Can\u27t Hold Me Back! Constraint-Induced Movement Therapy for Children with CP: Evidence Based Review

Children with cerebral palsy (CP) have various functional impairments impacting participation in meaningful occupations. While Constraint-Induced Movement Therapy (CIMT) is a widely used intervention for adult populations, a modified version of this technique is a relatively new practice in pediatrics (Charles et al., 2006). Occupational therapy intervention, such as CIMT, can support functional goal attainment to enhance participation and quality of life (Boyd et al., 2010). The purpose of this presentation is to synthesize results of a comprehensive evidence-based review and identify treatment characteristics that impact efficacious use of mCIMT on children with hemiplegic CP. Practitioners will learn about best practice strategies according to current literature. After formulation of a clinical research question, a systematic search of 3 databases was conducted, yielding 15 articles. A rigorous screening process was used with specific inclusion and exclusion criteria. These articles were critiqued to identify the effectiveness of mCIMT. Using Law and MacDermid’s (2008) Appendix M, each article was reviewed by a primary rater with input from a secondary rater. Findings were synthesized and will be discussed in this presentation. The literature review indicated overall positive results for the use of mCIMT with pediatric CP populations. The majority of studies have found statistically significant results, however, there are mixed conclusions regarding clinical effect. A variety of protocol durations and types of constraints have been investigated, and demonstrate that a minimum of 1-2 hours of constraint wear time for 10-14 consecutive days may be effective in a clinic or home environment. Evidence suggests that the most effective mCIMT protocol involves a child-friendly approach using functional and age-appropriate tasks. Both preparatory and occupation-based activities were assessed utilizing a variety of standardized outcome measures. This presentation impacts clinical practice by providing evidence about the most effective intervention characteristics for implementing mCIMT as a useful and feasible treatment approach. Overall, children who received mCIMT by a trained interventionist improved functionally regardless of the protocol. Findings suggest less restrictive methods may be comparable to more intensive mCIMT interventions. Therefore, interventionists can tailor a specific mCIMT approach to meet the unique needs of each child. References: Boyd, R., Sakzewski, L., Ziviani, J., Abbott, D. F., Badawy, R., Gilmore, R., . . . Jackson, G. D. (2010). INCITE: A randomised trial comparing constraint induced movement therapy and bimanual training in children with congenital hemiplegia. BMC Neurology, 10, 1-15. doi:10.1186/1471-2377-10-4 Charles, J. R., Wolf, S. L., Schneider, J. A., & Gordon, A. M. (2006). Efficacy of a child-friendly form of constraint-induced movement therapy in hemiplegic cerebral palsy: A randomized control trial. Developmental Medicine and Child Neurology, 48(8), 635-642. doi:10.1017/S0012162206001356 Law, M. & MacDermid, J. (2008). Appendix M: Effectiveness Study Quality Checklist. In Evidence-based rehabilitation: A guide to practice (413-423). Thorofare, NJ: Slack, Inc

Pregnancy-Related Disease Outcomes in Women With Moderate to Severe Multiple Sclerosis Disability

Importance: Understanding the association between pregnancy and clinical outcomes in women with moderate to severe multiple sclerosis (MS) disability is crucial for guiding family planning and management strategies. Objective: To assess peripregnancy relapse activity and disability progression in women with a preconception Expanded Disability Status Scale (EDSS) score of 3 or higher. Design, Setting, and Participants: This multicenter retrospective cohort study used data from the MSBase Registry, with clinical observations spanning 1984 through 2024. Study cohorts included pregnant women with MS with a preconception EDSS score of 3 or higher (range: 3-10, with higher scores indicating more severe MS-related disability) and propensity score-matched nonpregnant women with MS (controls). Main Outcomes and Measures: The main outcomes were peripregnancy annualized relapse rates (ARRs) and time to 6-month confirmed disability worsening (CDW). Results: A total of 1631 women with MS were included, of whom 575 were in the pregnant cohort (median [IQR] age at pregnancy, 32.5 [29.1-36.1] years) and 1056 were in the nonpregnant cohort (median [IQR] age, 32.6 [27.5-37.2] years). The median (range) preconception EDSS score was 3.5 (3.0-7.5). Relapse activity decreased during pregnancy, with a 75% reduction in ARR during the first trimester (rate ratio [RR], 0.25; 95% CI, 0.15-0.43), and increased to 36% above preconception levels in the first 3 months post partum (RR, 1.36; 95% CI, 1.06-1.75). Relapse during pregnancy was associated with a higher preconception ARR (odds ratio [OR], 1.56; 95% CI, 1.10-2.20) and preconception use of natalizumab (OR, 4.42; 95% CI, 1.24-23.57) or fingolimod (OR, 14.07; 95% CI, 2.81-91.30). Older age (OR, 0.92; 95% CI, 0.85-0.99) and continuation of disease-modifying therapy into pregnancy (OR, 0.42; 95% CI, 0.19-1.00) were associated with reduced risk. Disease-modifying therapy reinitiation within 1 month post partum was associated with lower odds of early postpartum relapse (OR, 0.45; 95% CI, 0.23-0.86). There was no significant difference in time to CDW between the pregnant and nonpregnant groups (hazard ratio [HR], 1.15; 95% CI, 0.96-1.38). However, ARR during pregnancy (HR, 1.37; 95% CI, 1.13-1.65) and postpartum EDSS score higher than 4 (HR, 2.69; 95% CI, 1.80-4.03) were associated with shorter time to CDW. Conclusions and Relevance: In this cohort study, women with moderate to severe MS disability exhibited a pattern of peripregnancy relapse activity similar to that reported in women with less disability. Pregnancy was not associated with worse long-term disability outcomes, although optimizing disease control in the peripregnancy period remained critical

Acute Stroke: A population based study of factors influencing delays in hospital arrival. Preliminary results.

P155 For acute stroke therapy, most stroke patients are ineligible due to delays in presenting to hospital. Previous studies have largely been hospital based, lacking specific information about the factors influencing non hospitalised patients. To plan for acute stroke care in the new millennium, we need to identify factors that may help increase the proportion eligible for these treatments. Arrival times were assessed for patients accrued in the NorthEast Melbourne Stroke Incidence Study (NEMESIS), a large population based stroke incidence study in Australia. Patients were identified using multiple overlapping sources including 60 hospitals. Stroke onset and hospital arrival times were assessed by review of medical records and interviews with the patient or next of kin. In this preliminary analysis, we assessed 254 stroke events among 244 patients. Two hundred and twenty seven were first-ever-in-a-life time strokes. The mean age was 75 years and 40% were male. In 254 events, 7% never attended hospital and 9% were in-patient strokes. Non attenders were older (mean age 79 years), predominantly female (88%) and 65% resided in nursing homes. Median hospital arrival time for the remaining 84%, was 9.1 hours (range 25 minutes to 1 month). Thirty percent of patients presenting to hospital arrived within 3 hours of the event, and 74% within the first 24 hours. Delays were greater with contact with the General Practitioner, living alone or in patients with a history of dementia. Factors associated with earlier arrival included ambulance transport, dense hemiplegia, impaired consciousness and sub-arachnoid haemorrhage. In this preliminary analysis, we have identified factors that affect hospital arrival times. Many non hospitalised patients may be ineligible for treatment due to pre existing disability or old age, reflected in their need for nursing home accommodation. Of those who attend hospital, potentially a greater proportion of the stroke population could be eligible for acute therapies if delays in arrival could be addressed. Strategies to improve early attendance need to be targeted at both the patient and the General Practitioner.</jats:p

Vitamin D did not reduce multiple sclerosis disease activity after a clinically isolated syndrome

Low serum levels of 25-hydroxyvitamin D (25(OH)D), and low sunlight exposure, are known risk factors for the development of multiple sclerosis. Add-on vitamin D supplementation trials in established multiple sclerosis have been inconclusive. The effects of vitamin D supplementation to prevent multiple sclerosis is unknown. We aimed to test the hypothesis that oral vitamin D3 supplementation in high-risk clinically isolated syndrome (abnormal MRI, at least three T2 brain and/or spinal cord lesions), delays time to conversion to definite multiple sclerosis, that the therapeutic effect is dose-dependent, and that all doses are safe and well tolerated. We conducted a double-blind trial in Australia and New Zealand. Eligible participants were randomised 1:1:1:1 to placebo, 1000, 5000, or 10 000 IU of oral vitamin D3 daily within each study centre (n=23) and followed for up to 48 weeks. Between 2013 and 2021, we enrolled 204 participants. Brain MRI scans were performed at baseline, 24 and 48 weeks. The main study outcome was conversion to clinically definite multiple sclerosis based on the 2010 McDonald criteria defined as either a clinical relapse or new brain MRI T2 lesion development. We included 199 cases in the intention-to-treat analysis based on assigned dose. Of these, 116 converted to multiple sclerosis by 48 weeks (58%). Compared to placebo, the HRs (95%CI) for conversion were 1000 IU 0.87 (0.50, 1.50); 5000 IU 1.37 (0.82, 2.29); and 10 000 IU 1.28 (0.76, 2.14). In an adjusted model including age, sex, latitude, study centre, and baseline symptom number, clinically isolated syndrome onset site, presence of infratentorial lesions, and use of steroids, the HRs (versus placebo) were 1000 IU 0.80 (0.45, 1.44); 5000 IU 1.36 (0.78, 2.38); 10 000 IU 1.07 (0.62, 1.85). Vitamin D3 supplementation was safe and well tolerated. We did not demonstrate reduction in multiple sclerosis disease activity by vitamin D3 supplementation after a high-risk clinically isolated syndrome. Trial registration Australian Clinical Trials Registration Number ACTRN12612001160820.Full Tex