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Haberfehlner H, Roth Z, Vanmechelen I, Buizer AI, Jeroen Vermeulen R, Koy A, Aerts JM, Hallez H, Monbaliu E. A Novel Video-Based Methodology for Automated Classification of Dystonia and Choreoathetosis in Dyskinetic Cerebral Palsy During a Lower Extremity Task. Neurorehabil Neural Repair 2024; 38:479-492. [PMID: 38842031 DOI: 10.1177/15459683241257522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
BACKGROUND Movement disorders in children and adolescents with dyskinetic cerebral palsy (CP) are commonly assessed from video recordings, however scoring is time-consuming and expert knowledge is required for an appropriate assessment. OBJECTIVE To explore a machine learning approach for automated classification of amplitude and duration of distal leg dystonia and choreoathetosis within short video sequences. METHODS Available videos of a heel-toe tapping task were preprocessed to optimize key point extraction using markerless motion analysis. Postprocessed key point data were passed to a time series classification ensemble algorithm to classify dystonia and choreoathetosis duration and amplitude classes (scores 0, 1, 2, 3, and 4), respectively. As ground truth clinical scoring of dystonia and choreoathetosis by the Dyskinesia Impairment Scale was used. Multiclass performance metrics as well as metrics for summarized scores: absence (score 0) and presence (score 1-4) were determined. RESULTS Thirty-three participants were included: 29 with dyskinetic CP and 4 typically developing, age 14 years:6 months ± 5 years:15 months. The multiclass accuracy results for dystonia were 77% for duration and 68% for amplitude; for choreoathetosis 30% for duration and 38% for amplitude. The metrics for score 0 versus score 1 to 4 revealed an accuracy of 81% for dystonia duration, 77% for dystonia amplitude, 53% for choreoathetosis duration and amplitude. CONCLUSIONS This methodology study yielded encouraging results in distinguishing between presence and absence of dystonia, but not for choreoathetosis. A larger dataset is required for models to accurately represent distinct classes/scores. This study presents a novel methodology of automated assessment of movement disorders solely from video data.
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Affiliation(s)
- Helga Haberfehlner
- Department of Rehabilitation Sciences, KU Leuven Bruges, Bruges, Belgium
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Rehabilitation Medicine, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Rehabilitation & Development, Amsterdam, The Netherlands
| | - Zachary Roth
- Department of Rehabilitation Sciences, KU Leuven Bruges, Bruges, Belgium
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium
| | - Inti Vanmechelen
- Department of Rehabilitation Sciences, KU Leuven Bruges, Bruges, Belgium
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium
| | - Annemieke I Buizer
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Rehabilitation Medicine, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Rehabilitation & Development, Amsterdam, The Netherlands
- Amsterdam UMC, Emma Children's Hospital, Amsterdam, The Netherlands
| | | | - Anne Koy
- Department of Pediatrics, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Jean-Marie Aerts
- Department of Computer Science, Mechatronics Research Group (M-Group), KU Leuven Bruges, Distrinet, Bruges, Belgium
| | - Hans Hallez
- Department of Biosystems, Division of Animal and Human Health Engineering, Measure, Model and Manage Bioresponse (M3-BIORES), KU Leuven, Leuven, Belgium
| | - Elegast Monbaliu
- Department of Rehabilitation Sciences, KU Leuven Bruges, Bruges, Belgium
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium
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Lewis SA, Aravamuthan B, Fehlings D, Kruer MC. Evolving understanding of CP phenotypes: the importance of dystonia. Pediatr Res 2024:10.1038/s41390-024-03327-9. [PMID: 38926549 DOI: 10.1038/s41390-024-03327-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 03/15/2024] [Indexed: 06/28/2024]
Abstract
Cerebral palsy (CP) is the core neurodevelopmental disorder affecting movement. Several distinct movement disorders can occur in people with cerebral palsy. Dystonia is a movement disorder that causes non-velocity-dependent hypertonia and/or abnormal, often repetitive, twisting movements, and/or postures. Dystonia occurs more frequently in patients with CP than has been recognized previously, and is treated differently than other aspects of CP. Dystonia is an important cause of chronic pain, hospitalization, and musculoskeletal complications. We describe recent advances in dystonia diagnosis in patients with cerebral palsy and highlight focus areas for ongoing research and clinical care. IMPACT: Dystonia is a movement disorder that is more common in people with cerebral palsy (CP) than previously thought. Dystonia contributes to hospitalization, chronic pain, and complications in CP patients. People with dystonic CP require different tools to diagnose and treat their condition. We summarize current state of the art in dystonia in CP and identify areas of focus for future work.
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Affiliation(s)
- Sara A Lewis
- Departments of Cellular & Molecular Medicine, Child Health, and Neurology and Program in Genetics, University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA
- Pediatric Movement Disorders Program, Barrow Neurological Institute, Phoenix Children's, Phoenix, AZ, USA
| | - Bhooma Aravamuthan
- Division of Pediatric Neurology, Department of Neurology, School of Medicine, Washington University in St Louis and St Louis Children's Hospital, St Louis, MO, USA
| | - Darcy Fehlings
- Holland Bloorview Kids Rehabilitation Hospital, Deparment of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Michael C Kruer
- Departments of Cellular & Molecular Medicine, Child Health, and Neurology and Program in Genetics, University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA.
- Pediatric Movement Disorders Program, Barrow Neurological Institute, Phoenix Children's, Phoenix, AZ, USA.
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Gemperli K, Folorunso F, Norin B, Joshua R, Hill C, Rykowski R, Galindo R, Aravamuthan BR. Mice born preterm develop gait dystonia and reduced cortical parvalbumin immunoreactivity. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.02.01.578353. [PMID: 38352408 PMCID: PMC10862908 DOI: 10.1101/2024.02.01.578353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
Preterm birth leading to cerebral palsy (CP) is the most common cause of childhood dystonia, a movement disorder that is debilitating and often treatment refractory. Dystonia has been typically associated with dysfunction of striatal cholinergic interneurons, but clinical imaging data suggests that cortical injury may best predict dystonia following preterm birth. Furthermore, abnormal sensorimotor cortex inhibition has been found in many studies of non-CP dystonias. To assess the potential for a cortical etiology of dystonia following preterm birth, we developed a new model of preterm birth in mice. Noting that term delivery in mice on a C57BL/6J background is embryonic day 19.1 (E19.1), we induced preterm birth at the limits of pup viability at embryonic day (E) 18.3, equivalent to human 22 weeks gestation. Mice born preterm demonstrate display clinically validated metrics of dystonia during gait (leg adduction amplitude and variability) and also demonstrate reduced parvalbumin immunoreactivity in the sensorimotor cortex, suggesting dysfunction of cortical parvalbumin-positive inhibitory interneurons. Notably, reduced parvalbumin immunoreactivity or changes in parvalbumin-positive neuronal number were not observed in the striatum. These data support the association between cortical dysfunction and dystonia following preterm birth. We propose that our mouse model of preterm birth can be used to study this association and potentially also study other sequelae of extreme prematurity.
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Affiliation(s)
- Kat Gemperli
- Department of Neurology, Washington University School of Medicine, St. Louis, MO
| | - Femi Folorunso
- Department of Neurology, Washington University School of Medicine, St. Louis, MO
| | - Benjamin Norin
- Department of Neurology, Washington University School of Medicine, St. Louis, MO
| | - Rebecca Joshua
- Department of Neurology, Washington University School of Medicine, St. Louis, MO
| | - Clayton Hill
- Department of Neurology, Washington University School of Medicine, St. Louis, MO
| | - Rachel Rykowski
- Department of Neurology, Washington University School of Medicine, St. Louis, MO
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Jaleel F, Rust A, Cheung S, Pearson TS, Ueda K, Robichaux‐Viehoever A, Leger K, Chintalapati K, Guez‐Barber D, Shusterman M, Aravamuthan B. Caregiver descriptions of dystonia in cerebral palsy. Ann Clin Transl Neurol 2024; 11:242-250. [PMID: 38174361 PMCID: PMC10863918 DOI: 10.1002/acn3.51941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 09/18/2023] [Accepted: 10/18/2023] [Indexed: 01/05/2024] Open
Abstract
OBJECTIVE To determine how caregivers describe dystonia in people with cerebral palsy (CP). METHODS In this prospective cohort study, paper surveys were administered to caregivers between September 7, 2021 and October 28, 2021 during CP Center visits at a large tertiary care center. Caregivers were asked to describe involuntary movements triggered by voluntary movement or triggered by tactile stimulation in the people with CP they cared for. Their CP Center medical provider separately assessed people with CP for dystonia. Movement features described exclusively by caregivers of people with CP and dystonia were determined using conventional content analysis. RESULTS 113 caregivers responded on behalf of 56 people with and 57 people without dystonia. If caregivers noted that both voluntary movement and tactile stimulation triggered involuntary movements, that had a 92% positive predictive value for a dystonia diagnosis. Movement features exclusively described in people with CP and dystonia included: (1) stiffening, tensing, or tightening (15% of respondents); (2) involvement of the head (10%), torso (5%), or feet (5%); and (3) triggers of stretching (12.5%), excitement (5%), or transfers (5%). INTERPRETATION In addition to a thorough exam, asking caregivers of people with CP to describe involuntary movements triggered by voluntary movement or tactile stimulation may inform clinical dystonia diagnosis.
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Affiliation(s)
- Fayza Jaleel
- Division of Pediatric Neurology, Department of NeurologyWashington University School of MedicineSt. LouisMissouriUSA
| | - Alyssa Rust
- Division of Pediatric Neurology, Department of NeurologyWashington University School of MedicineSt. LouisMissouriUSA
| | - Shirley Cheung
- Division of Pediatric Neurology, Department of NeurologyWashington University School of MedicineSt. LouisMissouriUSA
| | - Toni S. Pearson
- Division of Pediatric Neurology, Department of NeurologyWashington University School of MedicineSt. LouisMissouriUSA
- Division of Neurology, Nationwide Children's HospitalOhio State UniversityColumbusOhioUSA
| | - Keisuke Ueda
- Division of Pediatric Neurology, Department of NeurologyWashington University School of MedicineSt. LouisMissouriUSA
| | - Amy Robichaux‐Viehoever
- Division of Pediatric Neurology, Department of NeurologyWashington University School of MedicineSt. LouisMissouriUSA
| | - Katie Leger
- Division of Pediatric Neurology, Department of NeurologyWashington University School of MedicineSt. LouisMissouriUSA
| | - Keerthana Chintalapati
- Division of Pediatric Neurology, Department of NeurologyWashington University School of MedicineSt. LouisMissouriUSA
| | - Danielle Guez‐Barber
- Division of Child Neurology, Department of PediatricsChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
- Department of Neurology, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | | | - Bhooma Aravamuthan
- Division of Pediatric Neurology, Department of NeurologyWashington University School of MedicineSt. LouisMissouriUSA
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Gilbert LA, Gandham S, Ueda K, Chintalapati K, Pearson T, Aravamuthan BR. Upper Extremity Dystonia Features in People With Spastic Cerebral Palsy. Neurol Clin Pract 2023; 13:e200207. [PMID: 37780812 PMCID: PMC10540938 DOI: 10.1212/cpj.0000000000200207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 08/14/2023] [Indexed: 10/03/2023]
Abstract
Background and Objectives Dystonia in cerebral palsy (CP) is debilitating and common, but underdiagnosed, especially when coexistent with spasticity. With dedicated research-based assessment, dystonia is found in most people with spastic CP but is only clinically diagnosed in the minority. To begin addressing the high rates of dystonia underdiagnosis in this population, we determined the key feature experts use to assess upper extremity dystonia in people with spastic CP. Methods In this prospective cohort study, 3 pediatric movement disorder specialists assessed upper extremity dystonia in neurologic examination videos of people with spastic CP and isolated periventricular leukomalacia (PVL) on brain MRI (i.e., those with a brain injury pattern typical for spastic CP). Dystonia severity was rated using the 10-point Global Dystonia Severity Rating Scale, first by each expert independently and then again after consensus-building discussion. Conventional content analysis of these discussions revealed salient features ("codes") that experts used to assess upper extremity dystonia. Code frequency distributions were compared between dystonia severity categories using χ2 tests. Results We identified 96 people with spastic CP with isolated PVL on brain MRI seen in the St. Louis Children's Hospital CP Center between 2005 and 2018. Of them, 26 people were able and willing to be recorded while doing a standardized set of upper extremity examination maneuvers (age 4-25 years; 28% nonambulatory, 77% White). When assessing their videos, experts cited the "hand" less often and "shoulder" more often with increasing dystonia severity (p < 0.005, χ2 test). "Mirror movements" and the "hand open/close" examination maneuver were cited significantly more frequently in videos when experts were attempting to distinguish between no dystonia and mild dystonia (p < 0.005). Discussion Expert clinicians use distinct movement features to assess upper extremity dystonia in people with spastic CP and PVL. Attention to involuntary shoulder (vs hand) movements can help gauge dystonia severity. Differentiation between mirror movements and dystonia, particularly during the hand open/close examination maneuver, may help identify mild dystonia. These results can help guide upper extremity dystonia assessment in people with spastic CP, thus potentially helping mitigate dystonia underdiagnosis.
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Affiliation(s)
- Laura A Gilbert
- Division of Pediatric Neurology (LAG, SG, KU, KC, BRA), Department of Neurology, Washington University School of Medicine, St. Louis, MO; and Division of Neurology (TP), Nationwide Children's Hospital, Ohio State University, Columbus
| | - Sushma Gandham
- Division of Pediatric Neurology (LAG, SG, KU, KC, BRA), Department of Neurology, Washington University School of Medicine, St. Louis, MO; and Division of Neurology (TP), Nationwide Children's Hospital, Ohio State University, Columbus
| | - Keisuke Ueda
- Division of Pediatric Neurology (LAG, SG, KU, KC, BRA), Department of Neurology, Washington University School of Medicine, St. Louis, MO; and Division of Neurology (TP), Nationwide Children's Hospital, Ohio State University, Columbus
| | - Keerthana Chintalapati
- Division of Pediatric Neurology (LAG, SG, KU, KC, BRA), Department of Neurology, Washington University School of Medicine, St. Louis, MO; and Division of Neurology (TP), Nationwide Children's Hospital, Ohio State University, Columbus
| | - Toni Pearson
- Division of Pediatric Neurology (LAG, SG, KU, KC, BRA), Department of Neurology, Washington University School of Medicine, St. Louis, MO; and Division of Neurology (TP), Nationwide Children's Hospital, Ohio State University, Columbus
| | - Bhooma R Aravamuthan
- Division of Pediatric Neurology (LAG, SG, KU, KC, BRA), Department of Neurology, Washington University School of Medicine, St. Louis, MO; and Division of Neurology (TP), Nationwide Children's Hospital, Ohio State University, Columbus
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Gemperli K, Lu X, Chintalapati K, Rust A, Bajpai R, Suh N, Blackburn J, Gelineau-Morel R, Kruer MC, Mingbundersuk D, O'Malley J, Tochen L, Waugh J, Wu S, Feyma T, Perlmutter J, Mennerick S, McCall J, Aravamuthan BR. Chronic striatal cholinergic interneuron excitation induces clinically-relevant dystonic behavior in mice. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.07.19.549778. [PMID: 37503287 PMCID: PMC10370117 DOI: 10.1101/2023.07.19.549778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
Dystonia is common, debilitating, often medically refractory, and difficult to diagnose. The gold standard for both clinical and mouse model dystonia evaluation is subjective assessment, ideally by expert consensus. However, this subjectivity makes translational quantification of clinically-relevant dystonia metrics across species nearly impossible. Many mouse models of genetic dystonias display abnormal striatal cholinergic interneuron excitation, but few display subjectively dystonic features. Therefore, whether striatal cholinergic interneuron pathology causes dystonia remains unknown. To address these critical limitations, we first demonstrate that objectively quantifiable leg adduction variability correlates with leg dystonia severity in people. We then show that chemogenetic excitation of striatal cholinergic interneurons in mice causes comparable leg adduction variability in mice. This clinically-relevant dystonic behavior in mice does not occur with acute excitation, but rather develops after 14 days of ongoing striatal cholinergic interneuron excitation. This requirement for prolonged excitation recapitulates the clinically observed phenomena of a delay between an inciting brain injury and subsequent dystonia manifestation and demonstrates a causative link between chronic striatal cholinergic interneuron excitation and clinically-relevant dystonic behavior in mice. Therefore, these results support targeting striatal ChIs for dystonia drug development and suggests early treatment in the window following injury but prior to dystonia onset. One Sentence Summary Chronic excitation of dorsal striatal cholinergic interneuron causes clinically-relevant dystonic phenotypes in mice.
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Nonnekes J, Buizer AI. Future directions for the assessment of gait dystonia in cerebral palsy. Dev Med Child Neurol 2023. [PMID: 36717760 DOI: 10.1111/dmcn.15523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 01/04/2023] [Indexed: 02/01/2023]
Affiliation(s)
- Jorik Nonnekes
- Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Department of Rehabilitation, Center of Expertise for Parkinson & Movement Disorders, Nijmegen, the Netherlands.,Department of Rehabilitation, Sint Maartenskliniek, Nijmegen, the Netherlands
| | - Annemieke I Buizer
- Department of Rehabilitation Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Amsterdam Movement Sciences, Rehabilitation & Development, Amsterdam, the Netherlands.,Emma Children's Hospital, Amsterdam University Medical Centers, Amsterdam, the Netherlands
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