The use of functional electrical stimulation to improve upper limb function in children with hemiplegic cerebral palsy: A feasibility study

Presumed Perinatal Ischemic Left Middle Cerebral Artery Stroke With Cerebral Palsy, Developmental Delay, and Epilepsy: A Case Report

The perinatal period is a high risk for ischemic events to occur leading to lifelong morbidity. Various patterns of ischemic injury to the fetal and neonatal brain have been studied depending on gestational age as well as the degree of hypoxia/ischemia. We present a case of presumed perinatal ischemic left middle cerebral artery stroke diagnosed by magnetic resonance imaging (MRI) in a child with global developmental delay, cerebral palsy, and epilepsy. Interestingly, the typical features of middle cerebral artery stroke are often not present in perinatal strokes, and hence these are not imaged perinatally. Since studies and research into neuroplasticity and neuromodulation are current topics of interest and several research studies are being conducted, we wish to add this case to the available scientific literature.

Contralateral C7 nerve transfer via the prespinal route in treatment of spastic paralysis of upper limb after cerebral palsy

BACKGROUND

Upper limb spasticity leads to different degrees of disabilities in cerebral palsy, which seriously affects the life of patients. Contralateral C7 nerve transfer has been shown to improve function and reduce spasticity in the affected upper limb with post-stroke hemiplegia. However, reports about the efficacy of this procedure in treating upper limb spasticity caused by hemiplegic cerebral palsy were limited.

CASE DESCRIPTION

We reported two cases (a 23-year-old male and a 18-year-old female) who suffered from hemiplegic cerebral palsy with unilateral sustained upper limb spasticity and underwent contralateral C7 nerve transfer in adulthood. The scores of Fugel-Meyer and ROM of the affected upper limbs were observed before and after surgery. Compared with the preoperative, scores of the latest follow-up both were significantly improved. The muscle tension of the upper limbs decreased, and the symptoms of spasm were alleviated.

CONCLUSIONS

Considering contralateral C7 nerve transfer could effectively relieve spasticity and improve upper limb activity, it can be recommended as one of the reliable methods to manage spasticity and dystonia of upper limbs in patients with hemiplegic cerebral palsy.

Exploring the Experiences and Perceptions of Pediatric Therapists who use Functional Electrical Stimulation in their Clinical Practice

Aim: This study aimed to 1) explore the experiences and perceptions of pediatric physical therapists (PTs) and occupational therapists (OTs) who use FES in their practice, and 2) provide recommendations for overcoming common barriers to FES implementation.Methods: Eight Canadian PTs (n = 6) and OTs (n = 2), who use FES in their pediatric practice, participated in semi-structured interviews. Open-ended questions queried the motivation, goals, perceived benefits and challenges, and facilitators and barriers of FES use. Interviews were audio recorded and transcribed verbatim. Interpretive description was used to analyze the transcripts.Results: One overarching theme emerged: FES is a useful adjunct to therapy for certain pediatric clients. Four sub-themes were identified: Participants described 1) motivation for incorporating FES into clinical practice, which led to 2) experiences with the implementation of FES in clinical practice, including strategies for overcoming implementation barriers. These experiences influenced 3) how FES is used in practice (e.g. for which populations and therapeutic goals), and informed 4) recommendations for pediatric FES practice (e.g. more educational opportunities, research, and access for families).Conclusions: Pediatric PTs and OTs who use FES in clinical practice view FES as a valuable adjunct, especially for motor training to improve functional skills.

BCI-activated electrical stimulation in children with perinatal stroke and hemiparesis: A pilot study

Background

Perinatal stroke (PS) causes most hemiparetic cerebral palsy (CP) and results in lifelong disability. Children with severe hemiparesis have limited rehabilitation options. Brain computer interface- activated functional electrical stimulation (BCI-FES) of target muscles may enhance upper extremity function in hemiparetic adults. We conducted a pilot clinical trial to assess the safety and feasibility of BCI-FES in children with hemiparetic CP.

Methods

Thirteen participants (mean age = 12.2 years, 31% female) were recruited from a population-based cohort. Inclusion criteria were: (1) MRI-confirmed PS, (2) disabling hemiparetic CP, (3) age 6–18 years, (4) informed consent/assent. Those with neurological comorbidities or unstable epilepsy were excluded. Participants attended two BCI sessions: training and rehabilitation. They wore an EEG-BCI headset and two forearm extensor stimulation electrodes. Participants’ imagination of wrist extension was classified on EEG, after which muscle stimulation and visual feedback were provided when the correct visualization was detected.

Results

No serious adverse events or dropouts occurred. The most common complaints were mild headache, headset discomfort and muscle fatigue. Children ranked the experience as comparable to a long car ride and none reported as unpleasant. Sessions lasted a mean of 87 min with 33 min of stimulation delivered. Mean classification accuracies were (M = 78.78%, SD = 9.97) for training and (M = 73.48, SD = 12.41) for rehabilitation. Mean Cohen’s Kappa across rehabilitation trials was M = 0.43, SD = 0.29, range = 0.019–1.00, suggesting BCI competency.

Conclusion

Brain computer interface-FES was well -tolerated and feasible in children with hemiparesis. This paves the way for clinical trials to optimize approaches and test efficacy.

Parents' perceptions of functional electrical stimulation as an upper limb intervention for young children with hemiparesis: qualitative interviews with mothers

Background/objective

To explore parents’ perceptions of an upper extremity (UE) intervention using functional electrical stimulation (FES) for young children with hemiparesis.

Methods

Parents of children aged 3–6 years with a history of perinatal stroke, impaired UE function, and participation in a 12-week FES intervention delivered at a hospital were included in this exploratory qualitative study. Nine mothers participated in a semi-structured interview < 1 week after their child completed the FES intervention (MyndMove®, MyndTec Inc.) targeting the hemiparetic UE. Open-ended questions queried parents’ goals, perceived benefits, and challenges of the FES intervention. Interviews were audio recorded and transcribed verbatim. Qualitative conventional content analysis was used to analyze the transcripts.

Results

Five themes were identified. 1) Parents’ expectations for the FES intervention. Mothers described setting functional, exploratory, and realistic goals, yet feeling initial apprehension towards FES. 2) Perceived improvement. Physical, functional, and psychological improvements were observed with FES; however, there was still room for improvement. 3) Factors influencing the FES intervention. Program structure, therapist factors, and child factors influenced perceived success. 4) Lack of access to intensive therapy. Mothers noted that FES is not provided in mainstream therapy; however, they wanted access to FES outside of the study. They also highlighted socioeconomic challenges to accessing FES. 5) Strategies to facilitate participation. The mothers provided suggestions for program structure and delivery, and session delivery.

Conclusions

Mothers perceived the FES intervention to have physical, functional and psychological benefits for their children. Interest in continuing with FES highlights a need to improve access to this therapy for young children.

Dysphagia rehabilitation following acquired brain injury, including cerebral palsy, across the lifespan: a scoping review protocol

BACKGROUND

Swallowing impairment (dysphagia) following brain injury can lead to life-threatening complications such as dehydration, aspiration pneumonia and acute choking episodes. In adult therapeutic practice, there is research and clinical evidence to support the use of swallowing exercises to improve swallowing physiology in dysphagia; however, the use of these exercises in treating children with dysphagia is largely unexplored. Fundamental questions remain regarding the feasibility and effectiveness of using swallowing exercises with children. This review aims to outline the published literature on exercise-based treatment methods used in the rehabilitation of dysphagia secondary to an acquired brain injury across the lifespan. This will allow the range and effects of interventions utilised to be mapped alongside differential practices between adult and child populations to be formally documented, providing the potential for discussions with clinicians about which rehabilitative interventions might be appropriate for further trial in paediatrics.

METHODS

This study will use a scoping review framework to identify and systematically review the existing literature using Joanna Briggs Institute (JBI) and Preferred Reporting Items for Systematic Reviews (PRISMA) scoping review guidelines. Electronic databases (MEDLINE, PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Allied and Complementary Medicine Database (AMED)), grey literature and the reference lists of key texts including systematic reviews will be searched. Information about the rehabilitation design, dosage and intensity of exercise programmes used as well as demographic information such as the age of participants and aetiology of dysphagia will be extracted. The number of articles in each area and the type of data source will be presented in a written and visual format. Comparison between the literature in adult and child populations will be discussed.

DISCUSSION

This review is unique as it directly compares dysphagia rehabilitation in adults with that of a paediatric population in order to formally identify and discuss the therapeutic gaps in child dysphagia rehabilitation. The results will inform the next stage of research, looking into the current UK-based speech and language therapy practices when working with children with acquired dysphagia.

SYSTEMATIC REVIEW REGISTRATION

Open science framework osf.io/ja4dr.

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.

A biofeedback-enhanced therapeutic exercise video game intervention for young people with cerebral palsy: A randomized single-case experimental design feasibility study

Importance/Background

Movement-controlled video games have potential to promote home-based practice of therapy activities. The success of therapy gaming interventions depends on the quality of the technology used and the presence of effective support structures.

Aim

This study assesses the feasibility of a novel intervention that combines a co-created gaming technology integrating evidence-based biofeedback and solution-focused coaching (SFC) strategies to support therapy engagement and efficacy at home.

Methods

Following feasibility and single-case reporting standards (CONSORT and SCRIBE), this was a non-blind, randomized, multiple-baseline, AB, design. Nineteen (19) young people with cerebral palsy (8–18 years old) completed the 4-week home-based intervention in France and Canada.

Participant motivations, personalized practice goals, and relevance of the intervention to daily activities were discussed in a Solution Focused Coaching-style conversation pre-, post-intervention and during weekly check-ins. Participants controlled a video game by completing therapeutic gestures (wrist extension, pinching) detected via electromyography and inertial sensors on the forearm (Myo Armband and custom software).

Process feasibility success criteria for recruitment response, completion and adherence rates, and frequency of technical issues were established a priori. Scientific feasibility, effect size estimates and variance were determined for Body Function outcome measures: active wrist extension, grip strength and Box and Blocks Test; and for Activities and Participation measures: Assisting Hand Assessment (AHA), Canadian Occupational Performance Measure (COPM) and Self-Reported Experiences of Activity Settings (SEAS).

Results

Recruitment response (31%) and assessment completion (84%) rates were good and 74% of participants reached self-identified practice goals. As 17% of technical issues required external support to resolve, the intervention was graded as feasible with modifications. No adverse events were reported.

Moderate effects were observed in Body Function measures (active wrist extension: SMD = 1.82, 95%CI = 0.85–2.78; Grip Strength: SMD = 0.63, 95%CI = 0.65–1.91; Box and Blocks: Hedge’s g = 0.58, 95%CI = -0.11–1.27) and small-moderate effects in Activities and Participation measures (AHA: Hedge’s g = 0.29, 95%CI = -0.39–0.97, COPM: r = 0.60, 95%CI = 0.13–0.82, SEAS: r = 0.24, 95%CI = -0.25–0.61).

Conclusion

A definitive RCT to investigate the effectiveness of this novel intervention is warranted. Combining SFC-style coaching with high-quality biofeedback may positively engage youth in home rehabilitation to complement traditional therapy.

Trial registration

ClinicalTrials.gov, U.S. National Library of Medicine: NCT03677193.

A Review on the Control of the Mechanical Properties of Ankle Foot Orthosis for Gait Assistance

In the past decade, advanced technologies in robotics have been explored to enhance the rehabilitation of post-stroke patients. Previous works have shown that gait assistance for post-stroke patients can be provided through the use of robotics technology in ancillary equipment, such as Ankle Foot Orthosis (AFO). An AFO is usually used to assist patients with spasticity or foot drop problems. There are several types of AFOs, depending on the flexibility of the joint, such as rigid, flexible rigid, and articulated AFOs. A rigid AFO has a fixed joint, and a flexible rigid AFO has a more flexible joint, while the articulated AFO has a freely rotating ankle joint, where the mechanical properties of the AFO are more controllable compared to the other two types of AFOs. This paper reviews the control of the mechanical properties of existing AFOs for gait assistance in post-stroke patients. Several aspects that affect the control of the mechanical properties of an AFO, such as the controller input, number of gait phases, controller output reference, and controller performance evaluation are discussed and compared. Thus, this paper will be of interest to AFO researchers or developers who would like to design their own AFOs with the most suitable mechanical properties based on their application. The controller input and the number of gait phases are discussed first. Then, the discussion moves forward to the methods of estimating the controller output reference, which is the main focus of this study. Based on the estimation method, the gait control strategies can be classified into subject-oriented estimations and phase-oriented estimations. Finally, suggestions for future studies are addressed, one of which is the application of the adaptive controller output reference to maximize the benefits of the AFO to users.