Upper limb impairments, process skills, and outcome in children with unilateral cerebral palsy

Does somatosensory discrimination therapy alter sensorimotor upper limb function differently compared to motor therapy in children and adolescents with unilateral cerebral palsy: study protocol for a randomized controlled trial

BACKGROUND

Besides motor impairments, up to 90% of the children and adolescents with unilateral cerebral palsy (uCP) present with somatosensory impairments in the upper limb. As somatosensory information is of utmost importance for coordinated movements and motor learning, somatosensory impairments can further compromise the effective use of the impaired upper limb in daily life activities. Yet, intervention approaches specifically designated to target these somatosensory impairments are insufficiently investigated in children and adolescents with uCP. Therefore, the aim of this randomized controlled trial (RCT) is to compare the effectiveness of somatosensory discrimination therapy and dose-matched motor therapy to improve sensorimotor upper limb function in children and adolescents with uCP, who experience somatosensory impairments in the upper limb. We will further explore potential behavioral and neurological predictors of therapy response.

METHODS

A parallel group, evaluator-blinded, phase-II, single-center RCT will be conducted for which 50 children and adolescents with uCP, aged 7 to 15 years, will be recruited. Participants will be randomized to receive 3 weekly sessions of 45 minutes of either somatosensory discrimination therapy or upper limb motor therapy for a period of 8 weeks. Stratification will be performed based on age, manual ability, and severity of tactile impairment at baseline. Sensorimotor upper limb function will be evaluated at baseline, immediately after the intervention and after 6 months follow-up. The primary outcome measure will be bimanual performance as measured with the Assisting Hand Assessment. Secondary outcomes include a comprehensive test battery to objectify somatosensory function and measures of bimanual coordination, unimanual motor function, and goal attainment. Brain imaging will be performed at baseline to investigate structural brain lesion characteristics and structural connectivity of the white matter tracts.

DISCUSSION

This protocol describes the design of an RCT comparing the effectiveness of somatosensory discrimination therapy and dose-matched motor therapy to improve sensorimotor upper limb function in children and adolescents with uCP. The results of this study may aid in the selection of the most effective upper limb therapy, specifically for children and adolescents with tactile impairments.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT06006065). Registered on August 8, 2023.

Electromyographic biofeedback training in a cerebral palsy patient undergoing pronator teres rerouting and brachioradialis to extensor carpi radialis brevis tendon transfer surgery: A case report

Several surgical procedures are used to treat dynamic pronation position of the forearm and flexion deformity of the wrist in cerebral palsy. Postoperative results of pronator teres rerouting were explored, while specially designed postoperative physiotherapy and its outcomes were limited. Herein, we present a case in whom the outcomes of electromyographic biofeedback (EMG-BF) training were assessed after pronator teres rerouting and brachioradialis tendon to extensor carpi radialis brevis tendon transfer combined with derotation osteotomy. The peak value increased, while the resting value decreased for the muscles after the intervention. Range of motion, hand function, manual ability, functional independence, and quality of life levels were improved. In conclusion, EMG biofeedback training may have a positive effect on neuromuscular control of pronator teres and brachioradialis. Free use of the upper extremity and improved manual ability positively affect the activity and quality of life of the patients.

Efficacy of Robot-Assisted Gait Therapy Compared to Conventional Therapy or Treadmill Training in Children with Cerebral Palsy: A Systematic Review with Meta-Analysis

BACKGROUND

Motor, gait and balance disorders reduce functional capabilities for activities of daily living in children with cerebral palsy (CP). Robot-assisted gait therapy (RAGT) is being used to complement conventional therapy (CT) or treadmill therapy (TT) in CP rehabilitation. The aim of this systematic review is to assess the effect of RAGT on gait, balance and functional independence in CP children, in comparison to CT or TT.

METHODS

We have conducted a systematic review with meta-analysis. A search in PubMed Medline, Web of Science, Scopus, CINAHL, PEDro and SciELO has been conducted for articles published until October 2022. Controlled clinical trials (CCT), in which RAGT was compared to TT or CT and assessed gait speed, step and stride length, width step, walking distance, cadence, standing ability, walking, running and jumping ability, gross motor function and functional independence in children with CP, have been included. Methodological quality was assessed with the PEDro scale and the pooled effect was calculated with Cohen's Standardized Mean Difference (SMD) and its 95% Confidence Interval (95% CI).

RESULTS

A total of 15 CCTs have been included, providing data from 413 participants, with an averaged methodological quality of 5.73 ± 1.1 points in PEDro. The main findings of this review are that RAGT shows better results than CT in the post-intervention assessment for gait speed (SMD 0.56; 95% CI 0.03 to 1.1), walking distance (SMD 2; 95% CI 0.36 to 3.65) and walking, running and jumping ability (SMD 0.63; 95% CI 0.12 to 1.14).

CONCLUSIONS

This study shows that the effect of RAGT is superior to CT on gait speed, walking distance and walking, running and jumping ability in post-intervention, although no differences were found between RAGT and TT or CT for the remaining variables.

Effectiveness of Mechanical Horse-Riding Simulator-Based Interventions in Patients with Cerebral Palsy-A Systematic Review and Meta-Analysis

BACKGROUND

Mechanical horse-riding simulator (HRS) exercises are a type of therapy based on the use of robotic or mechanical devices that produces movement similar to a real horse with the aim of simulating hippotherapy. This review analyses the effectiveness of HRS therapies in patients with cerebral palsy (CP).

METHODS

A systematic review and a meta-analysis were carried out by searching studies in PubMed Medline, SCOPUS, Web of Science, CINAHL, PEDro and SciELO up until October 2022. We selected clinical trials that assessed the effectiveness of HRS therapy, compared to other interventions, in patients with CP. The main variables were gross motor function (its global score and dimensions, such as sitting ability), functional balance, spasticity, hip range of motion (ROM), posturographic balance and satisfaction. The risk of bias was assessed using the Cochrane Risk of Bias Tool. The pooled effect was calculated using Cohen's Standardized Mean Difference (SMD) for a 95% confidence interval (95% CI).

RESULTS

Twelve studies were included in the systematic review, and 10 were included in the meta-analysis, providing data from 343 patients with spastic diplegic CP. Our findings revealed that HRS plus physiotherapy is more effective than physiotherapy in improving the total gross motor function (SMD 0.98; 95% CI 0.35-1.62), sitting ability of the gross motor function (SMD 0.84; 95% CI 0.32-1.36) and functional balance (SMD 0.6; 95% CI 0.1-1.08), and HRS therapy is better than sham to improve pelvic abduction ROM (SMD 0.79; 95% CI 0.21-1.37).

CONCLUSIONS

Horse-riding simulator-based therapy is an effective therapy to improve gross motor function, functional balance and abduction pelvic ROM in children with CP, in comparison to physiotherapy or sham.

Nintendo® Wii Therapy Improves Upper Extremity Motor Function in Children with Cerebral Palsy: A Systematic Review with Meta-Analysis

BACKGROUND

Nintendo^® Wii-based therapy (NWT) is a non-immersive virtual reality therapy used to recover upper extremity (UE) motor function in children with cerebral palsy (CP). We aimed primarily to elucidate the effectiveness of NWT in improving UE motor and functional impaired abilities in children with CP, compared to conventional therapy or no intervention. The secondary aim was to assess if NWT is more effective when used alone or combined with conventional therapy.

METHODS

A systematic review with meta-analysis was conducted from a bibliographic search in PubMed, Scopus, PEDro, Web of Science, and CINHAL, ending in October 2021, in accordance with PRISMA guidelines. We included randomized controlled trials that compared NWT vs. conventional therapy or no intervention in terms of their impact on different UE impaired abilities (grip strength, tip grip strength, UE dissociated movements, functional capacity in daily living activities, gross and fine motor dexterity, and grasping ability) in children with CP. Effect size was calculated with standardized mean difference (SMD) and its 95% confidence interval (95% CI).

RESULTS

Nine studies (276 participants) were included. NWT is more effective than conventional therapy at improving grip strength (SMD = 0.5, 95% CI 0.08, 0.91), tip grip strength (SMD = 0.95, 95% CI 0.3, 1.61), and grasping ability (SMD = 0.72, 95%CI 0.14, 1.3). NWT is more effective than conventional therapy at improving functional capacity in daily living activities (SMD = 0.83, 95% CI 0.07, 1.56). For fine manual dexterity, NWT was better than no intervention (SMD = 3.12, 95% CI 1.5, 4.7).

CONCLUSIONS

Our results indicate that NWT is effective at improving various UE impaired motor skills in children with CP.

Effect of upper extremity constraints on functional and dynamic postural control in children with hemiplegic cerebral palsy

PURPOSE

To compare the effects of upper extremity constraints on functional and dynamic postural control in children with hemiplegic cerebral palsy.

MATERIALS AND METHODS

Twelve children with hemiplegic cerebral palsy and 12 typically developing children ages 5 to 12 years (GMFCS I-II) were evaluated with the Timed Up and Go (TUG) and Biodex Balance System during three upper extremity (UE) conditions: 1) Free UEs (no constraints), 2) Simple UE constraint (unaffected/dominant UE constrained with a sling), and 3) Difficult UE constraint (Simple constraint plus the other UE holding cup of water).

RESULTS

The UE condition had significant effects on Overall Stability Index (OSI) (F_(2,44) = 24.899, p < .001), Medial-Lateral Stability Index (MLSI) (F_(2,44) = 4.380, p = .018), Anterior-Posterior Stability Index (F_(2,44) = 6.187, p = .004), and TUG scores (F_(2,44) = 113.372, p < .001). Group was significant for OSI (F_(1,22) = 7.906, p = .010), MLSI (F_(1,22) = 13.113, p = .002), and TUG (F_(1,22) = 36.282, p < .001).

CONCLUSIONS

The upper extremity appears to have a role in maintaining functional balance and postural stability in children with hemiplegic cerebral palsy and should be considered during intervention programs.

Nintendo Wii Balance Board therapy for postural control in children with cerebral palsy: a systematic review and meta-analysis

AIM

To analyse the efficacy of Nintendo Wii therapy (NWT) on functional balance in children with cerebral palsy (CP).

METHOD

A systematic review with meta-analysis (PROSPERO identification number CRD42020169510) was performed using randomized controlled trials (RCTs) that examined the effect of NWT on functional, dynamic, and static balance in children with CP, assessed with the Pediatric Balance Scale, the Timed Get Up and Go Test, and the One Leg Stance Test respectively. The pooled effect was calculated using the Cohen's standardized mean difference (SMD).

RESULTS

Eleven RCTs with 270 children (when sex was reported: 43% females, 57% males) with CP (mean age [SD] 10y 1mo [1y 1mo], range 5-16y) were included. On functional balance, we found very low-quality evidence with a large effect of NWT compared with no intervention (SMD 0.95, 95% confidence interval [CI] 0.02-1.89) and moderate-quality evidence for using NWT plus conventional physical therapy (CPT) versus CPT (SMD 0.78, 95% CI 0.20-1.35) in sessions of approximately 30 minutes (SMD 0.86, 95% CI 0.20-1.52) and interventions lasting longer than 3 weeks (SMD 1.03, 95% CI 0.58-1.47). For dynamic balance, very low-quality evidence for a medium effect for using NWT plus CPT versus CPT (SMD 0.70, 95% CI 0.12-1.29) was found.

INTERPRETATION

NWT can be considered an effective treatment for improving functional and dynamic balance in children with CP, especially when combined with CPT in 30-minute sessions with interventions lasting longer than 3 weeks. What this paper adds Moderate-quality evidence with a large effect of Nintendo Wii therapy (NWT) on functional balance, compared with conventional physical therapy (CPT). Moderate-quality evidence with medium effect of NWT plus CPT on functional and dynamic balance, compared with CPT. Appropriate NWT sessions should be equal to or slightly less than 30 minutes. NWT interventions must be longer than 3 weeks.

Perinatal stroke: mapping and modulating developmental plasticity

Most cases of hemiparetic cerebral palsy are caused by perinatal stroke, resulting in lifelong disability for millions of people. However, our understanding of how the motor system develops following such early unilateral brain injury is increasing. Tools such as neuroimaging and brain stimulation are generating informed maps of the unique motor networks that emerge following perinatal stroke. As a focal injury of defined timing in an otherwise healthy brain, perinatal stroke represents an ideal human model of developmental plasticity. Here, we provide an introduction to perinatal stroke epidemiology and outcomes, before reviewing models of developmental plasticity after perinatal stroke. We then examine existing therapeutic approaches, including constraint, bimanual and other occupational therapies, and their potential synergy with non-invasive neurostimulation. We end by discussing the promise of exciting new therapies, including novel neurostimulation, brain-computer interfaces and robotics, all focused on improving outcomes after perinatal stroke.

Impact of Sensory Deficits on Upper Limb Motor Performance in Individuals with Cerebral Palsy: A Systematic Review

People living with cerebral palsy (CP) exhibit motor and sensory impairments that affect unimanual and bimanual functions. The importance of sensory functions for motor control is well known, but the association between motor and sensory functions remains unclear in people living with CP. The objective of this systematic review was to characterize the relationship between sensory deficits and upper limb motor function in individuals living with CP.

METHODS

Five databases were screened. The inclusion criteria were: (1) including people living with CP, (2) reporting measurements of upper limb motor and sensory functions. A qualitative analysis of the studies' level of evidence was done.

RESULTS

Thirty-three articles were included. Twenty-five articles evaluated tactile functions, 10 proprioceptive functions and 7 visual functions; 31 of the articles reported on unimanual functions and 17 of them reported on bimanual functions. Tactile functions showed a moderate to high association; it was not possible to reach definitive conclusions for proprioceptive and visual functions.

CONCLUSIONS

The heterogeneity of the results limits the ability to draw definitive conclusions. Further studies should aim to perform more comprehensive assessments of motor and sensory functions, to determine the relative contribution of various sensory modalities to simple and more complex motor functions.

Hand function and self-care in children with cerebral palsy

AIM

To examine the relationship between self-care and bimanual performance in children aged 8 to 12 years with cerebral palsy (CP).

METHOD

This was a cross-sectional study of 74 children with CP (unilateral n=30, bilateral n=44; 48 males, 26 females; median age 9y 8mo [25th, 75th centiles 9y 1mo, 10y 8mo], Manual Abilities Classification System level I=30, II=28, III=16). Self-care was measured using the Pediatric Evaluation of Disability Inventory-Computer Adaptive Test (PEDI-CAT), and bimanual performance using the Assisting Hand Assessment (AHA) and Both Hands Assessment (BoHA). Measures of cognition, behavioural regulation, inattention, and gross motor function were included. Analyses used a directed acyclic graph to select variables for linear regression modelling.

RESULTS

Higher AHA and BoHA scores were associated with higher PEDI-CAT scores. An increase of 1 AHA unit was associated with an increase of 0.12 PEDI-CAT scores, and a 1 BoHA unit increase was associated with an increase of 0.17 PEDI-CAT scores. The BoHA accounted for 57% of variance in PEDI-CAT scores for children with bilateral CP, while BoHA and cognition accounted for 68% of variance. The AHA accounted for 40% of variance in PEDI-CAT scores for unilateral CP with no effect of cognition on self-care.

INTERPRETATION

Self-care was strongly and positively associated with bimanual performance. Associations between self-care and bimanual performance differed for those with unilateral and bilateral CP.

WHAT THIS PAPER ADDS

There is a strong positive relationship between self-care and bimanual performance for unilateral and bilateral cerebral palsy (CP). Both Hands Assessment (BoHA) scores have a stronger association with self-care than Assisting Hand Assessment scores. BoHA scores also account for more variation in self-care. There is a strong positive relationship between self-care and cognition overall. The effect of cognition on self-care performance differed for bilateral and unilateral CP.

Sleep, cognition and executive functioning in young children with cerebral palsy

Children with cerebral palsy (CP) are at higher risk for sleep disturbances than their typically developing peers. In typically developing young children, lack of sufficient sleep results in deficits in cognition, behavior and executive functioning. Unfortunately, research on sleep in infancy rarely focuses on children with neurodevelopmental disabilities. Studies of older children with CP demonstrate that roughly half of children with CP have a sleep disorder, though screening for sleep disorders in children with CP is not routinely performed. Given the high prevalence of sleep abnormalities in older children with CP and the resulting adverse effects on functioning, understanding sleep derangements and how they affect cognition and executive functioning in these children at earlier ages is critical. In this chapter, we present the state of the evidence for sleep characteristics, cognition and executive functions for infants and toddlers 0-3years old with CP.

Development and evaluation of a novel music-based therapeutic device for upper extremity movement training: A pre-clinical, single-arm trial

Restoration of upper limb motor function and patient functional independence are crucial treatment targets in neurological rehabilitation. Growing evidence indicates that music-based intervention is a promising therapeutic approach for the restoration of upper extremity functional abilities in neurologic conditions such as cerebral palsy, stroke, and Parkinson's Disease. In this context, music technology may be particularly useful to increase the availability and accessibility of music-based therapy and assist therapists in the implementation and assessment of targeted therapeutic goals. In the present study, we conducted a pre-clinical, single-arm trial to evaluate a novel music-based therapeutic device (SONATA) for upper limb extremity movement training. The device consists of a graphical user interface generated by a single-board computer displayed on a 32" touchscreen with built-in speakers controlled wirelessly by a computer tablet. The system includes two operational modes that allow users to play musical melodies on a virtual keyboard or draw figures/shapes whereby every action input results in controllable sensory feedback. Four motor tasks involving hand/finger movement were performed with 21 healthy individuals (13 males, aged 26.4 ± 3.5 years) to evaluate the device's operational modes and main features. The results of the functional tests suggest that the device is a reliable system to present pre-defined sequences of audiovisual stimuli and shapes and to record response and movement data. This preliminary study also suggests that the device is feasible and adequate for use with healthy individuals. These findings open new avenues for future clinical research to further investigate the feasibility and usability of the SONATA as a tool for upper extremity motor function training in neurological rehabilitation. Directions for future clinical research are discussed.

The Upper Extremity Flexion Synergy Is Minimally Expressed in Young Individuals With Unilateral Cerebral Palsy Following an Early Brain Injury

Hemiparetic stroke in adulthood often results in the grouped movement pattern of the upper extremity flexion synergy thought to arise from an increased reliance on cortico-reticulospinal pathways due to a loss of lateral corticospinal projections. It is well established that the flexion synergy induces reaching constraints in individuals with adult-onset hemiplegia. The expression of the flexion synergy in individuals with brain injuries onset earlier in the lifespan is currently unknown. An early unilateral brain injury occurring prior to six months post full-term may preserve corticospinal projections which can be used for independent joint control and thus minimizing the expression of the flexion synergy. This study uses kinematics of a ballistic reaching task to evaluate the expression of the flexion synergy in individuals with pediatric hemiplegia (PH) ages six to seventeen years. Fifteen individuals with brain injuries before birth (n = 8) and around full-term (n = 7) and nine age-matched controls with no known neurological impairment completed a set of reaches in an admittance controlled robotic device. Descending drive, and the possible expression of the upper extremity flexion synergy, was modulated by increasing shoulder abduction loading. Individuals with early-onset PH achieved lower peak velocities when reaching with the paretic arm compared to controls; however, no differences in reaching distance were found between groups. Relative maintenance in reaching seen in individuals with early brain injuries highlights minimal expression of the flexion synergy. We interpret this conservation of independent control of the paretic shoulder and elbow as the use of more direct corticospinal projections instead of indirect cortico-reticulospinal pathways used in individuals with adult-onset hemiplegia.

Robotic assessment of rapid motor decision making in children with perinatal stroke

Background

Activities of daily living frequently require children to make rapid decisions and execute desired motor actions while inhibiting unwanted actions. Children with hemiparetic cerebral palsy due to perinatal stroke may have deficits in executive functioning in addition to motor impairments. The objective of this study was to use a robotic object hit and avoid task to assess the ability of children with hemiparetic cerebral palsy to make rapid motor decisions.

Methods

Forty-five children with hemiparetic cerebral palsy due to perinatal stroke and 146 typically developing children (both groups ages 6–19 years) completed a robotic object hit and avoid task using the Kinarm Exoskeleton. Objects of different shapes fell from the top of the screen with increasing speed and frequency. Children were instructed to hit two specific target shapes with either hand, while avoiding six distractor shapes. The number of targets and distractors hit were compared between children with hemiparetic cerebral palsy and typically developing children, accounting for age effects. We also compared performance to a simpler object hit task where there were no distractors.

Results

We found that children with hemiparetic cerebral palsy hit a greater proportion of total distractors compared to typically developing children, demonstrating impairments in inhibitory control. Performance for all children improved with age. Children with hemiparetic cerebral palsy hit a greater percentage of targets with each arm on the more complex object hit and avoid task compared to the simpler object hit task, which was not found in typically developing children.

Conclusions

Children with hemiparetic cerebral palsy due to perinatal stroke demonstrated impairments in rapid motor decision making including inhibitory control, which can impede their ability to perform real-world tasks. Therapies that address both motor performance and executive functions are necessary to maximize function in children with hemiparetic cerebral palsy.

Assessment of bilateral motor skills and visuospatial attention in children with perinatal stroke using a robotic object hitting task

Background

While motor deficits are the hallmark of hemiparetic cerebral palsy, children may also experience impairments in visuospatial attention that interfere with participation in complex activities, including sports or driving. In this study, we used a robotic object hitting task to assess bilateral sensorimotor control and visuospatial skills in children with hemiparesis due to perinatal arterial ischemic stroke (AIS) or periventricular venous infarct (PVI). We hypothesized that performance would be impaired bilaterally and be related to motor behavior and clinical assessment of visuospatial attention.

Methods

Forty-nine children with perinatal stroke and hemiparetic cerebral palsy and 155 typically developing (TD) children participated in the study. Participants performed a bilateral object hitting task using the KINARM Exoskeleton Robot, in which they used virtual paddles at their fingertips to hit balls that fell from the top of the screen with increasing speed and frequency over 2.3 min. We quantified performance across 13 parameters including number of balls hit with each hand, movement speed and area, biases between hands, and spatial biases. We determined normative ranges of performance accounting for age by fitting 95% prediction bands to the TD children. We compared parameters between TD, AIS, and PVI groups using ANCOVAs accounting for age effects. Lastly, we performed regression analysis between robotic and clinical measures.

Results

The majority of children with perinatal stroke hit fewer balls with their affected arm compared to their typically developing peers. We also found deficits with the ipsilesional (“unaffected”) arm. Children with AIS had greater impairments than PVI. Despite hitting fewer balls, we only identified 18% of children as impaired in hand speed or movement area. Performance on the Behavioral Inattention Test accounted for 21–32% of the variance in number of balls hit with the unaffected hand.

Conclusions

Children with perinatal stroke-induced hemiparetic cerebral palsy may have complex bilateral deficits reflecting a combination of impairments in motor skill and visuospatial attention. Clinical assessments and interventions should address the interplay between motor and visuospatial skills.

The relationship between neuroimaging and motor outcome in children with cerebral palsy: A systematic review-Part B diffusion imaging and tractography

BACKGROUND

Diffusion magnetic resonance imaging (dMRI) is able to detect, localize and quantify subtle brain white matter abnormalities that may not be visible on conventional structural MRI. Over the past years, a growing number of studies have applied dMRI to investigate structure-function relationships in children with cerebral palsy (CP).

AIMS

To provide an overview of the recent literature on dMRI and motor function in children with CP.

METHODS

A systematic literature search was conducted in PubMed, Embase, Cochrane Central Register of Controlled trials, Cinahl and Web of Science from 2012 onwards.

RESULTS

In total, 577 children with CP in 19 studies were included. Sixteen studies only included unilateral CP, while none included dyskinetic CP. Most studies focused on specific regions/tracts of interest (n = 17) versus two studies that investigated the whole brain. In unilateral and bilateral CP, white matter abnormalities were widespread including non-motor areas. In unilateral CP, consistent relationships were found between white matter integrity of the corticospinal tract and somatosensory pathways (e.g. thalamocortical projections, medial lemniscus) with upper limb sensorimotor function. The role of commissural and associative tracts remains poorly investigated. Also results describing structure-function relationships in bilateral CP are scarce (n = 3).

CONCLUSIONS

This review underlines the importance of both the motor and somatosensory tracts for upper limb sensorimotor function in unilateral CP. However, the exact contribution of each tract requires further exploration. In addition, research on the relevance of non-motor pathways is warranted, as well as studies including other types of CP.