Aim To determine whether home‐based, parent‐delivered therapy comprising action observation (AO) and repeated practice (RP) improves upper limb function more than RP alone in children with unilateral cerebral palsy (UCP). Method Design: single‐blinded parallel‐group randomized controlled trial with 1:1 allocation comparing AO+RP (intervention) with RP alone (control). Randomization: computer‐generated, with allocation concealment by opaque sequentially‐numbered envelopes. Setting: northern England, August 2011 to September 2013. Participants: 70 children with UCP; mean age 5.6 years (SD 2.1), 31 female. Intervention: home‐based activities were provided, tailored to interests and abilities. Duration: 15 minutes/day, 5 days/week for 3 months. Assessments: Assisting Hand Assessment (AHA; primary outcome measure), Melbourne Assessment 2 (MA2), and ABILHAND‐Kids at baseline, 3 months, and 6 months. Results Outcome data was available at 3 months for 28 children in the AO+RP group and 31 controls, and at 6 months for 26 and 28 children respectively. There were no between‐group differences in AHA, MA2, or ABILHAND‐Kids at 3 or 6 months versus baseline (all p>0.05). Combined‐group improvements (p<0.001), observed in AHA and MA2 at 3 months, were maintained at 6 months. ABILHAND‐Kids also showed improvement at 3 months (p=0.003), maintained at 6 months. Interpretation Parent‐delivered RP (with or without AO) improves upper limb function and could supplement therapist input.

Children with hemiplegic cerebral palsy often have marked hand involvement with excessive thumb adduction and flexion and limited active wrist extension from infancy. Post-lesional aberrant plasticity can lead to progressive abnormalities of the developing motor system. Disturbances of somatosensory and visual function and developmental disregard contribute to difficulties with hand use. Progressive soft tissue and bony changes may occur, leading to contractures, which further limit function in a vicious cycle. Early intervention might help to break this cycle, however, the precise nature and appropriateness of the intervention must be carefully considered. Traditional approaches to the hemiplegic upper limb include medications and botulinum toxin injections to manage abnormalities of tone, and surgical interventions. Therapist input, including provision of orthoses, remains a mainstay although many therapies have not been well evaluated. There has been a recent increase in interventions for the hemiplegic upper limb, mostly aimed outside the period of infancy. These include trials of constraint-induced movement therapy (CIMT) and bimanual therapy as well as the use of virtual reality and robot-assisted therapy. In future, non-invasive brain stimulation may be combined with therapy. Interventions under investigation in the infant age group include modified CIMT and action observation therapy. A further approach which may be suited to the infant with thumb-in-palm deformity, but which requires evaluation, is the use of elastic taping. Enhanced cutaneous feedback through mechanical stimulation to the skin provided by the tape during movement has been postulated to modulate ongoing muscle activity. If effective, this would represent a low-cost, safe, widely applicable early intervention.

AimThe aims of this study were twofold: first, to develop and validate a timed test of unimanual and bimanual dexterity suitable for those with disability affecting hand function; second, to explore relationships between unimanual and bimanual completion times.MethodWe developed the Tyneside Pegboard Test (TPT), an electronically timed test with three peg sizes, incorporating an asymmetrical bimanual task. Nine hundred and seventy‐four participants (455 males, 519 females; age range 4–80y) provided normative data. Test–retest reliability and construct validity were assessed (50 adults: 14 males, 36 females; 15–73y) on two occasions 2 weeks apart. Bimanual and unimanual completion times were measured in 87 children (51 males, 36 females) with unilateral cerebral palsy (CP) and 498 individuals in a comparison group (238 males, 260 females; 5–15y).ResultsThe comparison group showed an asymmetrical U‐shaped relationship between completion times and age. Intraclass correlation coefficients ranged from 0.74 to 0.91, indicating moderate test–retest reliability. There was a negative relationship between average TPT bimanual times and Purdue pegboard bimanual scores (Spearman's rho −0.611, degrees of freedom 44, p<0.001). Children with unilateral CP had greater prolongation of bimanual than unimanual completion times compared with the comparison group (mean difference 20.31s, 95% confidence interval 18.13–22.49, p<0.001).InterpretationThe TPT is accessible for those with impaired hand function. Children with unilateral CP demonstrated disproportionate bimanual deficits, even allowing for unimanual dexterity: this has implications for therapy.What this paper adds We developed an adapted, electronically timed 9‐hole pegboard test.Our modifications facilitate use by those with disability affecting hand function.The test incorporates an asymmetrical bimanual task.Children with unilateral cerebral palsy showed disproportionate bimanual dexterity deficits even allowing for unimanual dexterity.