Impaired Voluntary Movement Control and Its Rehabilitation in Cerebral Palsy

The Bead Maze Hand Function Test for Children

IMPORTANCE

There is a need for a pediatric hand function test that can be used to objectively assess movement quality. We have developed a toy-based test, the Bead Maze Hand Function (BMHF) test, to quantify how well a child performs an activity. This is achieved by assessing the control of forces applied while drawing a bead over wires of different complexity.

OBJECTIVE

To study the psychometric properties of the BMHF test and understand the influence of age and task complexity on test measures.

DESIGN

A cross-sectional, observational study performed in a single visit.

SETTING

Clinical research laboratory.

PARTICIPANTS

Twenty-three participants (ages 4-15 yr) were recruited locally. They were typically developing children with no illness or conditions that affected their movement. Interventions/Assessments: Participants performed the BMHF test and the Box and Block test with both hands.

OUTCOMES AND MEASURES

Total force and completion time were examined according to age and task complexity using a linear mixed-effects model. We calculated intraclass correlation coefficients to measure interrater reliability of the method and estimated concurrent validity using the Box and Block test.

RESULTS

Total force and completion time decreased with age and depended on task complexity. The total force was more sensitive to task complexity. The Box and Block score was associated with BMHF completion time but not with total force. We found excellent interrater reliability.

CONCLUSIONS AND RELEVANCE

A familiar toy equipped with hidden sensors provides a sensitive tool to assess a child's typical hand function. Plain-Language Summary: We developed the Bead Maze Hand Function (BMHF) test to determine how well a child performs an activity with their hands. The BMHF test is a toy equipped with hidden sensors. Twenty-three typically developing children with no illnesses or conditions that affected their hand movement participated in the study. We asked the children to perform the BMHF test with both hands. Our study found that occupational therapists can reliably use the BMHF test to assess a child's hand function.

Effects of Nonimmersive Virtual Reality Intervention on Children With Spastic Cerebral Palsy: A Meta-analysis and Systematic Review

ABSTRACT

This review aimed to assess the effectiveness of nonimmersive virtual reality intervention compared with traditional rehabilitation in improving the functions of the upper and lower limbs, balance, and social participation among children with spastic cerebral palsy. We used librarian-designed searches of 10 databases to identify research articles on randomized controlled trials that assessed the effectiveness of nonimmersive virtual reality in intervening spastic cerebral palsy patients up to April 15, 2023. Independent evaluation was conducted by two trained investigators using the evaluation criteria of randomized controlled trial quality indicated in the Cochrane Manual of Assessment "risk-of-bias tool." The Physical Therapy Evidence Database scale was used to evaluate the method and quality of the literature. Twenty-one research articles involving 779 patients with spastic cerebral palsy were included. Significant differences between the nonimmersive virtual reality rehabilitation and traditional rehabilitation groups were observed in all indicators, except for the Jebsen-Taylor Hand Function Test. Nonimmersive virtual reality intervention is effective in improving the function of the lower extremity, balance, and social participation in children with spastic cerebral palsy, but its effect on upper limb function is still controversial.

Upper Limb Motor Planning in Individuals with Cerebral Palsy Aged between 3 and 21 Years Old: A Systematic Review

Individuals with cerebral palsy have difficulties performing activities of daily living. Beyond motor execution impairments, they exhibit motor planning deficits contributing to their difficulties. The objective of this review is to synthesize the behavioral evidence of motor planning deficits during an upper limb motor task in children, adolescents and young adults with cerebral palsy aged between 3 and 21 years. Methods: The inclusion criteria were: (1) including individuals with cerebral palsy from 3 to 21 years old; (2) assessing upper limb motor planning. Six databases were screened. The quality assessment of the studies was performed. Results: Forty-six studies and 686 participants were included. Five articles have been identified as very high quality, 12 as high, 20 as moderate, six as low, three as very low. Force planning studies reported a deficit for the more affected hand but adequate performances for the less affected hand. Object-manipulation studies reported hand posture planning deficits irrespectively of the hand assessed. Conclusions: Motor planning deficits has been shown in the more affected hand for force scaling, while the results for other variables showed overall deficits. Hence, variables affected by motor planning deficits in both hands should be considered in children with cerebral palsy to optimize intervention.

Improvements in Upper Extremity Function Following Intensive Training Are Independent of Corticospinal Tract Organization in Children With Unilateral Spastic Cerebral Palsy: A Clinical Randomized Trial

Background/Objectives: Intensive training of the more affected upper extremity (UE) has been shown to be effective for children with unilateral spastic cerebral palsy (USCP). Two types of UE training have been particularly successful: Constraint-Induced Movement Therapy (CIMT) and Bimanual training. Reorganization of the corticospinal tract (CST) early during development often occurs in USCP. Prior studies have suggested that children with an ipsilateral CST controlling the affected UE may improve less following CIMT than children with a contralateral CST. We tested the hypothesis that improvements in UE function after intensive training depend on CST laterality.

Study Participants and Setting: Eighty-two children with USCP, age 5 years 10 months to 17 years, University laboratory setting.

Materials/Methods: Single-pulse transcranial magnetic stimulation (TMS) was used to determine each child's CST connectivity pattern. Children were stratified by age, sex, baseline hand function and CST connectivity pattern, and randomized to receive either CIMT or Bimanual training, each of which were provided in a day-camp setting (90 h). Hand function was tested before, immediately and 6 months after the intervention with the Jebsen-Taylor Test of Hand Function, the Assisting Hand Assessment, the Box and Block Test, and ABILHAND-Kids. The Canadian Occupational Performance Measure was used to track goal achievement and the Pediatric Evaluation of Disability Inventory was used to assess functioning in daily living activities at home.

Results: In contrast to our hypothesis, participants had statistically similar improvements for both CIMT and Bimanual training for all measures independent of their CST connectivity pattern (contralateral, ipsilateral, or bilateral) (p < 0.05 in all cases).

Conclusions/Significance: The efficacy of CIMT and Bimanual training is independent of CST connectivity pattern. Children with an ipsilateral CST, previously thought to be maladaptive, have the capacity to improve as well as children with a contralateral or bilateral CST following intensive CIMT or Bimanual training.

Clinical Trial Registration:www.ClinicalTrials.gov, identifier NCT02918890.

Performance Variability During Motor Learning of a New Balance Task in a Non-immersive Virtual Environment in Children With Hemiplegic Cerebral Palsy and Typically Developing Peers

Background: Motor impairments contribute to performance variability in children with cerebral palsy (CP) during motor skill learning. Non-immersive virtual environments (VEs) are popular interventions to promote motor learning in children with hemiplegic CP. Greater understanding of performance variability as compared to typically developing (TD) peers during motor learning in VEs may inform clinical decisions about practice dose and challenge progression. Purpose: (1) To quantify within-child (i.e., across different timepoints) and between-child (i.e., between children at the same timepoint) variability in motor skill acquisition, retention and transfer in a non-immersive VE in children with CP as compared to TD children; and (2) To explore the relationship between the amount of within-child variability during skill acquisition and learning outcomes. Methods: Secondary data analysis of 2 studies in which 13 children with hemiplegic CP and 67 TD children aged 7-14 years undertook repeated trials of a novel standing postural control task in acquisition, retention and transfer sessions. Changes in performance across trials and sessions in children with CP as compared to TD children and between younger (7-10 years) and older (11-14 years) children were assessed using mixed effects models. Raw scores were converted to z-scores to meet model distributional assumptions. Performance variability was quantified as the standard deviation of z-scores. Results: TD children outperformed children with CP and older children outperformed younger children at each session. Older children with CP had the least between-child variability in acquisition and the most in retention, while older TD children demonstrated the opposite pattern. Younger children with CP had consistently high between-child variability, with no difference between sessions. Within-child variability was highest in younger children, regardless of group. Within-child variability was more pronounced in TD children as compared to children with CP. The relationship between the amount of within-child variability in performance and performance outcome at acquisition, retention and transfer sessions was task-specific, with a positive correlation for 1 study and a negative correlation in the other. Conclusions: Findings, though preliminary and limited by small sample size, can inform subsequent research to explore VE-specific causes of performance variability, including differing movement execution requirements and individual characteristics such as motivation, attention and visuospatial abilities.

Brain Metabolism During A Lower Extremity Voluntary Movement Task in Children With Spastic Cerebral Palsy

Reduced selective voluntary motor control (SVMC) is a primary impairment due to corticospinal tract (CST) injury in spastic cerebral palsy (CP). There are few studies of brain metabolism in CP and none have examined brain metabolism during a motor task. Nine children with bilateral spastic CP [Age: 6-11 years, Gross Motor Function Classification System (GMFCS) Levels II-V] completed this study. SVMC was evaluated using Selective Control Assessment of the Lower Extremity (SCALE) ranging from 0 (absent) to 10 (normal). Brain metabolism was measured using positron emission tomography (PET) scanning in association with a selective ankle motor task. Whole brain activation maps as well as ROI averaged metabolic activity were correlated with SCALE scores. The contralateral sensorimotor and superior parietal cortex were positively correlated with SCALE scores (p < 0.0005). In contrast, a negative correlation of metabolic activity with SCALE was found in the cerebellum (p < 0.0005). Subsequent ROI analysis showed that both ipsilateral and contralateral cerebellar metabolism correlated with SCALE but the relationship for the ipsilateral cerebellum was stronger (R ² = 0.80, p < 0.001 vs. R ² = 0.46, p = 0.045). Decreased cortical and increased cerebellar activation in children with less SVMC may be related to task difficulty, activation of new motor learning paradigms in the cerebellum and potential engagement of alternative motor systems when CSTs are focally damaged. These results support SCALE as a clinical correlate of neurological impairment.

Children with cerebral palsy display altered neural oscillations within the visual MT/V5 cortices

Cortical visual processing in visual MT/V5 is necessary for tracking movement and performing reliable visuomotor transformations. Although the role of this cortical area is well recognized, the activity of the visual MT/V5 cortical area in children with cerebral palsy (CP) has not been examined nor has its potential role in the atypical motor actions of these children been considered. This study used magnetoencephalography to image the neural activity in the motion-sensitive MT/V5 cortices of typically developing (TD) children (n = 21; mean age 14 yrs. ± 2, 12 males) and children with CP (n = 21; mean age 16 yrs. ± 4, 13 males) as they viewed a horizontally moving stimulus. Behavioral measures of visual perception were additionally assessed by having the participants press a button when the visual stimulus changed to moving in vertical direction. Our results showed that the horizontal movement of the visual stimulus evoked changes in the strength of the theta-alpha (5-10 Hz) and alpha-beta (8-20 Hz) oscillations in the visual MT/V5 area of all participants. Compared with the TD children, the children with CP had weaker alpha-beta oscillations in the visual MT/V5 cortices. In addition, the children with CP took longer to perceive a directional change of the visual stimulus and made more errors in detecting the change. Lastly, weaker alpha-beta oscillations were correlated with slower detection of the change in motion direction and less accuracy in identifying the change. This study shows that the uncharacteristic neural oscillations in the visual MT/V5 cortical area may partially account for the abnormal perceptions and motor decisions seen in children with CP.

Constraint-induced movement therapy in a patient with ataxia after cerebellar tumor resection

Abstract Introduction: Constraint-induced movement therapy (CIMT) is a very modern method used in rehabilitation to treat individuals with functional impairment of the upper limbs. Objective: To apply the CIMT method and evaluate its effects in a patient with ataxia after removal of a cerebellar tumor. Method: This is a longitudinal interventional study of the case report type. The participant complained of tremors and difficulty writing and typing with the right hand as a result of the cerebellar tumor’s removal. She was subjected to CIMT daily in three-hour sessions for 10 days. The participant was evaluated with the Motor Activity Log (MAL) and the Wolf Motor Function Test (WMFT). Results: There was an improvement in the quantity, quality, speed, accuracy and strength with which the participant performed the tasks according to the MAL and WMFT scales. Improvement in writing was also identified and the report of better use of the member for daily tasks demonstrated the patient’s satisfaction after the end of therapy. Conclusion: This case report demonstrated the benefits of the application of the CIMT method in a patient with ataxia as a consequence of a rare cerebellar tumor, improving task execution time, strength and functional improvement of the affected upper limb.

The Relationship Between Hand Function and Overlapping Motor Representations of the Hands in the Contralesional Hemisphere in Unilateral Spastic Cerebral Palsy

BACKGROUND

In many children with unilateral spastic cerebral palsy (USCP), the corticospinal tract to the affected hand atypically originates in the hemisphere ipsilateral to the affected hand. Such ipsilateral connectivity is on average a predictor of poor hand function. However, there is high variability in hand function in these children, which might be explained by the complexity of motor representations of both hands in the contralesional hemisphere.

OBJECTIVE

To measure the link between hand function and the size and excitability of motor representations of both hands, and their overlap, in the contralesional hemisphere of children with USCP.

METHODS

We used single-pulse transcranial magnetic stimulation to measure the size and excitability of motor representations of both hands, and their overlap, in the contralesional hemisphere of 50 children with USCP. We correlated these measures with manual dexterity of the affected hand, bimanual performance, and mirror movement strength.

RESULTS

The main and novel findings were (1) the large overlap in contralesional motor representations of the 2 hands and (2) the moderate positive associations of the size and excitability of such shared-site representations with hand function. Such functional associations were not present for overall size and excitability of representations of the affected hand.

CONCLUSIONS

Greater relative overlap of the affected hand representation with the less-affected hand representation within the contralesional hemisphere was associated with better hand function. This association suggests that overlapping representations might be adaptively "yoked," such that cortical control of the child's less-affected hand supports that of the affected hand.

Effects of Robot-Assisted Training for the Unaffected Arm in Patients with Hemiparetic Cerebral Palsy: A Proof-of-Concept Pilot Study

On a voluntary basis, 10 adolescents with hemiparesis due to cerebral palsy and 11 neurologically healthy control subjects participated in this proof-of-concept pilot study. The aim was to examine the effects of robot-assisted training for the unaffected arm in patients with hemiparetic cerebral palsy. Baseline comparison between the unaffected arm of the hemiparetic patients with cerebral palsy and the dominant arm of healthy control subjects showed significant differences on the Jebsen-Taylor Hand Function test and action planning ability tests. Within-group comparison after ten 30-minute sessions (five days a week for two consecutive weeks) of robot-assisted training for the unaffected arm showed significant improvements in patients with cerebral palsy on the Jebsen-Taylor Hand Function test (performed at both hands) and action planning ability test (evaluated at the unaffected arm). Our findings are in line with previous evidences of action planning deficits at the unaffected arm in patients with hemiparetic cerebral palsy and support the hypothesis that robot-assisted training for the unaffected arm may be useful to improve manual dexterity and action planning in patients with hemiparesis due to cerebral palsy.