Innovative study shows therapy’s lasting impact on children’s hand function
Sometimes rigorous scientific research and therapeutic treatment comes in the form of a ninja warrior course.
A Hand-Arm Bimanual Intensive Training, or HABIT, study participant shoots a basketball on the court at the Health Sciences Student Center gym.
Natalie McBryde graduated from East Carolina University in May 2024 with a degree in exercise physiology. The Holly Springs native’s master’s thesis revolved around self-efficacy in children who received treatment for muscular deficits in their hands and arms.
As part of her research, she assisted with a camp that assessed novel treatments for kids with muscular deficits in their hands and arms, often a result of cerebral palsy. One child, an 8-year-old with a love of watching extreme obstacle courses on TV, had longed to be just another kid swinging from the monkey bars at his school’s playground. His motor deficits made that nearly impossible — until McBryde and other ECU student physical therapists and interventionists created an obstacle course specifically for him.
“A big thing for him was watching the show, ‘American Ninja Warrior,’ with his family. He said, ‘This is the one thing that I would love to be able to do’ and he could not stop talking about it,” McBryde remembered.
McBryde recalled the challenge of creating a course that not only filled a child’s long-held desire but was also as therapeutic as it was creative and fulfilling to the camp staff.
“Our team had to make sure the kids were lifting themselves up, pulling up, holding their own weight and using their hands to crawl through obstacles. It was such a joy, and was the most meaningful experience because it was not only enjoyable for the child, but the parents had a blast watching their child participate, too,” McBryde said.
McBryde works in Raleigh as an exercise specialist in a rehabilitation clinic, and is applying to physical therapy doctoral programs, in large part because of seeing the smile on her ninja warrior’s face at the end of the course.
A novel study
In mid-2022 Dr. Swati Surkar, assistant professor of physical therapy at the College of Allied Health Sciences and the study’s director, began researching the applicability of Hand-Arm Bimanual Intensive Training, or HABIT, in children with unilateral cerebral palsy.
A student volunteer helps a Hand-Arm Bimanual Intensive Training, or HABIT, participant in a race at the Health Sciences Student Center gym.
The technique involves inducing ischemia, or the restriction of blood flow, to part of a person’s arm and then having the person perform a series of tasks once the blood flow resumes normally. In past studies, HABIT interventions had proven effective in improving coordination, but little research had been conducted to assess its effectiveness in improving and retaining real-world bimanual activities and hand function.
Over the past two years, Surkar and a team of student volunteers from a wide range of majors and research interests have held HABIT camps for children mostly from North Carolina, but from as far away as Florida, New Hampshire and even Mexico.
During the camps, the children were fitted with watch-like monitors that were worn on both wrists and captured an incredible amount of data about how their hands and arms moved —including range of motion and speed — during the intensive therapy. After the ischemia was induced through a blood pressure cuff, the children would stack cups, throw balls or move through obstacle courses that demanded a lot of effort from both arms.
Her research is showing very promising results.
“We found that after the therapy the affected hand’s function improves and not only that, but it transferred into day-to-day activities,” Surkar said.
The second part of the study asked the children to wear the same monitors at home at three-day intervals at one, three and six months after the in-person camps to see if measurable improvements from the therapy helped in the real world. Once Surkar and her team received the tracking devices back in the mail, they crunched the data and found that while the therapy is effective, the benefits start to wane after a few months.
“We found the effect of this intensive therapy kind of lasts for three months, but after that it started declining,” Surkar said.
It’s not just the wrist-worn tracking devices that are giving Surkar and her team insight into how the body is connected to the brain in her study participants, she is also using a sophisticated brain scanning technique called transcranial magnetic stimulation (TMS) that can show how “excitable” a person’s brain is before and after treatment. Surkar is plowing through a huge data set from two study cohorts that promises novel results.
An anomaly in the results that Surkar is pursing is why some of the children saw a significant response to the therapy and others had relatively modest improvements.
“We are trying to identify what the factors are that make someone responsive versus nonresponsive to the therapy,” Surkar said.
Improving self-efficacy
McBryde master’s project investigated the way that the children — who are limited in their physical capability and are often self-conscious of their condition — perceive the effects of the therapy. Did they feel a greater sense of self-confidence? Did they perceive themselves as being more capable physically because of the therapy?
Natalie McBryde, an ECU alum, participated in the College of Allied Health Science’s Hand-Arm Bimanual Intensive Training, or HABIT, research study.
The results were an emphatic ‘yes.’
“The children felt that they improved, and they actually improved on their assessment,” Surkar said. “The biggest improvement that we saw was that the children actually believed, after the intervention, that they were using their hands better. We also saw improvements in their self-efficacy — how well they believed they were using their hands, which was really awesome,” McBryde said.
The intensive nature of the therapy camps — 7 hours a day for 5 days — with lots of one-one-one attention from physical therapists and students in training, meant the kids saw incredible gains, but their experiences weren’t without some setbacks, she said.
“The camp translates to anything we do in life: the more practice, the better that we get. What the children were seeing was not only the skills that they needed to learn, but also that the skills we need to learn can also be fun and our team really worked hard to make it that way,” McBryde said.
For many children with physical differences, in addition to the frustrations of not being as capable as their more able-bodied peers is the emotional and social challenge of being the other. McBryde believes one of the reasons the campers achieved so much progress is being able to let their guard down — to just be another kid.
“When they see other children who may need to work on the same skills, the children feel a sense of belonging which in turn, leads to further success. This is important because we know group and peer support can be crucial in terms of performance,” McBryde said.
While the children benefited from the intensive therapies, so did their caregivers. Parents learned the therapeutic techniques the children were exposed to and were able to translate those play-based activities at home, which McBryde believes helped reinforce and extend the gains they saw outside of the camp.
A way forward
While a silver bullet solution for the kids in Surkar’s study would be an incredible gift, that isn’t likely — but her findings are promising.
“We found, overall, that intensive therapies are great, they do work, but the effects are not lifelong. They need to repeat those intensive therapies, we can infer from our study at least every three months, so the effects that we saw could be retained longer,” Surkar said.
Surkar’s research shows that the improvements that the children in her study experienced will require dedication and effort to maintain — it’s no different than the rest of the population needs to go to the gym to stay strong, or musicians who need to practice their instrument to play fluidly.
McBryde knows that the path forward for the children in the HABIT study will be challenging, but she saw in their faces the hope and promise for improvement and greater self-confidence in kids who need both the most.
“It’s common in this type of research to just see the data on the sheet, but when you watch these children and how much they gain, even over five days, it’s mind blowing,” McBryde said. “To be a part of that is spectacular.”