Illustration of how the arm workspace can be divided into quadrants so that activities of the left upper limb can be practiced. The objective of trunk-restraint therapy is to “force” the child to extend their elbow and shoulder far from the body by performing activities in the far (a) and upper (b) ipsilateral and contralateral arm workspace, while restricting the compensatory movement of the trunk with a harness or strap
Fundamental Principles for Clinical Use
When motor compensations occur during movement production, the central nervous system receives nonoptimal sensory information from the trunk and limb (Adkins et al. 2006) which could interfere with the recovery of premorbid movement patterns.
A Brief Guide to Clinical Practice
The technique is most effective in clients with moderate-to-severe hemiparesis who use more trunk compensation than those who have mild hemiparesis (Michaelsen et al. 2006; Thielman et al. 2004). Trunk anterior displacement and rotation are restricted by a harness (de Oliveira et al. 2007) or two 3–4-inch-wide straps diagonally across the trunk from the right shoulder to the left hip and from the left shoulder to the right hip (Michaelsen and Levin 2004; Michaelsen et al. 2006; Fig. 39.2). Straps can be secured around the body to a high-backed chair with buckles or Velcro closures. For adults, the straps should be applied so that no more than 2 cm of trunk anterior displacement in the sagittal plane and no more than 5° of trunk rotation are permitted while shoulder girdle movement is relatively unrestricted. If trunk restraint is used in children with cerebral palsy , up to 5 cm of trunk movement should be permitted depending on the age of the child (Schneiberg et al. 2002, 2010).
Example of a trunk-restraint system used for children with cerebral palsy. Child-friendly straps are attached diagonally across the shoulder and hip bilaterally to the back of the chair
How the Intervention Eases Impairments, Activity Limitations, and Participation Restrictions
Permitting the use of motor compensations could lead to a pattern of learned nonuse (Alaverdashvili and Whishaw 2010, 2013; Allred et al. 2005; Taub et al. 1993), limiting the capacity for subsequent gains in motor function of the paretic arm. Interventions that include the restriction of trunk motor compensations by physical trunk restraint may encourage the nervous system to find new motor solutions to task accomplishment and to overcome learned nonuse. These motor solutions may be more effective in improving upper-limb function through the emergence of new motor patterns. Improvement in upper-limb function will decrease activity limitations and social participation restrictions.
Trunk-restraint therapy is beneficial for motor recovery in adults (16–80 years of age) with chronic acquired brain damage (stroke) leading to disrupted motor control of the trunk and arms. Beneficial effects have also been demonstrated in children with cerebral palsy for both improvement in motor function (Schneiberg et al. 2010) and motor learning (Robert et al. 2013). The principles should be equally applicable to individuals with other types of acquired brain damage such as traumatic brain injury , and to children with other developmental motor disorders.
Trunk restraint combined with task-related training improved arm motor function in adults with stroke in six high-quality randomized control studies (Michaelsen and Levin 2004; Michaelsen et al. 2006; Woodbury et al. 2009; Thielman 2010; Wu et al. 2012a, b), in one pre- and postdesign study (de Oliveira et al. 2007) and in one high-quality randomized control trial in children with cerebral palsy (Schneiberg et al. 2010). Michaelsen et al. (2006) compared arm motor impairment and function in clients with stroke practicing task-related training with (n = 15) or without trunk restraint (n = 15). Clients in the trunk-restraint group made greater improvements in motor function than those in the control group. Improvements were accompanied by increased active joint range and were greater in clients with greater initial severity of hemiparesis. In these clients, task-related training with trunk restraint led to less trunk movement and increased elbow extension during reaching, while clients in the control group increased compensatory trunk movement. In addition, changes in arm functions were correlated with changes in arm and trunk kinematics in the trunk-restraint group. Schneiberg et al. (2010) compared task-oriented training with and without trunk restraint in 12 children with cerebral palsy in a prospective single-subject randomized control trial. Each group received a total of 15 h of training. Some children in each group improved arm trajectory smoothness and elbow extension range. However, more children in the trunk-restraint group reduced their excessive trunk displacement after training and retained the improvements longer.
Further research is needed to identify the effectiveness of trunk restraint during task-related training of the upper limb in larger groups of children with cerebral palsy and in children with different motor control deficits. The effectiveness of combining the approach with other approaches or as an element in shaping arm movement during constraint-induced therapy has not yet been evaluated in children.
Clinical Case Study of Jason: Quality of Unimanual Arm Function in Child with Cerebral Palsy
Keywords: Grasping, motor compensations, reaching, recovery, training, upper limb
The theme of this case study concerns the development of a treatment approach to improve arm and hand function in child with hemiplegic cerebral palsy.
The student’s task includes:
To recommend an occupational therapy intervention and provide a rationale for its use
To summarize the evidence for the effectiveness of the intervention
As a starting point, students should use the following references to gather background information.
For a description of the Content and Clinical Application of the Intervention
Michaelsen SM, Dannenbaum R, Levin MF (2006) Task-specific training with trunk restraint on arm recovery in stroke: randomized control trial. Stroke 37:186–192
Schneiberg S, McKinley P, Sviestrup H, Gisel E, Mayo NE, Levin MF (2010) The effectiveness of task-oriented intervention and trunk restraint on upper limb movement quality in children with cerebral palsy. Dev Med Child Neurol 52:e245–e253
For Fundamental Concepts on Which the Intervention Is Based
Cirstea MC, Levin MF (2000) Compensatory strategies for reaching in stroke. Brain 123:940–953
Levin MF (2000) A model of sensorimotor deficits in clients with central nervous system lesions. Hum Mov Sci 19:107–132
Levin MF, Michaelsen S, Cirstea C, Roby-Brami A (2002) Use of the trunk for reaching targets placed within and beyond the reach in adult hemiparesis. Exp Brain Res 143:171–180
Michaelsen SM, Levin MF (2004) Short-term effects of practice with trunk restraint on reaching movements in clients with chronic stroke: a controlled trial. Stroke 35:1914–1919
Michaelsen SM, Luta A, Roby-Brami A, Levin MF (2001) Effect of trunk restraint on the recovery of reaching movements in hemiparetic clients. Stroke 32:1875–1883
Michaelsen SM, Jacobs S, Roby-Brami A, Levin MF (2004) Compensation for distal impairments of grasping in adults with hemiparesis. Exp Brain Res 157:162–173
van der Lee JH Wagenaar RC, Lankhorst GJ, Vogelaar TW, Deville WL, Bouter LM (1999) Forced use of the upper extremity in chronic stroke clients: results from a single-blind randomized clinical trial. Stroke 30:2369–2375
Overview of the Content
Aim: To choose an occupational therapy (OT) intervention that will facilitate the learning and reinforcement of optimal movement patterns of the upper limb for unimanual reaching and grasping tasks.
Background History of Clinical Case Study
Jason is a boy, aged 5 years 6 months. He is attending a specialized school because of his mobility impairment but his academic performance is equivalent to typically developing children of his age. He enjoys music and playing with friends.
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