Intervention bimanual stimulates the abilities in infants with asymmetry

Introduction: The cerebral palsy and brachial plexus injury may cause asymmetry in the use of the upper limbs (UL). This condition requires early treatment to reduce the impact of the child's life; therefore, several proposed interventions aim to increase their functional independence. The Constraint-Induced Movement Therapy (CIMT) and Hand-Arm Bimanual Intensive Therapy (HABIT) have been widely considered effective interventions to improve hand function. Objective: Investigate the effects of an intervention protocol based on the CIMT and HABIT theoretical foundations in the stimulation of manual function in infants with the UL asymmetry. Methods: Five infants (6-24 months) participated in the study. To evaluate the motor function of infants we used Pediatric Motor Activity Log (PMAL-R) and Manual Function Evaluation (AMIGO), and to assess the caregiver's perception of the participation of the infant in daily tasks, we used the Pediatric Disability Assessment Inventory (PEDI). All evaluations occurred before, immediately after the intervention, and after four months for follow-up recording, and were analyzed descriptively by Jacobson- Truax method. Results: The results between evaluation and reevaluation demonstrated evolution in all aspects studied. In the PEDI self-care session, an average of 38.6 (±8.4) - 44.2 (±7.4); PEDI Mobility: 28.8 (±20.3) -36.28 (±21.7); PEDI Social Function: 40.1 (±10.2) - 42.3 (±8.9). The PMAL-R quantity and quality results evidence a highly positive clinical significance in all infants. Conclusion: The application of the modified restriction intervention protocol resulted in reliable and clinically significant changes in all cases.

predominantly the individual's first choice in performing tasks and handling objects with, while the most affected limb can often be neglected. 4 Thus, many hemiparetic children use only their unaffected limb to perform tasks usually performed bimanually. 5 Therefore, to rehabilitate children and infants' asymmetry is crucial because, at this stage, there is an intense development of the nervous system that is influenced and modulated by the activities and experiences lived. 6 The literature has currently shown two main The CIMT presents a rehabilitation protocol for motor function and to overcome the learned nonuse, which influences daily activities and functional independence, 10 and combines structured and systematized elements that restrict the non-affected side to encourage the use of the affected limb. 11 Although CIMT can improve the quantity and quality of the affected upper limb movements, it does not focus on developing bimanual handling and coordination capacity as its objective, since the unaffected limb is restricted most of the time. Although studies have shown that unimanual practices can transfer improvements to bimanual coordination, 10 motor learning principles emphasize the importance of task specificity in practice to maximize learning. 12 Therefore, the direct training of bimanual skills corroborates to the improvement of bimanual coordination. 6 In 2014, nine experts proposed a consensus to distinguish the CIMT from other training models for upper limbs. 13 The CIMT is the original model, whose criteria involve the restraint of UL unaffected by 90% during waking hours, intensive training with the affected UL for at least 6 hours daily, and a minimum duration of 2 weeks. 13 The modified restriction-induced motion therapy (mCIMT) involves the type of restriction (sling, Few studies focused on the CIMT and HABIT with infants, and none, up until now, presented the use of the combined approach in the stimulation of bimanual abilities in infants. Eliasson et al. 13 pointed that among 24 randomized controlled trials and controlled clinical trials using the CIMT, 23 studies needed to alter at least one variable (a type of restriction, time to application, intensity, etc.) due to the age of the child. The adaptations performed, using the HABIT, were related to time and intensity of application due to the child. 5 Concerning the duration and intensity of application, both methods originally propose the practice of 6 hours daily, from 10 to 21 days. 9,11 However, it can be modified and adapted to become more suitable for younger children, restricting physical and psychological risks. 5,6 In the original protocol of CIMT, the sessions' Patients undergoing physiotherapy and occupational therapy maintained their usual treatment during the application of this protocol. Only patient P3 did not participate in any rehabilitation program since his injury was recent. Table 1 shows the characteristics of participants and their families.

Results
We used the JT method to analyze the reliability of the changes between the pre-and post-intervention scores, the Reliable Change Index (RCI) ( Table 2), and the clinical significance of the changes (Figure 2). The RCI analyzes the reliability of measurements and is reliable and positive when it exceeds 1.96.    Table 2).

Discussion
Of all disorders caused by hemiparesis, manual function alteration is the most disabling since many children perform typically bimanual activities, using only the unaffected UL. 5 The present study recruited infants aged 6 to 24 months with hemiparesis, focused on applying an effective rehabilitation method to the upper limbs. Only three hemiparesis CP, one bilateral hemiparesis, and one BPI participated in this study.
We decided not to include participants who did not  However, our study differs in that it is more efficient in younger children, with a daily intensity of only 1 hour and less invasive restriction. Similar to ours, results were also obtained by Eliasson et al., 10 who used a more modified CIMT protocol, whose intervention was applied by parents or teachers and supervised weekly by a professional, and demonstrated an improvement of hemiparetic hand utilization capacity.

Study limitations
The main limitations are the sample's size and heterogeneity, not allowing the formation of a control group. Therefore, we used the JT Method, a procedure utterly distinct from inferential statistics since it is possible to find reliable changes without statistically significant

Conclusion
This study allowed us to observe an increase in the uni and bimanual function in infants, hypothesizing that treatment at an early age positively influences sensorymotor development in infants with nervous system injuries since there are presumably critical periods during the maturation of the developing brain that ensure greater effectiveness at earlier ages.