Robot Reinforcement and Error-Based Movement Learning in Infants With and Without Cerebral Palsy

The wide world of technological telerehabilitation for pediatric neurologic and neurodevelopmental disorders - a systematic review

Introduction

The use of Information and Communication Technology (ICT) for assessing and treating cognitive and motor disorders is promoting home-based telerehabilitation. This approach involves ongoing monitoring within a motivating context to help patients generalize their skills. It can also reduce healthcare costs and geographic barriers by minimizing hospitalization. This systematic review focuses on investigating key aspects of telerehabilitation protocols for children with neurodevelopmental or neurological disorders, including technology used, outcomes, caregiver involvement, and dosage, to guide clinical practice and future research.

Method

This systematic review adhered to PRISMA guidelines and was registered in PROSPERO. The PICO framework was followed to define the search strategy for technology-based telerehabilitation interventions targeting the pediatric population (aged 0-18) with neurological or neurodevelopmental disorders. The search encompassed Medline/PubMed, EMBASE, and Web of Science databases. Independent reviewers were responsible for selecting relevant papers and extracting data, while data harmonization and analysis were conducted centrally.

Results

A heterogeneous and evolving situation emerged from our data. Our findings reported that most of the technologies adopted for telerehabilitation are commercial devices; however, research prototypes and clinical software were also employed with a high potential for personalization and treatment efficacy. The efficacy of these protocols on health or health-related domains was also explored by categorizing the outcome measures according to the International Classification of Functioning, Disability, and Health (ICF). Most studies targeted motor and neuropsychological functions, while only a minority of papers explored language or multi-domain protocols. Finally, although caregivers were rarely the direct target of intervention, their role was diffusely highlighted as a critical element of the home-based rehabilitation setting.

Discussion

This systematic review offers insights into the integration of technological devices into telerehabilitation programs for pediatric neurologic and neurodevelopmental disorders. It highlights factors contributing to the effectiveness of these interventions and suggests the need for further development, particularly in creating dynamic and multi-domain rehabilitation protocols. Additionally, it emphasizes the importance of promoting home-based and family-centered care, which could involve caregivers more actively in the treatment, potentially leading to improved clinical outcomes for children with neurological or neurodevelopmental conditions.

Systematic review registration

PROSPERO (CRD42020210663).

Generating variability from motor primitives during infant locomotor development

Motor variability is a fundamental feature of developing systems allowing motor exploration and learning. In human infants, leg movements involve a small number of basic coordination patterns called locomotor primitives, but whether and when motor variability could emerge from these primitives remains unknown. Here we longitudinally followed 18 infants on 2-3 time points between birth (~4 days old) and walking onset (~14 months old) and recorded the activity of their leg muscles during locomotor or rhythmic movements. Using unsupervised machine learning, we show that the structure of trial-to-trial variability changes during early development. In the neonatal period, infants own a minimal number of motor primitives but generate a maximal motor variability across trials thanks to variable activations of these primitives. A few months later, toddlers generate significantly less variability despite the existence of more primitives due to more regularity within their activation. These results suggest that human neonates initiate motor exploration as soon as birth by variably activating a few basic locomotor primitives that later fraction and become more consistently activated by the motor system.

Stimulating the motor development of very premature infants: effects of early crawling training on a mini-skateboard

Aim

To examine the effects of an early home-based 8-week crawling intervention performed by trained therapists on the motor and general development of very premature infants during the first year of life.

Methods

At term-equivalent age, immediately following discharge from the Neonatal Intensive Care Unit (NICU), we randomly allocated 44 premature infants born before 32 weeks' gestation without major brain damage to one of three conditions in our intervention study: crawling on a mini-skateboard, the Crawliskate (Crawli), prone positioning control (Mattress), or standard care (Control). The Crawli and Mattress groups received 5 min daily at-home training administered by trained therapists for 8 consecutive weeks upon discharge from the NICU. The outcomes of greatest interest included gross motor development (Bayley-III) at 2, 6, 9, and 12 months (primary outcome) corrected age (CA), mature crawling at 9 months CA and general development at 9 and 12 months CA [Ages and Stages Questionnaires-3 (ASQ-3)]. The study was registered at www.clinicaltrials.gov; registration number: NCT05278286.

Results

A 3 (Condition) × 4 (Age) repeated measures ANOVA revealed that Crawli group infants had significantly higher Bayley-III gross motor development scores than Mattress and Control group infants. Crawli group infants also scored significantly higher on groups of Bayley-III items related to specific motor skills than infants in the other groups, including crawling at 9 months CA. We found significant differences in favor of the Crawli group in separate one-way ANOVAs at each of the ages we examined. A 3 (Condition) × 2 (Age) repeated measures ANOVA revealed that the Crawli group scored significantly higher than the Control group for the ASQ-3 total score and communication score and significantly higher for the fine motor score than the Control and Mattress groups. We found additional significant differences in favor of the Crawli group for other dimensions of the ASQ-3 in separate one-way ANOVAs at 9 and 12 months CA.

Interpretation

Early crawling training on a Crawliskate provides an effective way to promote motor and general development in very premature infants. The findings also provide clear evidence for a link between newborn crawling and more mature crawling later in development.

Effect of Motor Intervention for Infants and Toddlers With Cerebral Palsy: A Systematic Review and Meta-analysis

PURPOSE

To conduct a systematic review and meta-analysis on the effect of motor intervention on motor function of infants and toddlers with cerebral palsy (CP).

METHODS

Four databases were searched for randomized controlled trials (RCTs) of motor interventions for children with or at high risk of CP younger than 36 months. Studies were excluded if less than 50% of children developed CP.

RESULTS

Eleven RCTs included 363 children; 85% diagnosed with CP. Very low-quality evidence supports that: (1) task-specific motor training was more effective than standard care for improving motor function (small effect), (2) constraint-induced movement therapy (CIMT) may be more effective than bimanual play or massage for improving function of the more affected hand (moderate effect), and high-intensity treadmill training is no more effective than low-intensity for improving walking.

CONCLUSIONS

Very low-quality evidence supports that task-specific motor training and CIMT may improve motor function of infants and toddlers with CP.The Supplemental Digital Content Video Abstract is available at: http://links.lww.com/PPT/A382 .

Effects of Early Motor Interventions on Gross Motor and Locomotor Development for Infants at-Risk of Motor Delay: A Systematic Review

Aim

To systematically examine the effect of early motor interventions on motor and locomotor development in infants <1 year of age with motor developmental disability or at risk of motor delay.

Methods

Pertinent literature from January 2000 to September 2021 was identified by searching the PubMed, Embase, Cochrane, Pedro and Web of Science databases. Selection criteria included interventions starting before 12 months corrected age. Methodological quality was assessed with AACPDM criteria, Mallen score and Cochrane risk of bias methodology. Evaluation procedure was performed using PRISMA protocol (PICO approach) and AMSTAR-2. This review was preregistered in PROSPERO (CRD42021286445).

Results

Ten articles met the inclusion criteria; seven had moderate to strong methodological quality. The interventions included treadmill training (n = 3), crawling training (n = 1), "tummy time" (n = 1), physical therapy with neonatal developmental program (n = 1) or Bobath approach (n = 1), treadmill training combined with active leg movements (n = 2) or Bobath physiotherapy (n = 1). The three key characteristics of effective interventions that emerged from the review were: (1) the infants' disability or risk of delay was well-defined; (2) the protocol was standardized and easy to replicate; (3) infants were required to make active movements.

Conclusion

There is an urgent need for additional high-quality studies on the effects of early motor interventions on the gross motor and locomotor development of infants with a range of disabilities or risks for delay. Suggestions for future research are outlined.

Robotic Systems for the Physiotherapy Treatment of Children with Cerebral Palsy: A Systematic Review

Cerebral palsy is a neurological condition that is associated with multiple motor alterations and dysfunctions in children. Robotic systems are new devices that are becoming increasingly popular as a part of the treatment for cerebral palsy. A systematic review of the Pubmed, Web of Science, MEDLINE, Cochrane, Dialnet, CINAHL, Scopus, Lilacs and PEDro databases from November 2021 to February 2022 was conducted to prove the effectiveness of these devices for the treatment of motor dysfunctions in children who were diagnosed with cerebral palsy. Randomized clinical trials in Spanish and English were included. In total, 653 potential manuscripts were selected but only 7 of them met the inclusion criteria. Motor dysfunctions in the lower limbs and those that are specifically related to gait are the main parameters that are affected by cerebral palsy and the robotic systems Lokomat, Innowalk, Robogait and Waltbox-K are the most commonly used. There is no consensus about the effectiveness of these devices. However, it seems clear that they have presented a good complement to conventional physical therapies, although not a therapy as themselves. Unfortunately, the low quality of some of the randomized clinical trials that were reviewed made it difficult to establish conclusive results. More studies are needed to prove and test the extent to which these devices aid in the treatment of children with cerebral palsy.

Effect of Contingency Paradigm-Based Interventions on Developmental Outcomes in Young Infants: A Systematic Review

PURPOSE

The purpose of this systematic review was to identify controlled trials evaluating the efficacy of contingency paradigm-based interventions to improve feeding, motor, or cognitive outcomes during the first year of life.

SUMMARY OF KEY POINTS

Seventeen studies, including 10 randomized controlled trials, incorporating contingency paradigm-based interventions were identified. Three of 3 trials reported improvements in nutritive sucking using pacifier-activated lullaby in preterm infants before term age. Seven of 12 trials reported improvements in reaching, manual exploration, and kicking behaviors in term and preterm infants; and 6 of 10 trials reported gains in early cognition using sticky mittens and contingent toys.

CONCLUSION AND RECOMMENDATIONS FOR CLINICAL PRACTICE

Contingency paradigm-based interventions can improve feeding outcomes in the neonatal intensive care unit in very preterm infants, and increase reaching, and perceptual-cognitive behaviors in term infants. Future research is needed to establish contingency paradigms as an effective early intervention strategy.

WHAT THIS ADDS TO THE EVIDENCE

This review synthesizes a body of literature on contingency paradigm-based interventions and highlights its potential paradigm-based interventions to improve developmental outcomes in infants.

The Impact of Cognition on Motor Learning and Skill Acquisition Using a Robot Intervention in Infants With Cerebral Palsy

Background: Cerebral Palsy (CP) is a neurodevelopmental disorder that encompasses multiple neurological disorders that appear in infancy or early childhood and persist through the lifespan of the individual. Early interventions for infants with CP utilizing assisted-motion robotic devices have shown promising effects in rehabilitation of the motor function skills. The impact of cognitive function during motor learning and skill acquisition in infants using robotic technologies is unclear.

Purpose: To assess the impact of cognitive function of infants with and without CP on their motor learning using the Self-Initiated Prone Progression Crawler (SIPPC) robot.

Methods: Statistical analysis was conducted on the data obtained from a randomized control trial in which the movement learning strategies in infants with or at risk for CP was assessed during a 16-week SIPPC robot intervention. Cognitive function was measured by the Bayley scales of Infant and Toddler Development–Third edition (Bayley-III) and motor function was measured by the Movement Observation Coding Scheme (MOCS). The infants were categorized into three distinct groups based on their cognitive scores at baseline: “above average” (n₁ = 11), “below average” (n₂ = 10), and “average” (n₃ = 26). Tri-weekly averages of the MOCS scores (observations at five time points) were used for the analyses. This study involved computing descriptive statistics, data visualization, repeated measures analysis of variances (rmANOVA), and survival analyses.

Results: The descriptive statistics were calculated for the MOCS and Bayley III scores. The repeated measures ANOVAs revealed that there was a statistically significant effect of time (p < 0.0001) on scores of all subscales of the MOCS. A statistically significant effect of interaction between group and time (p < 0.05) was found in MOCS scores of subscales 1 and 2. The survival analyses indicated that infants in different cognition groups significantly differed (p < 0.0001) in their ability to achieve the crawling milestone within the 16-week intervention period.

Conclusion: The findings in this study reveal the key movement strategies required to move the SIPPC robot, assessed by the MOCS, vary depending on the infants’ cognition. The SIPPC robot is well-matched to cognitive ability of infants with CP. However, lower cognitive ability was related to delayed improvement in their motor skills.

Implications of Optimal Feedback Control Theory for Sport Coaching and Motor Learning: A Systematic Review

Best practice in skill acquisition has been informed by motor control theories. The main aim of this study is to screen existing literature on a relatively novel theory, Optimal Feedback Control Theory (OFCT), and to assess how OFCT concepts can be applied in sports and motor learning research. Based on 51 included studies with on average a high methodological quality, we found that different types of training seem to appeal to different control processes within OFCT. The minimum intervention principle (founded in OFCT) was used in many of the reviewed studies, and further investigation might lead to further improvements in sport skill acquisition. However, considering the homogenous nature of the tasks included in the reviewed studies, these ideas and their generalizability should be tested in future studies.

Powered mobility interventions for very young children with mobility limitations to aid participation and positive development: the EMPoWER evidence synthesis

BACKGROUND

One-fifth of all disabled children have mobility limitations. Early provision of powered mobility for very young children (aged < 5 years) is hypothesised to trigger positive developmental changes. However, the optimum age at which to introduce powered mobility is unknown.

OBJECTIVE

The aim of this project was to synthesise existing evidence regarding the effectiveness and cost-effectiveness of powered mobility for very young children, compared with the more common practice of powered mobility provision from the age of 5 years.

REVIEW METHODS

The study was planned as a mixed-methods evidence synthesis and economic modelling study. First, evidence relating to the effectiveness, cost-effectiveness, acceptability, feasibility and anticipated outcomes of paediatric powered mobility interventions was reviewed. A convergent mixed-methods evidence synthesis was undertaken using framework synthesis, and a separate qualitative evidence synthesis was undertaken using thematic synthesis. The two syntheses were subsequently compared and contrasted to develop a logic model for evaluating the outcomes of powered mobility interventions for children. Because there were insufficient published data, it was not possible to develop a robust economic model. Instead, a budget impact analysis was conducted to estimate the cost of increased powered mobility provision for very young children, using cost data from publicly available sources.

DATA SOURCES

A range of bibliographic databases [Cumulative Index to Nursing and Allied Health Literature (CINHAL), MEDLINE, EMBASE™ (Elsevier, Amsterdam, the Netherlands), Physiotherapy Evidence Database (PEDro), Occupational Therapy Systematic Evaluation of Evidence (OTseeker), Applied Social Sciences Index and Abstracts (ASSIA), PsycINFO, Science Citation Index (SCI; Clarivate Analytics, Philadelphia, PA, USA), Social Sciences Citation Index™ (SSCI; Clarivate Analytics), Conference Proceedings Citation Index - Science (CPCI-S; Clarivate Analytics), Conference Proceedings Citation Index - Social Science & Humanities (CPCI-SSH; Clarivate Analytics), Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), NHS Economic Evaluation Database (NHS EED), Health Technology Assessment (HTA) Database and OpenGrey] was systematically searched and the included studies were quality appraised. Searches were carried out in June 2018 and updated in October 2019. The date ranges searched covered from 1946 to September 2019.

RESULTS

In total, 89 studies were included in the review. Only two randomised controlled trials were identified. The overall quality of the evidence was low. No conclusive evidence was found about the effectiveness or cost-effectiveness of powered mobility in children aged either < 5 or ≥ 5 years. However, strong support was found that powered mobility interventions have a positive impact on children's movement and mobility, and moderate support was found for the impact on children's participation, play and social interactions and on the safety outcome of accidents and pain. 'Fit' between the child, the equipment and the environment was found to be important, as were the outcomes related to a child's independence, freedom and self-expression. The evidence supported two distinct conceptualisations of the primary powered mobility outcome, movement and mobility: the former is 'movement for movement's sake' and the latter destination-focused mobility. Powered mobility should be focused on 'movement for movement's sake' in the first instance. From the budget impact analysis, it was estimated that, annually, the NHS spends £1.89M on the provision of powered mobility for very young children, which is < 2% of total wheelchair service expenditure.

LIMITATIONS

The original research question could not be answered because there was a lack of appropriately powered published research.

CONCLUSIONS

Early powered mobility is likely to have multiple benefits for very young children, despite the lack of robust evidence to demonstrate this. Age is not the key factor; instead, the focus should be on providing developmentally appropriate interventions and focusing on 'movement for movement's sake'.

FUTURE WORK

Future research should focus on developing, implementing, evaluating and comparing different approaches to early powered mobility.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42018096449.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology programme and will be published in full in Health Technology Assessment; Vol. 24, No. 50. See the NIHR Journals Library website for further project information.

Early Intervention for Children Aged 0 to 2 Years With or at High Risk of Cerebral Palsy: International Clinical Practice Guideline Based on Systematic Reviews

IMPORTANCE

Cerebral palsy (CP) is the most common childhood physical disability. Early intervention for children younger than 2 years with or at risk of CP is critical. Now that an evidence-based guideline for early accurate diagnosis of CP exists, there is a need to summarize effective, CP-specific early intervention and conduct new trials that harness plasticity to improve function and increase participation. Our recommendations apply primarily to children at high risk of CP or with a diagnosis of CP, aged 0 to 2 years.

OBJECTIVE

To systematically review the best available evidence about CP-specific early interventions across 9 domains promoting motor function, cognitive skills, communication, eating and drinking, vision, sleep, managing muscle tone, musculoskeletal health, and parental support.

EVIDENCE REVIEW

The literature was systematically searched for the best available evidence for intervention for children aged 0 to 2 years at high risk of or with CP. Databases included CINAHL, Cochrane, Embase, MEDLINE, PsycInfo, and Scopus. Systematic reviews and randomized clinical trials (RCTs) were appraised by A Measurement Tool to Assess Systematic Reviews (AMSTAR) or Cochrane Risk of Bias tools. Recommendations were formed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework and reported according to the Appraisal of Guidelines, Research, and Evaluation (AGREE) II instrument.

FINDINGS

Sixteen systematic reviews and 27 RCTs met inclusion criteria. Quality varied. Three best-practice principles were supported for the 9 domains: (1) immediate referral for intervention after a diagnosis of high risk of CP, (2) building parental capacity for attachment, and (3) parental goal-setting at the commencement of intervention. Twenty-eight recommendations (24 for and 4 against) specific to the 9 domains are supported with key evidence: motor function (4 recommendations), cognitive skills (2), communication (7), eating and drinking (2), vision (4), sleep (7), tone (1), musculoskeletal health (2), and parent support (5).

CONCLUSIONS AND RELEVANCE

When a child meets the criteria of high risk of CP, intervention should start as soon as possible. Parents want an early diagnosis and treatment and support implementation as soon as possible. Early intervention builds on a critical developmental time for plasticity of developing systems. Referrals for intervention across the 9 domains should be specific as per recommendations in this guideline.

Parents of Preterm and Very Low Birthweight Infants and Their Childrearing Practices

Emerging research supports that early intervention leads to better health and higher functional status for infants with very low birthweight and/or low gestational age. Optimizing the transition from neonatal intensive care to early intervention programs relies heavily on parent engagement. The purpose of this descriptive correlational study was to investigate the relationship between parental characteristics, childrearing behaviors, and participation in early intervention. We used convenience sampling of 49 parents who participated in early intervention and the Parent Behavior Checklist to assess parent characteristics. Correlation coefficients between parenting behaviors, birthweight, and participation in early intervention were low. An important finding was that most parents in this study were within the "average" range for childrearing practices, despite the documented challenges associated with very low birthweight or gestational age. Despite documented challenges, parents of preterm infants with very low birthweight and parents of typical birthweight infants have similar parenting beliefs and behavior.

Maturation of the Locomotor Circuitry in Children With Cerebral Palsy

The first years of life represent an important phase of maturation of the central nervous system, processing of sensory information, posture control and acquisition of the locomotor function. Cerebral palsy (CP) is the most common group of motor disorders in childhood attributed to disturbances in the fetal or infant brain, frequently resulting in impaired gait. Here we will consider various findings about functional maturation of the locomotor output in early infancy, and how much the dysfunction of gait in children with CP can be related to spinal neuronal networks vs. supraspinal dysfunction. A better knowledge about pattern generation circuitries in infancy may improve our understanding of developmental motor disorders, highlighting the necessity for regulating the functional properties of abnormally developed neuronal locomotor networks as a target for early sensorimotor rehabilitation. Various clinical approaches and advances in biotechnology are also considered that might promote acquisition of the locomotor function in infants at risk for locomotor delays.