Hand-Arm Bimanual Intensive Therapy Improves Prefrontal Cortex Activation in Children With Hemiplegic Cerebral Palsy

Disruption of Sensorimotor Cortical Oscillations by Visual Interference Predicts the Altered Motor Performance of Persons with Cerebral Palsy

Emerging evidence indicates that aberrations in sensorimotor cortical oscillations likely play a key role in uncharacteristic motor actions seen in cerebral palsy. This interpretation is largely centered on the assumption that the aberrant cortical oscillations primarily reflect the motor aspects, with less consideration of possible higher-order cognitive connections. To directly probe this view, we examined the impact of cognitive interference on the sensorimotor cortical oscillations seen in persons with cerebral palsy using magnetoencephalography. Persons with cerebral palsy (N = 26, 9-47 years old) and controls (N = 46, 11-49 years) underwent magnetoencephalographic imaging while completing an arrow-based version of the Eriksen flanker task. Structural equation modeling was used to evaluate the relationship between the extent of interference generated by the flanker task and the strength of the sensorimotor cortical oscillations and motor performance. Our results indicated that the impact of cognitive interference on beta and gamma oscillations moderated the interference effect on reaction times in persons with cerebral palsy, above and beyond that seen in controls. Overall, these findings suggest that alterations in sensorimotor oscillatory activity in those with cerebral palsy at least partly reflects top-down control influences on the motor system. Thus, suppression of distracting stimuli should be a consideration when evaluating altered motor actions in cerebral palsy.

Prefrontal cortex hemodynamic activity during a test of lower extremity functional muscle strength in children with cerebral palsy: A functional near-infrared spectroscopy study

Children with cerebral palsy (CP) exhibit impaired motor control and significant muscle weakness due to a brain lesion. However, studies that assess the relationship between brain activity and performance on dynamic functional muscle strength assessments in CP are needed. The aim of this study was to determine the effect of a progressive lateral step-up test on prefrontal cortex (PFC) hemodynamic activity in children with CP. Fourteen ambulatory children with spastic CP (Gross Motor Function Classification System level I; 5-11 y) and 14 age- and sex-matched typically developing control children completed a progressive lateral step-up test at incremental step heights (0, 10, 15 and 20 cm) using their non-dominant lower limb. Hemodynamic activity in the PFC was assessed using non-invasive, portable functional neuroimaging (functional near-infrared spectroscopy). Children with CP completed fewer repetitions at each step height and exhibited lower PFC hemodynamic activity across step heights compared to controls. Lower PFC activation in CP was maintained after statistically controlling for the number of repetitions completed at each step height. PFC hemodynamic activity was not associated with LSUT task performance in children with CP, but a positive relationship was observed in controls at the most challenging 20 cm step height. The results suggest there is an altered PFC recruitment pattern in children with CP during a highly dynamic test of functional strength. Further studies are needed to explore the mechanisms underlying the suppressed PFC activation observed in children with CP compared to typically developing children.

Neuromechanism, recovery effect and case study of swimming training intervention in children with cerebral palsy: A case report

BACKGROUND

Cerebral palsy, hereinafter referred to as "cerebral palsy", refers to a non progressive injury that occurs during the development of brain tissue in fetuses or infants. The patients often have walking dysfunction, abnormal balance ability and abnormal body stability, which are mainly caused by Cranial nerves injury.

PATIENT CONCERNS

One child diagnosed with ataxia cerebral palsy by the hospital was recruited, aged 6 years and 9 months. The symptoms were: lower limb adduction and internal rotation, left neck tilt to the left due to insufficient muscle tension, and eyes squint to the right. The movement is clumsy and the coordination ability of limbs is poor; Its body balance function is poor, the sitting and standing position cannot keep the body upright and balanced for a long time, and the coordination of the random movement of hands and eyes is poor; Weak spatial cognition and orientation ability; Have persistent central motor dysfunction. When walking, the body leans forward and sideways, and the gait is staggered, which is easy to fall; In terms of expression, it shows vague language and unclear speech; Relatively retarded in intelligence.

DIAGNOSIS AND INTERVENTION

The study used swimming training intervention to report a twelve months training intervention program for a child with ataxic cerebral palsy, and evaluated it with Berg balance scale and modified Ashworth scale.

OUTCOMES

Swimming training has a significant effect on the rehabilitation of children with ataxic cerebral palsy; The forces from different directions in the water can improve the balance of children with cerebral palsy; Muscle endurance training with medium load intensity can help restore unilateral muscle tension deficiency to a certain extent, and make bilateral muscle tension gradually becomes.consistent, thus enhancing the balance ability, gait and body stability of children with cerebral palsy.

Bimanual Movement Characteristics and Real-World Performance Following Hand-Arm Bimanual Intensive Therapy in Children with Unilateral Cerebral Palsy

The purpose of this study was to quantify characteristics of bimanual movement intensity during 30 h of hand-arm bimanual intensive therapy (HABIT) and bimanual performance (activities and participation) in real-world settings using accelerometers in children with unilateral cerebral palsy (UCP). Twenty-five children with UCP participated in a 30 h HABIT program. Data were collected from bilateral wrist-worn accelerometers during 30 h of HABIT to quantify the movement intensity and three days pre- and post-HABIT to assess real-world performance gains. Movement intensity and performance gains were measured using six standard accelerometer-derived variables. Bimanual capacity (body function and activities) was assessed using standardized hand function tests. We found that accelerometer variables increased significantly during HABIT, indicating increased bimanual symmetry and intensity. Post-HABIT, children demonstrated significant improvements in all accelerometer metrics, reflecting real-world performance gains. Children also achieved significant and clinically relevant changes in hand capacity following HABIT. Therefore, our findings suggest that accelerometers can objectively quantify bimanual movement intensity during HABIT. Moreover, HABIT enhances hand function as well as activities and participation in real-world situations in children with UCP.

The Efficacy of Two Models of Intensive Upper Limb Training on Health-Related Quality of Life in Children with Hemiplegic Cerebral Palsy Mainstreamed in Regular Schools: A Double-Blinded, Randomized Controlled Trial

BACKGROUND

Children with hemiplegic cerebral palsy (CP) are at risk of reduced upper limb function and poorer quality of life than their typically developing peers. Although upper limb impairments have potential negative impact on the health-related quality of life (HRQOL) in children with hemiplegic CP, the efficacy of upper limb rehabilitation approaches aiming to improve upper limb impairments on HRQOL has not been adequately investigated.

OBJECTIVE

This study compares the efficacy of two modes of activity-based upper limb rehabilitation (modified constraint-induced movement therapy [mCIMT] and bimanual training [BIM]) on HRQOL outcomes in children with hemiplegic CP mainstreamed in regular schools.

METHODS

Thirty children with hemiplegic CP aged between 7 and 11 years (mean age 8.53 ± 1.54 years) who had functional ability levels of I-III according to the Manual Ability Classification System (MACS), Gross Motor Classification System (GMFCS), and Communication Function Classification System (CFCS) were randomly assigned to receive mCIMT or BIM training. Result: Both mCIMT and BIM yielded statistically significant improvements in all HRQOL domains immediately after the 10-week interventions (P < .001), which were retained at 16 weeks.

CONCLUSION

While there were some differences in the intervention effects, both of these upper limb rehabilitation approaches based on intensive unimanual or bimanual activity may be beneficial for improving perceived life satisfaction related to physical activity, general mood, family, friends, and school among children with hemiplegic CP mainstreamed in regular schools.

Hand-Arm Bimanual Intensive Training in Virtual Reality: A Feasibility Study

OBJECTIVE

The aim of the study was to evaluate the feasibility of virtual reality (VR) software built using the core concepts of hand-arm bimanual intensive training (HABIT) for improving upper extremity motor function in children with cerebral palsy (CP).

METHODS

Eight children with CP participated in a 10-day, 40-hour HABIT program. Half of the time custom VR software, HABIT-VR was used. The children's motor skills were assessed pre- and postintervention with the Assisting Hand Assessment, Box and Blocks Test, and Nine-Hole Peg Test.

RESULTS

The children had significant and clinically relevant changes in the Assisting Hand Assessment and Box and Blocks Test; however, Nine-Hole Peg Test scores did not change with intervention.

CONCLUSION

These data suggest that combining traditional HABIT strategies with HABIT-VR games improve upper extremity function and gross motor skills but not fine motor skills.

Selecting assessment tools to characterize upper limb function of children with cerebral palsy: A mega-review of systematic reviews

AIM

A mega-review of published systematic reviews without restriction on year of publication was implemented to summarize available assessment tools of upper limb (UL) function in children with Cerebral Palsy (CP).

METHOD

A multi-prong search strategy was used to identify 12 systematic literature reviews for inclusion in the mega-review. Included reviews were coded by descriptive analyses, which included methodological and reported measurement property description. Methodological quality of the selected systematic reviews was evaluated with the AMSTAR-2. We synthetized the measurement properties of the revised assessment tools and their coverage within the International Classification of Functioning, Disability and Health (ICF) domains.

RESULTS

The 12 systematic reviews addressed 84 assessment tools. Systematic reviews' methodological quality varied between critically low to moderate. Suggested assessment tools covered ICF domains of body structure and function, and activities and participation. Measurement property data analysis was based mostly on reliability and validity.

INTERPRETATION

Based on the findings of the mega-review, the ABILHAND-Kids, Assisting Hand Assessment (AHA) and Melbourne Assessment of Unilateral Upper Limb Function (MUUL) are the most suitable tools to evaluate children between 6 and 12 years of age with unilateral CP.

Exercise Prescription Improve the Rehabilitation of a Child With Viral Encephalitis Sequelae: A Case Report

This study conducted a personalized exercise prescription intervention on a child with viral encephalitis sequelae (VES). The purpose was to observe the rehabilitation process from the aspects of brain activation, and the curative effects on balance function and gait. A further aim was to explore the possible nerve biomechanical mechanisms between the extent of brain activation and the improvement in balance function and gait. A 12-week exercise prescription was used as the treatment method, and functional near-infrared spectroscopy (fNIRS), balance function test system, plantar pressure distribution system, and 3D gait system were used to assess the effects of the rehabilitation process pre and post the intervention. Following the exercise prescription intervention: (1) fNIRS showed that brain activation in the S1-D1, S1-D2, S1-D3, S2-D1, S3-D2, S3-D3, S4-D3, S5-D5, S5-D6, S5-D7, S7-D6, S7-D7, S8-D7, and S8-D8 increased significantly (P < 0.05). (2) The balance test showed that the area of motion ellipse and movement length of the child with eyes open decreased significantly and area of motion ellipse, back and forth swing, left and right swing and movement length of the child with eyes closed all decreased significantly (P < 0.05). (3) The static plantar pressure distribution demonstrated that the pressure center of the left and right foot decreased significantly (P < 0.05) from 5.3° dislocation in a straight line in the sagittal plane to 1°; an increment of the pressure loading was found on the forefoot of both feet compared with what was recorded in the pre-test. (4) The testing results of the 3D gait system showed that she had a shortened time of unilateral support phase and prolonged swing phase on the affected leg (P < 0.05), compared to that of the non-affected leg. Furthermore, the dual support phase had also been prolonged (P < 0.05). Conclusion: 12 weeks' individualized exercise training can enhance the activation in the motor areas and improve balance function and gait in a child with VES.

Cognitive-Motor Interference Heightens the Prefrontal Cortical Activation and Deteriorates the Task Performance in Children With Hemiplegic Cerebral Palsy

OBJECTIVE

To compare the prefrontal cortex (PFC) activation and task performance during single- and dual-task conditions between typically developing (TD) children and children with hemiplegic cerebral palsy (HCP).

DESIGN

A prospective, comparative design.

SETTING

Research laboratory.

PARTICIPANTS

Participants (N=21) included 12 TD children (age, 6.0±1.1y) and 9 children with HCP (age, 7.2±3.1).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

PFC activation was assessed by measuring the concentration of oxygenated hemoglobin while the children performed a shape-matching task with their more affected arm while sitting on a stable (single task) vs dynamic surface (dual task). The task performance was assessed with the total number of shapes matched, dual-task cost, and reaction time (RT).

RESULTS

For both conditions, the children with HCP exhibited greater PFC activation, matched a fewer shapes, and had slower RT than the TD children. These differences were accentuated during the dual-task condition and the dual-task cost was greater. An increase in the PFC activation during the dual-task condition was tightly correlated with a higher dual-task cost in children with HCP (r=0.77, P=.01).

CONCLUSIONS

Children with HCP appear to have a heightened amount of PFC activity while performing a dual task. The greater cortical activity may be a result of the finite attentional resources that are shared between both the motor as well as cognitive demands of the task. The cognitive-motor interference is likely exacerbated in children with HCP because of the structural and functional brain changes as a result of an insult to the developing brain.

Brain activation patterns underlying upper limb bilateral motor coordination in unilateral cerebral palsy: an fNIRS study

AIM

To explore cortical activation during bimanual tasks and functional correlates in unilateral cerebral palsy (CP).

METHOD

This cross-sectional study included eight participants with unilateral CP (six females, two males; mean age [SD] 20y 10mo [5y 10mo], 13y 8mo-31y 6mo) in Manual Ability Classification System levels II to III and nine age-matched participants with typical development (seven females, two males; mean age [SD] 17y 8mo [5y 7mo], 9y 4mo-24y 2mo). They performed bimanual symmetric squeezing (BSS) and bimanual asymmetric squeezing (BAS) tasks at 1Hz, and a pouring task with dominant hand (DPour) and a pouring task with non-dominant hand (NDPour) at 0.67Hz, all while a custom array of functional near-infrared spectroscopy (fNIRS) optodes were placed over their sensorimotor area. Mixed-effects were used to contrast groups, tasks, and hemispheres (corrected p-values [q] reported). Analysis of variance and t-tests compared performance measures across groups and tasks.

RESULTS

Participants with unilateral CP showed greater activation in both hemispheres during BAS (non-lesioned: q<0.001; lesioned: q<0.001), and in the lesioned hemisphere during BSS (q<0.001), DPour (q=0.02), and NDPour (q=0.02) than those with typical development. The lesioned hemisphere in unilateral CP showed more activity than the non-lesioned one (BSS: q=0.01; BAS: q=0.009; NDPour: q=0.04). During BAS, higher cortical activity correlated with more synchronous arm activation (r=0.79; p=0.02); activity lateralized towards the non-lesioned hemisphere correlated with better Pediatric Evaluation of Disability Inventory computer adaptive test scores (r=0.81; p=0.03).

INTERPRETATION

Results suggest abnormally increased sensorimotor cortical activity in unilateral CP, with implications to be investigated.

WHAT THIS PAPER ADDS

Cortical activity in manual tasks is described with functional near-infrared spectroscopy in typical and atypical cohorts. Activation levels in unilateral cerebral palsy appear to escalate with task difficulty. Increased brain activity may be associated with poorer selective manual control. Specific patterns of brain activity may be related to impaired bimanual function.

Changes of Structural Brain Network Following Repetitive Transcranial Magnetic Stimulation in Children With Bilateral Spastic Cerebral Palsy: A Diffusion Tensor Imaging Study

Introduction: Bilateral spastic cerebral palsy (BSCP) is the most common subtype of cerebral palsy (CP), which is characterized by various motor and cognitive impairments, as well as emotional instability. However, the neural basis of these problems and how repetitive transcranial magnetic stimulation (rTMS) can make potential impacts on the disrupted structural brain network in BSCP remain unclear. This study was aimed to explore the topological characteristics of the structural brain network in BSCP following the treatment of rTMS. Methods: Fourteen children with BSCP underwent 4 weeks of TMS and 15 matched healthy children (HC) were enrolled. Diffusion tensor imaging (DTI) data were acquired from children with bilateral spastic cerebral palsy before treatment (CP1), children with bilateral spastic cerebral palsy following treatment (CP2) and HC. The graph theory analysis was applied to construct the structural brain network. Then nodal clustering coefficient (C _i ) and shortest path length (L _i ) were measured and compared among groups. Results: Brain regions with significant group differences in C _i were located in the left precental gyrus, middle frontal gyrus, calcarine fissure, cuneus, lingual gyrus, postcentral gyrus, inferior parietal gyri, angular gyrus, precuneus, paracentral lobule and the right inferior frontal gyrus (triangular part), insula, posterior cingulate gyrus, precuneus, paracentral lobule, pallidum. In addition, significant differences were detected in the L _i of the left precental gyrus, lingual gyrus, superior occipital gyrus, middle occipital gyrus, superior parietal gyrus, precuneus and the right median cingulate gyrus, posterior cingulate gyrus, hippocampus, putamen, thalamus. Post hoc t-test revealed that the CP2 group exhibited increased C _i in the right inferior frontal gyrus, pallidum and decreased L _i in the right putamen, thalamus when compared with the CP1 group. Conclusion: Significant differences of node-level metrics were found in various brain regions of BSCP, which indicated a disruption in structural brain connectivity in BSCP. The alterations of the structural brain network provided a basis for understanding of the pathophysiological mechanisms of motor and cognitive impairments in BSCP. Moreover, the right inferior frontal gyrus, putamen, thalamus could potentially be biomarkers for predicting the efficacy of TMS.

Hand Motor Actions of Children With Cerebral Palsy Are Associated With Abnormal Sensorimotor Cortical Oscillations

Background. The neuroimaging literature on cerebral palsy (CP) has predominantly focused on identifying the structural aberrations (eg, fiber track integrity), with very few studies examining neural activity within the key networks that serve the production of hand movements. Objective. We aimed to start to fill this knowledge gap by using magnetoencephalographic brain imaging to quantify the temporal dynamics of the sensorimotor oscillations during a hand motor action. Methods: Children with CP (n = 12; MACS [Manual Abilities Classification System] levels I-III) and typically developing (TD) children (n = 26) performed an arrow-based version of the Eriksen flanker task where a button press was performed with either the second or third digit of the right hand depending on the arrow's direction. Results: Overall, the children with CP were less accurate and had slower reaction times compared with the TD children. These behavioral differences were closely linked with aberrant sensorimotor cortical oscillations seen in the children with CP. Compared with the TD children, the children with CP had a weaker gamma (68-82 Hz) response during motor execution and a weaker post-movement beta rebound (PMBR; 14-26 Hz) response on movement termination. Moreover, we observed a significant correlation between the amplitude of the gamma and PMBR with reaction time, with weaker gamma and PMBR responses being linked with slower reaction times. Conclusions: Overall, these results suggest that aberrations in motor-related gamma and beta cortical oscillations are associated with the impaired hand motor actions seen in children with CP.

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.

Impaired anticipatory vision and visuomotor coordination affects action planning and execution in children with hemiplegic cerebral palsy

BACKGROUND

Action-planning and execution deficits in children with hemiplegic cerebral palsy (HCP) are potentially due to deficits in the integration of sensory information, such as vision, with motor output.

AIMS

To determine differences in anticipatory visual patterns in children with HCP compared to typically developing (TD) children, and to assess visuomotor coordination in children with HCP.

METHODS AND PROCEDURES

We included 13 children with HCP (Age = 6.8 + 2.9 yrs) and 15 TD children (Age = 5.8 + 1.1 yrs). The experimental task used in this study is a valid action-planning task, which consisted of initially reaching and grasping an object placed at a fixed position, followed by placing the object in a random target position. Visual patterns were recorded using a head-mounted eye-tracker system and arm movements were recorded using motion capture (120 Hz).

OUTCOMES AND RESULTS

Children with HCP had delayed anticipatory gaze time and longer latency than TD children during the planning and execution phases. Children with HCP also had a higher frequency of gaze shifts, longer reaction times (RT) and movement times (MT) than TD children.

CONCLUSIONS AND IMPLICATIONS

Children with HCP may have deficits in anticipatory vision, which potentially affected planning and executing a goal-directed action. Therapeutic interventions focusing on improving visuomotor coordination may improve the motor performance in children with HCP.