Effects of Hand-Arm Bimanual Intensive Therapy on Self-Efficacy, Motivation, and Real-World Bimanual Performance in Children with Unilateral Cerebral Palsy

Abstract

Background: Unilateral cerebral palsy (UCP) is a neurodevelopmental disorder that causes deficits in the child's upper extremity motor control, which further affects hand-arm use in relation to bimanual coordination tasks which are essential for daily living activities. These motor control deficits are known to cause low self-esteem, low self-efficacy, and anxiety in social settings. It is also known that children with UCP may experience issues with appropriate emotional regulation when facing new challenges during motor performance tasks. However, the effects that low self-esteem, low self-efficacy, emotional regulation, and motivation have on real-world bimanual performance are still unknown. Purpose: This study aims to evaluate whether hand-arm bimanual intensive therapy (HABIT), a structured, task-specific intensive intervention to improve bimanual coordination, improves self-efficacy and motivation along with real-world bimanual hand use in children with UCP. We hypothesize that (1) self-efficacy levels, in addition to motivation, affected hand use, and perceptual hand use will increase through the child's participation in the intensive bimanual intervention, HABIT and that (2) children with UCP with higher levels of motivation and self-efficacy will have greater bimanual performance gains in a real-world environment following HABIT. Methods: Twenty-two children with unilateral cerebral palsy (UCP) underwent HABIT, 6-hours per day for 5 consecutive days. During HABIT, children participated in age appropriate, intensive, task-specific, structured bimanual activities. Children with UCP were also administered questionnaires before, during, and after HABIT to evaluate changes in perceptual hand use, affected hand use, self-efficacy, and motivation levels throughout the intervention. The Children's Hand-Use Experience Questionnaire (CHEQ) and The Dimensions of Mastery Motivation Questionnaire (DMQ-18) were used to evaluate perceptual hand use and motivation levels pre- to post-intervention. Real-world bimanual performance was assessed using bilateral wrist-worn accelerometer data. Each child's responses were then recorded for further data analysis along with a self-efficacy and motivation survey that was administered during HABIT on intervention day four. A paired t-test was used to assess changes in all perceptual, motivation, and real-world bimanual performance measures. Mean improvement scores were calculated to measure improvements in self-efficacy during HABIT. A Pearson correlation analysis assessed the relationship between perceptual, self-efficacy, and real-world bimanual performance measures. Results: Following HABIT, there was a significant improvement in the perception of hand use and hand use count (p[less-than]0.01). There was a significant improvement in cognitive object persistence as well as gross motor persistence which indicates an increase in motivation to perform daily living activities in a real-world environment following HABIT (p[less-than]0.001). Mean improvement scores from both parents and interventionists showed improvements in self-efficacy because of HABIT (parents = 7± 2.08, interventionists = 7±1.01) on a 10-point Likert scale, which indicates that both parents and interventions believed their child's self-efficacy related to their affected hand use improved. There was also a significant increase in use ratio (p= 0.04), which indicates an increased contribution of the affected hand use in real-world bimanual activities. However, no correlation (p [greater-than]0.05) was found between perceptual hand use, self-efficacy, motivation, and real-world bimanual performance. Conclusion: HABIT improves the perception of hand use, self-efficacy, as well as the affected arm use in real-world activities; however, improved perception of hand use in addition to increased hand use count and motivation do not directly correlate to improved real-world bimanual performance outcomes. Given the importance of hand-arm bimanual intensive therapy as an efficacious intervention in children with UCP, more research is needed to understand the relationship between the perception and action paradigm and the factors that influence the real-world bimanual performance.