training lead to improved performance of upper extremity

therapy and bimanual training on activity outcomes. Dev Med

function in children with hemiplegia. Dev Med Child Neurol

Child Neurol 2011; 53: 31320.

hemiplegic cerebral palsy: a randomized trial. Neurorehabil

Neural Repair (forthcoming).

8. Gordon AM, Hung YC, Brandao M, Ferre CL, Kuo HOC,

9. Gordon AM. To constrain or not to constrain, and other sto-

7. Sakzewski L, Ziviani J, Abbott D, Macdonell R, Jackson G,

Friel K, Petra E, Chinnan A, Charles JR. Bimanual training

ries of intensive upper extremity training for children with uni-

Boyd R. Randomized trial of constraint induced movement

and constraint-induced movement therapy in children with

lateral cerebral palsy. Dev Med Child Neurol (forthcoming).

2008; 50: 9578.

Bracing and splinting interventions in the upper limbs of people with

cerebral palsy
CHRISTINE IMMS
La Trobe University and Murdoch Childrens Research Institute, Melbourne, Victoria,
Australia.
doi: 10.1111/j.1469-8749.2010.03881.x
This commentary is on the original article by Louwers et al. on pages
321326 of this issue.

Research investigating the effectiveness of upper limb splinting, casting, and orthotic use with children and adults with
cerebral palsy has not, in general, been prolific or strong in
design. Clinical experience suggests that splinting contributes
to preventing contracture and deformity, and that supporting
the wrist and thumb in the functional position through splinting can enhance hand use. Thus the application of upper limb
devices is routine in settings where resources are available.
However, these interventions need to be investigated rigorously to determine both the magnitude and the mechanism of
the effect.
The study by Louwers et al.,1 although not a randomized
controlled trial (RCT), contributes evidence as a proof-ofconcept study. The single group design used the participants
as their own controls and demonstrated that bracing the wrist
and thumb enabled 50% of the children to improve bimanual
performance immediately as measured by the Assisting Hand
Assessment. Findings were consistent with a previous small
RCT2 which found that in comparison to static splints, the
immediate effect of a dynamic splint was improved grip and
dexterity with less compensatory shoulder movements. The
strengths of the Louwers et al.1 study included a priori sample
size estimate, use of a valid and reliable outcome tool, a standardized, repeatable intervention protocol, and appropriate
data analysis. Although it was not possible to blind assessors to
the treatment, strategies were implemented that aimed to
reduce measurement bias.
In 2010, a systematic review3 of RCTs investigated the
effect of muscle stretch applied using splints, casts, or orthoses
to reduce or prevent contracture in people with a wide range
of disorders. The review found no evidence of a clinically
important effect (>10) either immediately following stretch or
in the short term (maximum 7mo) for people with neurologi-

cal conditions. No research was located that addressed longterm effects. In the first instance this finding is sobering the
findings certainly suggest that we cannot expect muscle length
to be maintained through positioning within a device. However, this review only included three studies of children with
cerebral palsy. Is there any reason to think their muscles might
respond differently from other included populations? We do
know that muscle morphology differs in this group4 and it is
possible that the effects of growth may be different to adults.
In this review, it was also not possible to distinguish between
the effects of stretch for prevention, versus treatment, of contracture due to inadequate distinctions in the included studies.
Thus, no change over 7 months might represent good
evidence of prevention; however, at present we have no
long-term evidence to provide us with unbiased estimates.
Splints are rarely supplied as a stand-alone intervention for
people with cerebral palsy, however it should be noted the systematic review3 specifically aimed to isolate the effect of
stretch. This does not mean the findings should be ignored,
but rather further understood in studies that more carefully
evaluate the effect of likely combinations of interventions. For
example, there is evidence that combining botulinum toxin A
(BoNT-A) injections in the upper limb with night-time resting
splints provided a superior effect to BoNT-A alone.5
At present, we can only argue the long-term implications
of neglecting to splint muscles in lengthened positions from
our clinical experience. We urgently require data describing
the longitudinal progression of upper limb performance and
contracture. Population registers provide a mechanism for
collecting data but only if we agree to include and collect
upper limb outcomes. What are the structural, body-function, and activity performance outcomes over time for children and adults within each Manual Ability Classification
System level who receive splinting, with or without spasticity
medication, surgery, or intense upper limb therapy? With
population data as a foundation, well-designed RCTs will
enable us to tease out mechanisms that work; to determine
who may benefit from devices aimed at improving hand use
and to make reasoned decisions with regard to whether
potentially painful prolonged splinting or casting is worth the
effort or not.
Commentaries 293

REFERENCES
1. Louwers AM, Meester-Delver A, Folmer K, Nolet FB, Beelen
A. Immediate effect of a wrist and thumb brace on bimanual

in children with spastic hemiplegia: a preliminary study.

palsy: a systematic review. Dev Med Child Neurol 2010; 52:

J Hand Ther 2008; 21: 3642; quiz 3.

794804.

activities in children with hemiplegic cerebral palsy. Dev Med

3. Katalinic OM, Harvey LA, Herbert RD, Moseley AM, Lannin

5. Kanellopoulos AD, Mavrogenis AF, Papagelopoulos D, et al.

Child Neurol 2011; 53: 32126. DOI: 10.1111/j.1469-8749.

NA, Schurr K. Stretch for the treatment and prevention of

Long lasting benefits following the combination of static night

2010.03849.x.

contractures. Cochrane Database Syst Rev 2010; 9: CD007455.

upper extremity splinting with botulinum toxin A injections in

2. Burtner PA, Poole JL, Torres T, et al. Effect of wrist hand

4. Barrett RS, Lichtwark GA, Barrett RS, Lichtwark GA.

splints on grip, pinch, manual dexterity, and muscle activation

Gross muscle morphology and structure in spastic cerebral

cerebral palsy children. Eur J Phys Rehabil Med 2009; 45: 501
6.

Balance and reading are separate symptoms of dyslexia

both balance and reading deficits in dyslexia may be
explained by differences in processing, based on cerebellar
dysfunction. This is an explanatory theory which provides an
independent explanation of the other major theories of dyslexia, in particular the phonological deficit and double-deficit
theories of dyslexia. The cerebellar hypothesis itself has generated further controversy, in particular as to whether the
cerebellum is a causal factor in dyslexia or whether it should
be seen as simply an innocent bystander. The basis for
these disputes rests on a simple misunderstanding and confusion between reading deficits and dyslexia. The cerebellar
deficit claims only that the language-related regions of the
cerebellum are affected in dyslexia. These are generally
considered to be lobule VI and VIIB in the neocerebellum
well away from the motor and balance regions in the
cerebellum. Other cerebellar regions may also be affected,
but this is not necessary. The ontogenetic causal chain for
dyslexia,3 which outlines development from birth to 8 years,
makes it clear that balance deficits are not directly linked to
reading deficits, because they involve a separate route in the
causal chain.
The cerebellar deficit hypothesis would therefore predict a
higher incidence of balance difficulties in dyslexia, but that
these would not necessarily be directly correlated with reading
difficulties. The balance difficulties are best seen as symptoms

ANGELA J FAWCETT
Centre for Child Research, Swansea University, Swansea, UK.
doi: 10.1111/j.1469-8749.2010.03886.x
This commentary is on the original article by Viholainen et al. on pages
350353 of this issue.

Research into dyslexia has been characterized by controversy,

but the issue of balance and whether or not it should be seen
as causal in dyslexia has been one of the most heatedly debated
issues in recent years. The consensus of research into balance
and dyslexia over a 20-year period has been that balance deficits may be identified in around 50% of a sample of children
with dyslexia and around 20% of a sample of adults with dyslexia. It has also been argued that any evidence of balance deficits may be attributed to comorbid attention deficit in the
participants with dyslexia studied. However, recent evidence
from the Sheffield group has established that deficits may be
found in adults if the level of difficulty is manipulated in dual
task paradigms1 and has demonstrated that balance difficulties
are found in children and adults with dyslexia with age-appropriate tests even when attention-deficithyperactivity disorder
is controlled for.2
Balance deficits have been linked to the cerebellum in the
cerebellar deficit hypothesis of dyslexia,3 which argues that

Dyslexia: An ontogenetic causal chain

Birth

5 years

8 years

Balance impairment
Motor skill impairment
Cerebellar
impairment
Corticocerebellar
loop

Articulatory
skill

Phonological
awareness

Problems in automatising
skill and knowledge

294 Developmental Medicine & Child Neurology 2011, 53: 292297

Writing

Graphemephoneme
conversion
'Word recognition
module'
Verbal working
memory
Orthographic
regularities

Reading
Difficulties

Spelling