Motor performance of children with cerebral palsy in anterior reach

Checks and balances: a meta-analysis on the known-groups validity of functional postural control tests in children

INTRODUCTION

Pediatric physical therapists commonly treat children with postural control deficits. Ideally, pediatric functional postural control tests should therefore be able to identify postural control deficits in children with various disorders. Despite a plethora of available tests, evidence for their validity - especially known-groups - remains scarce. This review aims to determine the known-group validity of available functional postural control tests to differentiate various pediatric pathological groups of different ages from their typically developing (TD) peers.

EVIDENCE ACQUISITION

PubMed, Web of Science and Scopus were systematically searched (last update: February 2023; PROSPERO: CRD42023408982). Forty case-control studies with a pathological pediatric sample (N.=1331) and TD peers (N.=1889) were included and selected for data-extraction and -analysis. Risk of bias was assessed using the SIGN checklist and level of evidence was scored using GRADE. Random-effect meta-analyses were performed to estimate pooled standardized mean differences (SMD) for the various test types and subclassified based on pathology and/or age.

EVIDENCE SYNTHESIS

When compared with TD peers, children with underlying pathologies performed significantly worse on pediatric functional postural control test batteries (SMD=-2.21), the Timed Up and Go Test and variants (SMD=2.30), the One Leg Stance test and variants (SMD=-2.14), while the Reach tests showed a smaller difference (SMD=-1.19). Subclassification within the meta-analyses showed that pathology was an influencing factor for the test batteries and the one leg stance test and variants. Age was an influencing factor for the reach tests. None of the included functional postural control tests exceeded a low level of evidence.

CONCLUSIONS

Pediatric functional postural control tests that assess multiple aspects of postural control (such as test batteries) seem to offer higher known-groups validity than single-task tests (e.g. reach tests). The underlying pathology has a larger impact on the validity of these tests than age. There remains an overall low level of evidence for the known-groups validity of pediatric functional postural control tests indicating the need for research with more homogenous groups and norm reference data.

A systematic review of instrumented assessments for upper limb function in cerebral palsy: current limitations and future directions

INTRODUCTION

Recently, interest in quantifying upper limb function in cerebral palsy has grown. However, the lack of reference tasks and protocols, have hindered the development of quantified movement analysis in clinical practice. This study aimed to evaluate existing instrumented assessments of upper limb function in cerebral palsy, with a focus on their clinical applicability, to identify reasons for the lack of adoption and provide recommendations for improving clinical relevance and utility.

METHODS

A systematic review was conducted by a multidisciplinary team of researchers and clinicians (Prospero CRD42023402382). PubMed and Web of Science databases were searched using relevant keywords and inclusion/exclusion criteria.

RESULTS

A total of 657 articles were initially identified, and after the selection process, 76 records were included for analysis comprising a total of 1293 patients with cerebral palsy. The quality assessment of the reviewed studies revealed a moderate overall quality, with deficiencies in sample size justification and participant information. Optoelectronic motion capture systems were predominantly used in the studies (N = 57/76). The population mainly consisted of individuals with spastic cerebral palsy (834/1293) with unilateral impairment (N = 1092/1293). Patients with severe functional impairment (MACS IV and V) were underrepresented with 3.4% of the 754 patients for whom the information was provided. Thirty-nine tasks were used across the articles. Most articles focused on unimanual activities (N = 66/76) and reach or reach and grasp (N = 51/76). Bimanual cooperative tasks only represented 3 tasks present in 4 articles. A total of 140 different parameters were identified across articles. Task duration was the most frequently used parameter and 23% of the parameters were used in only one article.

CONCLUSION

Further research is necessary before incorporating quantified motion analysis into clinical practice. Existing protocols focus on extensively studied populations and rely on costly equipment, limiting their practicality. Standardized unimanual tasks provide limited insights into everyday arm use. Balancing methodological requirements and performance evaluation flexibility is a challenge. Exploring the correlation between outcome parameters and therapeutic guidance could facilitate the integration of quantified movement assessment into treatment pathways.

Effects of a multi-component virtual reality program on motor skills and functional postural control in children with hemiplegic cerebral palsy

Background

Pediatric neurorehabilitation has recently employed virtual reality (VR) technologies as a platform to design and implement novel modalities.

Aims

To evaluate the feasibility of a multi-component VR-based program on motor skills and functional postural control for children with hemiplegic cerebral palsy (HCP).

Methods

A single-case-experimental design was conducted on eight children with HCP (12.33 ± 4.71 years and GMFCS= II, I). The VR-based program consisted of 3 sessions per week for four weeks. Timed Up and Go (TUG) test, Functional Reach Test (FRT), Pediatric Balance Scale (PBS), Activities Scale for Kids (ASK), ABILHAND-Kids, and Box and Block Test (BBT) were used to evaluate functional changes.

Outcomes and results

Statistical analysis showed that improvements in functional postural control were significant on at least one balance measure for seven out of eight participants during the intervention phase. For all participants, a significant increase was observed in the BBT scores. Before-after intervention analysis revealed statistically significant improvements in PBS (z = -2.52, p ≤ 0.01), ABILHAND-Kids (z = -2.25, p ≤ 0.01), and ASK (z = -2.38, p ≤ 0.01).

Conclusions and implications

This study provided early evidence of the effectiveness of the multi-component VR-based program in children with HCP. However, future studies with randomized controlled trial design are needed to evaluate the long-term effects and compare them with conventional rehabilitation practice.

Acupuncture in the Treatment of Abnormal Muscle Tone in Children with Cerebral Palsy: A Meta-Analysis

Objective

To analyse the clinical efficacy of acupuncture and routine treatment in improving dystonia in children with cerebral palsy.

Method

The randomized controlled trials published from the establishment of the databases to August 2022 on acupuncture in the treatment of dystonia in children with cerebral palsy were collected and comprehensively searched in China national knowledge infrastructure (CNKI), weipu (VIP), Wanfang, SinoMed, PubMed, Excerpta medica database (EMBASE), and Cochrane Library. The literature was selected according to the established standards, the quality of the included studies was evaluated, the heterogeneity of the included studies was evaluated with the I² test, and the appropriate model was selected for analysis. Sensitivity analysis was used to evaluate the reliability of the results, and a funnel plot was used to evaluate the publication bias.

Results

Fifteen studies were included in the meta-analysis. The control group was treated with routine treatment and acupuncture combined with routine treatment. The outcome index showed that the effect in the treatment group was better: Modified Ashworth Scale score: -0.52, 95% confidence interval (CI) (-0.62 to -0.41), p < 0.01. The treatment group showed reduced muscle tension to a greater extent (integral eletromyographic (iEMG) score: standard mean square deviation = -2.97, 95% CI (-4.87 to -1.06), p < 0.01). The effective rate in the control group was 74.2% and that in the treatment group was 91.5%, odds ratio = 3.70, 95% CI (2.02-6.78), p < 0.01. The funnel plot showed publication bias.

Conclusion

Acupuncture combined with routine training could improve muscle tension abnormalities and improve the efficiency of clinical treatment.

Neuromuscular Electrical Stimulation Improves Muscle Strength, Biomechanics of Movement, and Functional Mobility in Children With Chronic Neurological Disorders: A Systematic Review and Meta-Analysis

OBJECTIVE

Chronic neurological disorders (CNDs) generally produce deleterious effects on the musculoskeletal system and can affect physical activity and increase sedentary behavior in children, hindering the execution of training programs and the attainment of a correct dose of exercise. The purpose of this systematic review was to analyze the effect of neuromuscular electrical stimulation (NMES) on skeletal muscle and then on biomechanics of movement, functional mobility, strength, spasticity, muscle architecture, and body composition of children and adolescents with CNDs and chronic diseases.

METHODS

The search was conducted in April 2020 in PubMed, MEDLINE, Scopus, the Cochrane Library, and Web of Science, without publication period restriction. Publications investigating the effect of NMES on children and adolescents with CNDs and other chronic diseases were independently selected by 2 researchers. One author independently extracted data from the studies selected, and a second author cross-checked.

RESULTS

Eighteen studies with 595 participants aged between 3 and 14 years were included. Quality assessment showed that 50% of the studies presented a low risk of bias. The pooled effect of NMES on gross motor functional measure, calculated as a standardized mean difference using a random effects model, was 0.41 (95% CI = 0.19-0.64).

CONCLUSION

The use of NMES programs for children diagnosed with cerebral palsy, spinal muscular atrophy, and obstetric injury of the brachial plexus was effective in improving muscle strength, biomechanics of movement, and functional mobility.

IMPACT

NMES can be a useful tool to prevent the reduction of mobility that results from CNDs.

Serious Game Platform as a Possibility for Home-Based Telerehabilitation for Individuals With Cerebral Palsy During COVID-19 Quarantine - A Cross-Sectional Pilot Study

Introduction

There is a need to maintain rehabilitation activities and motivate movement and physical activity during quarantine in individuals with Cerebral Palsy (CP).

Objective

This paper sets out to evaluate the feasibility and potential benefits of using computer serious game in a non-immersive virtual reality (VR) implemented and evaluated completely remotely in participants with CP for Home-Based Telerehabilitation during the quarantine period for COVID-19.

Methods

Using a cross-sectional design, a total of 44 individuals participated in this study between March and June 2020, 22 of which had CP (14 males and 8 females, mean age = 19 years, ranging between 11 and 28 years) and 22 typically developing individuals, matched by age and sex to the individuals with CP. Participants practiced a coincident timing game¹ and we measured movement performance and physical activity intensity using the rating of perceived exertion Borg scale.

Results

All participants were able to engage with the VR therapy remotely, reported enjoying sessions, and improved performance in some practice moments. The most important result in this cross-sectional study was the significant increasing in rating of perceived exertion (through Borg scale) in both groups during practice and with CP presenting a higher rating of perceived exertion.

Conclusion

Children with CP enjoyed participating, were able to perform at the same level as their peers on certain activities and increased both their performance and physical activity intensity when using the game, supporting the use of serious games for this group for home therapy and interactive games.

Clinical Trials Registration

https://Clinicaltrials.gov, NCT04402034. Registered on May 20, 2020.

Analysis of dynamic elbow flexion deformity in children with hemiplegic cerebral palsy

BACKGROUND

Cerebral palsy affects 1 per 1.000 children, and in 83% of the cases upper extremity is involved. Dynamic elbow flexion deformity is a movement disorder observed in individuals with hemiparesis secondary to cerebral palsy. We sought to determine whether children with hemiplegic cerebral palsy exhibit dynamic elbow flexion deformity during daily activities and its influence to reaching function.

METHODS

Sixteen children with upper limb hemiparesis and cerebral palsy (age 11y 7mo (SD 3y 2mo); 11 boys, 5 girls; Gross Motor Function Classification System level I or II) were included in this observational descriptive study. Manual Ability Classification System, Children's Hand-use Experience Questionnaire and Shriners Hospital for Children Upper Extremity Evaluation were used to evaluate affected upper extremity function. Spasticity was assessed with Modified Ashworth scale. Involuntary elbow flexion was recorded in eight daily activities. Elbow motion during reach function was measured.

FINDINGS

Fifteen out of 16 individuals showed dynamic elbow flexion deformity. There was a significative increase of involved median elbow flexion in all the activities studied, except for "high speed stairs climbing" evaluation. Children's Hand-use Experience Questionnaire showed that children were independent in most of the daily activities (21 out of 29). Correlation between dynamic elbow flexion deformity and Shriners Hospital for Children Upper Extremity Evaluation was observed only in sitting-standing activity (Spearman's ρ 0.549, P = 0.028).

INTERPRETATION

Dynamic elbow flexion deformity is very common in hemiplegic cerebral palsy and occurs proportionally to the degree of the effort demanded by the activities. Despite of presenting this movement disorder, it does not affect in children participation in daily activities.

Balance confidence and physical activity participation of independently ambulatory youth with cerebral palsy: an exploration of youths' and parents' perspectives

AIM

Youth with cerebral palsy generally participate in less physical activity than typically developing peers. In adults with physical disabilities, balance confidence is a strong predictor of participation and community re-integration. However, balance confidence has not been studied in youth with cerebral palsy.

METHOD

Qualitative descriptive methodology with interviews of eight youth with cerebral palsy (9-17 years old, three girls) in Gross Motor Function Classification System Levels I-III, and eight parents (five mothers) of youth with cerebral palsy (9-17 years old, two girls) in Levels I-III.

RESULTS

Three themes arose: (1) youth in Gross Motor Function Classification System Levels I-II are more concerned about losing their balance during physical activities than those in Level III; (2) when balance is lost, embarrassment and frustration are more common than fear, especially for those in Levels I-II; and (3) social factors can create a favorable participation environment when balance confidence is low, especially for youth in Levels I-II.

CONCLUSION

Balance confidence may have greater influence on physical activity participation for youth in Gross Motor Function Classification System Levels I-II than those in Level III. Youth in Levels I-II may draw greater benefit from interventions targeting balance confidence when addressing physical activity goals.IMPLICATIONS FOR REHABILITATIONBalance confidence may have a greater influence on activity avoidance for youth with cerebral palsy in Gross Motor Function Classification System Levels I and II (who are independently ambulatory without walkers or cane(s)) than for those in Level II (who use walkers or cane(s) to ambulate).Youth who are independently ambulatory without walkers or cane(s) may benefit more from interventions directed at balance confidence (e.g., enactive mastery and verbal persuasion) to address their physical activity participation goals.For youth who are independently ambulatory without walkers or cane(s), addressing factors that could reduce the influence of balance confidence on physical activity participation, such as providing a positive and supportive social environment in which to participate, may be beneficial.