Uso das mãos por crianças com paralisia cerebral: contextos e intervenções

Abstract

The use of the hands during the accomplishment of daily living activities by children with hemiparetic cerebral palsy is influenced by contextual factors (environmental and personal) where children live. Such factors can contribute to the discrepancy between the childs capacity in the therapeutic context and his/her performance at home. Moreover, an increasing number of studies regarding high intensity interventions, such as Constraint Induced Movement Therapy (CIMT) and Hand-Arm Bimanual Intensive Training (HABIT) are presenting benefits on childrens hand function. It is important to evaluate the effects of these interventions on childrens daily functioning as it illustrates the possible transference of gains in unimanual and bimanual abilities on childrens routine. The objectives of this thesis were to comprehend the influence of contextual factors on the functional use of the hands and to evaluate the effects of high intensity interventions, CIMT and HABIT, on childrens daily living functioning. Two studies, a qualitative and a quantitative one, were performed. On Study 1 (qualitative), seven children with hemiparetic CP and his/her caregivers and occupational therapists were included. Interviews with the caregivers and occupational therapists and observations were conducted at home and clinical setting, in order to obtain information regarding physical, support and attitudinal contexts that may impact on the use of the hands by children with hemiparetic cerebral palsy, as well as childrens strategies and reactions to difficulties related to hand function. The content from the interviews and the daily log were analyzed using the N-Vivo 8 software. Three thematic categories were presented: (1) use of the hands: facilitators and barriers; (2) dealing with difficulties: strategies and reactions; (3) helping the child: types and reasons for supporting. The results point to discrepancies between the actions of caregivers and therapists, revealing the contextual specificities, facilitating or hindering the use of the hands in daily living activities, the choice of strategies and childrens reactions to the difficulties. On Study 2 (quantitative), the participants were 16 children with spastic hemiparesis who were randomly assigned to CIMT or HABIT interventions that lasted 6 hours daily, during 3 weeks, totaling 90 hours of intervention. The Pediatric Evaluation of Disability Inventory (PEDI) and the Canadian Occupational Performance Measure (COPM) were used to assess childrens daily functioning. Both groups presented significant improvements on the investigated outcomes, with group x assessment interaction on the COPM performance scale, with superior improvements on the HABIT group. The results suggest that both techniques can be used to improve childrens daily functioning.