow-up, post hoc analyses suggested that children aged 3 to 4 years did not achieve a clinically meaningful change on the Assisting Hand Assessment, with the authors suggesting that an even higher dose would be necessary. A recent meta-analysis of the dose-response relationship for upper limb therapy across all age groups identified 40 hours as the threshold for clinically important change on the Assisting Hand Assessment.3 As practice must be task-specific to induce experience-dependent neuroplasticity,1 consideration must be given as to how combining both upper and lower extremity training into a single block impacts the required dose.
Active Start Active Future: Feasibility of a Behaviour-Change Intervention to Reduce Sedentary Behaviour and Promote Physical Activity in Young Children with Cerebral Palsy. Physical & Occupational Therapy In Pediatrics • May 26, 2025
Sarah Reedman, Gaela Kilgour, Sjaan Gomersall, Leanne Sakzewski, Stewart Trost, Roslyn Boyd
Children with cerebral palsy (CP) have low physical activity (PA) and high sedentary behavior. The aim was to trial a participation-focused behavior-change intervention to increase PA and decrease sedentary behavior. Twelve children with CP were recruited (mean age 5 years 6 months ± 1 year 2 months, Gross Motor Function Classification System [GMFCS] levels I = 1, II = 1, III = 1, IV = 4, V = 5); eight with complete post-intervention data (mean 5 years 10 months ± 1 year 4 months, GMFCS I = 1, III = 1, IV = 4, V = 2). Children received 8 weekly sessions targeting individualized PA participation goals in a pre-post feasibility trial. Outcomes included: implementation, effectiveness (Canadian Occupational Performance Measure [COPM]), device-measured PA, goal confidence, quality of life, and barriers to PA participation. Semi-structured interviews explored acceptability and were analyzed thematically. Implementation was feasible with ≥90% sessions attended and high enjoyment (89.5%). After 8 wk, COPM goal performance (mean difference [MD] = 2.9, 95% CI 0.7, 5.0; p = 0.02), satisfaction with performance (MD = 3.0, 95% CI 1.6, 4.4; p = 0.002), and confidence (MD = 1.4, 95% CI 0.4, 2.5; p = 0.02) significantly increased with no change in other outcomes. All six caregivers interviewed reported the intervention to be acceptable. Active Start Active Future was feasible to conduct, acceptable and showed preliminary evidence to improve PA in young children with CP.
Study protocol for Active Start Active Future: a randomised control trial of an early behaviour-change intervention targeting physical activity participation and sedentary behaviour in young children with cerebral palsy living in South East Queensland, Australia.BMJ Open • May 19, 2025
Gaela Kilgour, Sarah Reedman, Sjaan Gomersall, Leanne Sakzewski, Stewart Trost, Roslyn Boyd
Background: The benefits of physical activity (PA) are compelling for all ages and abilities. For children with cerebral palsy (CP), two distinct health behaviours, being physically active and reducing sedentary time, are critical to target as an early intervention to reduce long-term morbidity. One approach may be to increase PA participation by empowering parents who are key to making family lifestyle changes. This study will compare Active Start Active Future, a participation-focused intervention, to usual care in a mixed-methods randomised waitlist-controlled trial.
Methods: A total of 40 children with CP (3-7 years), classified in Gross Motor Function Classification System (GMFCS) levels II-V, will be stratified (GMFCS II vs III, IV vs V) and randomised to receive either (1) Active Start Active Future, an 8-week intervention for 1 hour per week in any setting or (2) usual care followed by delayed intervention. Active Start Active Future aims to increase PA and reduce sedentary behaviour of young children with CP by providing participatory opportunities to promote PA behaviour change. Outcomes will be measured at baseline (T1), immediately postintervention at 8 weeks (T2) and at 26 weeks postbaseline (T3). The primary outcomes are the Canadian Occupational Performance Measure for both child and parent participation goals and child physical performance goal. Secondary outcomes include daily time spent in moderate to vigorous PA and sedentary time, gross motor function, quality of life, barriers to participation for the children and parents' PA and sedentary time. Intervention acceptability and experiences of PA participation will be explored using a qualitative descriptive approach. Background: The Children's Health Queensland Hospital and Health Service Human Research Ethics Committee (HREC/23/QCHQ/100850) and The University of Queensland Human Research Ethics Committee (2024/HE000054) have approved this study. The results of the study will be disseminated to families and community agencies as guided by our advisory group and as conference abstracts and presentations, peer-reviewed articles in scientific journals and institution newsletters and media releases. Background: ACTRN12624000042549, Universal Trial Number: U1111-1300-7421; Australian New Zealand Clinical Trials Registry.
A Multisite Randomized Controlled Trial of Hand Arm Bimanual Intensive Training Including Lower Extremity for Children with Bilateral Cerebral Palsy.The Journal Of Pediatrics • January 23, 2025
Leanne Sakzewski, Yannick Bleyenheuft, Iona Novak, Catherine Elliott, Sarah Reedman, Catherine Morgan, Kerstin Pannek, Natalie Santos, Ashleigh Hines, Sherilyn Nolan, Robert Ware, Roslyn Boyd
Objective: To test the efficacy of Hand Arm Bimanual Intensive Therapy Including Lower Extremity (HABIT-ILE) to improve gross motor function, manual ability, goal performance, walking endurance, mobility, and self-care for children with bilateral cerebral palsy. Methods: This prospective, waitlist randomized controlled trial included children with bilateral cerebral palsy, aged 6-to-16-years and classified Gross Motor Function Classification System levels II to IV. HABIT-ILE delivered for 2 weeks (65 hours) was compared with usual care. Primary outcomes postintervention were gross motor function (Gross Motor Function Measure-66) and manual ability (ABILHAND-Kids). Secondary outcomes were goal performance (Canadian Occupational Performance Measure), self-care and mobility (Pediatric Evaluation of Disability Inventory-Computer Adapted Test), bimanual hand performance (Both Hands Assessment), and walking endurance (6 Minute Walk Test). Linear regression models were used to determine between group differences, adjusted for baseline scores. Results: Ninety-two children were recruited; 2 were deemed ineligible after randomization and were excluded. Ninety children (HABIT-ILE n = 46, usual care n = 44), mean age 10.4 (SD 3.0) years, Gross Motor Function Classification System II = 32; III = 31; IV = 27 were included. HABIT-ILE led to superior gains in manual ability (mean difference 0.85, 95% CI 0.38-1.33; P < .001) but not gross motor function. HABIT-ILE led to superior changes on goal performance, self-care, and mobility. Conclusions: HABIT-ILE was effective in improving manual ability, mobility, self-care, and goal performance, but not gross motor function. Significant gains were immediately retained at 26 weeks postintervention. Large individual variability suggests further analyses need to be performed to understand characteristics of children who achieved clinically meaningful gains across outcomes.
Participate CP 2: optimising participation in physically active leisure for children with cerebral palsy - protocol for a phase III randomised controlled trial.BMJ Open • October 03, 2023
Leanne Sakzewski, Sarah Reedman, Catherine Elliott, Jenny Ziviani, Iona Novak, Stewart Trost, Annette Majnemer, Tracy Comans, Keiko Shikako, Robert Ware, Lynda Mcnamara, Sian Williams, Syed Keramat, Denise Brookes, Roslyn Boyd
Introduction: Children with cerebral palsy (CP) participate less in physical activities and have increased sedentary behaviour compared with typically developing peers. Participate CP is a participation-focused therapy intervention for children with CP with demonstrated efficacy in a phase II randomised controlled trial (RCT) to increase perceived performance of physical activity participation goals. This study will test the effectiveness of Participate CP in a multisite phase III RCT. Methods and analysis: One hundred children with CP, aged 8-14 years, classified Gross Motor Function Classification System levels I-IV will be randomised to either (1) receive Participate CP once/week for 1 hour for 12 weeks, or (2) waitlist control, usual care group. The waitlist group will then receive Participate CP following the 26-week retention time point. Outcomes will be assessed at baseline, 12 weeks and then 26 weeks post baseline. The primary outcomes are (1) self-reported participation goal performance on the Canadian Occupational Performance Measure at 12 weeks and (2) daily time in moderate-to-vigorous physical activity. Secondary outcomes include home and community participation frequency, involvement and environmental supportiveness, contextual barriers to participation, quality of life, intrinsic motivation for physical activities, child perception of an autonomy-supportive climate for physical activities and physical literacy at 12 and 26 weeks post study entry. Ethics and dissemination: The Children's Health Queensland Hospital and Health Service, The University of Queensland and the New Zealand Health and Disability Ethics Committees have approved this study. Findings will be disseminated in peer-reviewed journals and conference presentations. Trial registration number: ACTRN12618000206224.
