Intensive care protocol for infants with asymmetry

Correr, Mayara Thais; Pfeifer, Luzia Iara

doi:10.4322/2526-8910.ctoAO1726

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Original Article • Cad. Bras. Ter. Ocup. 27 (2) • Apr-Jun 2019 • https://doi.org/10.4322/2526-8910.ctoAO1726 copy

Intensive care protocol for infants with asymmetry

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Introduction

Injuries to the developing central nervous system can cause changes in muscle tone, coordination, and balance, as well as asymmetry of the upper limbs resulting in more obvious functional limitations in a body hemisphere and restriction in the social participation of children.

Objective

Based on the principle that therapy is more effective when started at an early age, the objective of this study was to develop a modified CIMT protocol (Constraint-Induced Movement Therapy) in association with HABIT (Hand-Arm Bimanual Intensive Therapy) and investigate the effects in infants with hemiparesis or asymmetry of upper limbs.

Method

Five infants aged 6 to 24 months who presented asymmetry of the upper limbs participated in the study. The General and Objective Manual Evaluation of Infants (AMIGO) was used to evaluate the motor function of the upper limbs. The Pediatric Evaluation of Disability Inventory (PEDI) was carried out with the caregivers in order to evaluate their perception of the functional participation of the infant in daily tasks. All evaluations were performed before and immediately after the intervention, and 4 months after protocol development for follow-up recording. The data were analyzed descriptively and by means of analysis using the Jacobson-Truax method.

Results

A significant increase in the spontaneous use of the more compromised upper limb was observed in infants with fine and gross motor tasks.

Conclusion

The adapted protocol used toys and tasks appropriate to the age and was effective in producing a quantitative and qualitative increase in the use of the most compromised upper limb as well as in the unimanual and bimanual function.

Keywords:
Early Intervention; Infant; Rehabilitation; Upper Extremity; Intensive Therapy

Task	Material	Description	Adaptation	Progression
Reaching an object	Colored objects of different sizes and textures (rattles, balls, felt-tip toy)	Reaching objects with the affected hands offered in different spatial positions (right, left, midline, the height of the shoulder, the head or above the head). Hand not affected ? postural support.	Offering an object closer to the baby’s trunk; and the projection side.	Increasing the distance of the object; contrary to the functional projection of the baby; performing postural transitions to achieve.
Holding a utensil	Colorful objects of different sizes and textures	Using the affected hand to hold and keep the object in the hand, while a song was sung or some game was offered.	Light and small objects (slightly smaller than the palm of the hand) and keep it for a short time	Larger and heavier objects and holding them longer
Taking a small object	Colored gel jelly and container	Dipping the hand into the container full of colored balls and grabbing them	Medium line container available	Placing the container in different spatial positions.
Touching body parts	-----	Using the affected hand to touch parts of the body	-----	-----
Sticking and unsticking	Objects with Velcro (small animals and felt balls of different sizes) and Velcro panel	Sticking the object on the panel with the affected hand. The other hand supports the panel or performs postural support depending on the position of the panel. Unsticking the object.	Placing the panel on the table and at the height of the baby’s hand. Only asking the child to stick the object.	Placing the panel vertically and on the side of the child. Asking the child to stick and scrape the object (to unstick it, the baby needs to get strength and muscle control)
Taking an object on 4 supports	Colorful objects of different sizes and textures	In the posture of 4 supports, taking with the affected hand a toy of greater interest.	Not reaching (remain in posture while watching a video or while singing a song)	Reaching the object in the posture of 4 supports, leaving the unaffected hand on the ground and progressing to the affected hand as support.
Position rings	Colored rings and a wooden bar	Putting the rings on the wooden bar.	Placing the rings on the unaffected arm.	Positioning the wooden bar in more distant places, lower or higher than the height of the hand.
Storing small objects in a container	Marbles or “ping pong” balls, plastic box, and mug.	Removing the marbles from within a wide-mouthed box and placing them inside a plastic mug. The unaffected hand supports the mug.	The box in the affected side and the mug on the Midline; pick up the ball with palmar grip and/or use a “ping pong” ball.	The box on the middle line and mug from the affected side. Containers at different heights; picking up the ball with 2-finger tweezers (thumb/index finger)
Pressing/ triggering	Toys with buttons that when triggered, they emit sounds or lights up.	Pressing the button with the affected hand. The affected hand was used to support the toy.	Button closer to the child, offering it on the affected side	Button farthest away (on the midline and then on the side opposite the affected limb, so the child should cross the midline to reach)
Cubes in the box	Icebreaker game	Moving the small cubes from the table to a box	Leaving the cubes and the box in front of the affected side	Placing the cubes on the unaffected side and the box on the affected side. Reverse the situation

Task	Material	Description	Adaptation	Progression
Handling toys	Objects of different sizes and textures	In the sitting position, playing freely with objects of different sizes and textures	Support of the unaffected or external hand, if necessary	Playing in the midline without the support and inserting situations of postural imbalance
Playing soccer	Ball of different sizes	Throwing the ball into the basket or goal using the affected hand and then both hands simultaneously	Small, light and soft balls. Delimiting a large space for the goal.	Larger balls; decreasing the target; placing the target in a more distant, higher and further away from the affected hemisphere.
Modeling	Play Dough	Squeezing the dough making rolls, balls, and spread the dough making “pizza”. The unaffected hand was used as support	Deliver a greater amount of play dough	The lower amount of dough, decreasing the diameter of the rolls, the balls and the thickness of the “pizza”.
Coloring	Paper and gouache	Putting the hand in the container with paint and bring the hand to the paper sheet painting freely. The unaffected hand supports the paper sheet.	The ink container is placed next to the affected hand	Placing the container next to the affected hand, but further away; evolving by placing the pot on the unaffected side
Drawing	Wax chalk, pen, and paper	Drawing with the wax chalk on the paper, using the affected hand. The unaffected hand is on the table and supports the paper	Large wax crayon, wax chalk	Small diameter wax chalk; paper farthest from the trunk.
Assembling parts	Game of grimaces	Picking up the pieces and making the faces. The pieces of this game are large and the non-stressed hand supports the board	Board close to the body and parts available next to the affected limb	Board away from the body of pieces on the unaffected side
Stacking blocks	Set of baby lego and/or colored cubes	Assembling a tower on the table using the largest number of pieces. The unaffected hand supports the tower	Cubes arranged in front of the patient’s midline or the affected side	Placing the blocks on the floor or on the unaffected side.
Hammering	Icebreaker game	Cubes positioned by the infant and the therapist on the play table and the baby should hit the cubes to knock down the pieces	Hitting with the hands	Hitting with the hammer.
Opening a pot	Plastic Box	Removing the lid from the box. The unaffected hand holds the trunk-supported box and the baby removes the lid with the affected hand.	Removing the cover unscrewed.	Unscrewing the lid and remove it
Transferring the container food	Plastic set with cooking utensils,* grape, and raw beans	Transferring the food from the shallow dish and passing to the bottom plate, using the affected hand	Transferring the grapes^* * Grapes without seed. with the hand	Transferring the beans by making 2-finger forceps (to develop greater accuracy of the fine forceps), as progression, passing the beans from the bottom plate to the shallow dish; performing the task using a spoon.
Feeding the doll	Raw beans and grapes*	The infant had to pick up the beans or the grape* with the unaffected hand and “feed the doll”.	Dolls and container with food near the infant	As a progression, do the same with the use of a spoon.
Self-feeding	Food and container brought by caregivers	Feeding by the hand, taking food out of a container	Big foods like cookies, strawberries, for example	The food should be smaller requiring finer tweezers and then the infant should be fed using a spoon
Fitting pin and/or threads	Board with pins and threads	Taking the pieces on the side and fitting them in the indicated places	Using threads and board near the infant’s torso	Using more pins and boards
Pushing a doll cart	Doll cart	The infant walking to support both hands in the cart and taking the “doll” in the cart	Padding the “handle” of the cart on the affected side	Keep both sides the same
Pulling a cart	Plastic carts	Pulling the cart	Pulling by hand	Pulling with a cord slightly tied in the affected hand and progress without any cord

Participants; gender; chronological age	Diagnosis	Main Caregiver	School level	Age	ABEP ( ASSOCIAÇÃO..., 2015 ASSOCIAÇÃO BRASILEIRA DE ESTUDOS POPULACIONAIS – ABEP. Critério de classificação econômica do Brasil. São Paulo, 2015. )
P1 - male; 18 months	Bilateral spastic hemiparesis CP, GMFCS E & R– IV; Mini-MACS – IV	Grandmother	Incomplete Elementary School	41	Class C2
P2 – female; 20 months	Spastic hemiparesis CP, GMFCS E & R– I; Mini-MACS – II	Grandmother	Complete high school	38	Class B2
P3 - female; 20 months	Stroke, spastic hemiparesis, GMFCS E & R- I; Mini-MACS – I.	Mother	Complete elementary school	19	Class C2
P4 - female; 6 months	CP, spastic hemiparesis, GMFCS E & R- III; Mini-MACS - III	Mother	Complete Higher Education	24	Class B2
P5 - male; 15 months	Brachial Plexus Injury; Mini-MACS - I	Grandmother	Incomplete Higher Education	46	Class C2

Participant	Evaluation	Pre	Post	*Follow-up*	TCI (pre e post)
P1	PEDI self-care	27.02	35.31	32.74	3.47
	PEDI Mobility	6.97	11.38	14.24	2.17
	PEDI social role	34.24	37.01	40.60	2.50
	AMIGO	2	10	7	2.82
P2	PEDI self-care	49.34	55.05	55.76	2.39
	PEDI Mobility	45.26	56.26	58.20	5.42
	PEDI v	47.45	50.02	51.67	2.32
	AMIGO	30	38	38	2.11
P3	PEDI self-care	37.68	46.24	49.34	3.58
	PEDI Mobility	36.80	46.67	51.94	4.86
	PEDI social role	47.45	48.32	50.02	0.78
	AMIGO	26	32	34	2.11
P4	PEDI self-care	35.31	39.85	52.94	1.90
	PEDI Mobility	6.97	14.24	27.85	3.58
	PEDI social role	24.85	29.16	47.45	3.88
	AMIGO	20	24	26	1.41
P5	PEDI self-care	43.69	44.57	49.34	0.37
	PEDI Mobility	48.11	52.76	51.94	2.29
	PEDI social role	46.56	47.45	49.18	0.80
	AMIGO	17	31	34	4.93

Universidade Federal de São Carlos, Departamento de Terapia Ocupacional Rodovia Washington Luis, Km 235, Caixa Postal 676, CEP: , 13565-905, São Carlos, SP - Brasil, Tel.: 55-16-3361-8749 - São Carlos - SP - Brazil
E-mail: cadto@ufscar.br

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[1] Corresponding author: Mayara Thais Correr, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Rua Ten. Catão Roxo, 2650, Vila Monte Alegre, CEP 14051-160, Ribeirão Preto, SP, Brasil, e-mail: mayara.correr@gmail.com