Our experienced Research Lead Dr Daisy Fancourt is working across a number of pioneering research programmes to explore the impact of the arts within clinical settings across the UK and further afield.
When it comes to the science part, rigorous research has been undertaken into our flagship programme – Breathe Magic Intensive Therapy Foundation. We are continuing to look at the psychosocial and physiological impacts of this programme and have expanded it to run successful pilots with adult stroke patients and young people with mental health problems.
We also regularly evaluate the impact of our Performing Arts programme to ensure what we offer genuinely helps patients, staff and visitors to enjoy more positive hospital experiences. In 2016 we hope to start a clinical research study to further explore its effect on the hospital community.
BREATHE MAGIC INTENSIVE THERAPY FOUNDATION: RESEARCH STUDIES
Breathe has successfully designed, researched and delivered an innovative treatment incorporating specially selected and scaled magic hand tricks and theatre skills into the Hand-Arm Bimanual Intensive Therapy (HABIT) programme, an intensive task-focused therapy for children with hemiplegia. The result is Breathe Magic Intensive Therapy Foundation (Breathe Magic).
Research on the programme, led by an international team since 2010, has been published in peer-reviewed journals, presented at international conferences and won a number of prestigious awards.
Below is a summary of these research studies. If you’d like to know more about our research or any of the following studies, please get in touch.
The first four research articles in this summary are about the HABIT protocol, the intensive therapy programme Breathe Magic is founded on. The second four list the results of our own research into the effects of incorporating magic into the HABIT approach.
An introduction to HABIT: hand-arm bimanual intensive training
Charles, J. R., & Gordon, A. M. (2006). Development of hand-arm bimanual intensive training (HABIT) for improving bimanual coordination in children with hemiplegic cerebral palsy. Developmental Medicine & Child Neurology, 48, 931–936.
There is limited evidence for the efficacy of most current treatments for hand rehabilitation.
Constraint-induced movement therapy (CI) (previously considered the gold-standard treatment for hemiplegia) has limitations such as being invasive due the use of restraints and not addressing important aspects such as bimanual coordination.
Treatment for hemiplegia should be seeking to increase functional independence during daily activities through using both hands.
Hand-arm bimanual intensive training (HABIT) retains the two major elements of CI therapy (intensive structured practice and child-friendliness) but addresses the weaknesses of CI.
HABIT focuses on (1) provision of structured practice increasing in complexity, (2) provision of functional activities that necessitate bimanual hand use, (3) remaining a child-friendly intervention.
HABIT requires 10 weekdays of 6 hours per day (60 hours) in groups.
HABIT differs from standard physical and occupational therapy and also from CIMT by (1) being of far greater intensity, (2) active involvement of the assisting hand rather than merely use as a passive assist.
However, HABIT can be challenging to administer because the tasks involved (such as toys and games) could be carried out by the strong hand so the only thing making a young person use their assisting hand is verbal cues from the therapist. This can lead to frustration from the young person.
Evidence of the benefits of HABIT
Gordon, A. M., Schneider, J., Chinnan, A., & Charles, J. R. (2007). Efficacy of a hand-arm bimanual intensive therapy (HABIT) in children with hemiplegic cerebral palsy: a randomized control trial. Developmental Medicine & Child Neurology, 49, 830–838.
Control: usual care
The intervention led to significant improvements in spontaneous use and performance of the affected hand (Assisting Hand Assessment, p<0.012), Changes were found in 17 of the 22 test items. Changes were still significantly higher than baseline at 1-month follow up.
Children increased their usage of the hand from 62.6% pre-intervention to 77.8% after (p<0.001). This was maintained at 1-month follow up.
The intervention led to significant improvements in motor skills (Bruininks-Oseretsky Test, p=0.023) and continued to improve for the month following.
There was no change in the efficiency of grasp and release of items (Jebsen-Taylor Test of Hand Function).
Caregivers of children perceived greater improvement in the amount of use of the affected hand (p<0.024). This improvement was maintained at 1-month post-test.
Caregivers also perceived improved quality of movement (p=0.016).
The intervention led to a three-fold decrease in time to complete tasks (drawer-opening task, near- significant p<0.055).
Noval, I., McIntyre, S., Morgan, C., Campbell, L., Dark, L., Morton, N., Stumbles, E., Wilson, S., Goldsmith, S. (2013) A systematic review of interventions for children with cerebral palsy: state of the evidence. Developmental Medicine and Child Neurology, 55, 885-910.
A systematic review of 166 papers involving young people with cerebral palsy was undertaken. Bimanual training was given a ‘green light’ meaning that its effect in improving motor activities can be reliably assumed and further research is very unlikely to change our confidence in the estimate of effect.
NICE (2012). Spasticity in children and young people with non-progressive brain disorders, July, Manchester.
National Institute for Health and Clinical Excellence (NICE) guidelines recommend bimanual therapy (unrestrained use of both arms) to enhance manual skills in children affected by spasticity with non- progressive brain disorders.
Task-focused active-use therapy is advised to be intensive over a short time period.
Following the intensive therapy, it is recommended that an adapted physical therapy programme is established, or children can go on to any of the further treatments such as Botulinum Toxin Type A or selective dorsal rhizotomy.
However, despite this recommendation, no HABIT programmes are currently available on the NHS in the UK.
MAGIC HABIT PROGRAMMES
An introduction to ‘Magic-themed’ HABIT: Breathe Magic
Novak, I. (2013). A magical moment in research translation: strategies for providing high intensity bimanual therapy. Developmental Medicine & Child Neurology, 55(6), 491–491.
It is extremely difficult to motivate children to do high-intensity practice.
Magic-themed HABIT is a novel learning mode and establishes a greater ‘achievement’ goal as motivation.
Magic HABIT is culturally broad, given evidence that it works equally amongst Israeli and British children.
Magic HABIT has been shown to work equally with more severe hemiplegia, which refutes previous clinical concerns that it was only suitable for mild versions.
Magic HABIT has been shown to work in a group setting, making it more cost-effective.
Traditional models of therapy (working weekly or monthly) are now outdated and HABIT should be considered instead.
Evidence of the benefits of Magic HABIT
Green, D., Schertz, M., Gordon, A. M., Moore, A., Schejter Margalit, T., Farquharson, Y., … Fattal-Valevski, A. (2013). A multi-site study of functional outcomes following a themed approach to hand–arm bimanual intensive therapy for children with hemiplegia. Developmental Medicine & Child Neurology, 55(6), 527–533.
Control: baseline control period for each participant prior to intervention
The intervention led to significant improvements in spontaneous use and performance of the affected hand (Assisting Hand Assessment, p=0.002) and in independence in bimanual activities (Children’s Hand Experience Questionnaire, p<0.001). Changes in independence in bimanual activities were maintained at follow-up (p<0.001).
Children improved their speed in the grasp and release of items (Jebsen-Taylor Test of Hand Function, p<0.001) with improvements of over 2 minutes (128.9 seconds) across the six tasks. These improvements were maintained at 3 month follow-up (p<0.001)
The affected hand was reported to be used in 72% of bimanual activities before the camp, progressing to 93% after camp, and decreasing to 86% at follow-up.
Neither age nor severity of impairment influenced progress.
92% of children with a Manual Ability Score of 2 (indicative of mild difficulty handling objects) showed improvements (12 out of 13 children)
75% of children with a Manual Ability Score of 3 (indicative of difficulty handling objects) showed improvements (6 out of 8 children).
Weinstein, M., Myers, V., Green, D., Schertz, M., Shiran, S., Geva, R., Artzi, M., Gordon, A. M., Fattal-Valevski, A. & Bashat, D. B. (2015). Brain plasticity following intensive bimanual therapy in children with hemiparesis: preliminary evidence. Neural Plasticity.
92% of children (N=12) had a clinically significant improvement in bimanual ability after the intervention on at least 1 test, and 67% on 2 or more tests
75% of children (n=8) maintained improvement at 6 week follow-up
This study also shows the first evidence of brain plasticity in hemiplegia following bimanual intervention:
a. Neuroimaging showed that there was a 26.14% increase in level of activation in the affected hemisphere from before to after the intervention (shown in beta values), and a 34.75% at follow- up.
b. In typically developing children, motor activation is primarily unilateral, limited to the hemisphere contralateral to the hand in movement. However, children in this study had primarily bilateral activity. But imaging showed that of the 11 children who improved behaviourally, 4 showed improvements in lateralisation index, with increased activation in the affected hemisphere.
c. Increased white matter integrity was detected in the corpus callosum and corticospinal tract after the 60 hours of therapy in about half of the participants. This was associated with better hand function.
Schertz, M., Shiran, S., Myers, V., Weinstein, M., Fattal-Valevski, Artzi, M., Bashat, D. B. Gordon, A. M. & Green, D. (2016). Imaging predictors of improvement from a motor learning based intervention for children with unilateral cerebral palsy. Neurorehabilitation and Neural Repair.
Improvements were seen across the 2-week programme in bimanual abilities, bimanual independence and unimanual hand function. Improvement was maintained in bimanual independence and unimanual hand function at follow-up.
Children with greater overall brain damage (higher radiological score and decreased cortical activation in the affected hemisphere in fMRI) had greater improvement in post-treatment on bimanual function.
Diffusion tensor imaging in the PLIC (posterior limb of the internal capsule) and CST (corticospinal tract), indicating more white matter damage, were also associated with greater improvement on bilateral function.
A number of studies have tried to determine ‘best responders’. Much remains unknown but what has been shown through this study is that no child had no capacity for improvement.
WANT TO LEARN MORE?
If you’re interested in finding out more about our research or any of the studies above, please get in touch.