Effect of motor imagery combined with physical practice on upper limb rehabilitation in children with hemiplegic cerebral palsy

Cognitive approaches in the rehabilitation of upper limbs function in children with cerebral palsy: a systematic review and meta-analysis

INTRODUCTION

Cerebral palsy (CP) is the predominant cause of children disability. It is characterized by motor, sensory, and postural deficits due to a non-progressive injury to the developing central nervous system. In recent years, new rehabilitation techniques targeting the central representations of motor patterns have been introduced: the most used are action observation therapy (AOT), motor imagery (MI), and mirror therapy (MT). Aim of this study is to assess the effectiveness of these cognitive strategies on the recovery of upper limb motor functions in children with CP.

EVIDENCE ACQUISITION

This study was designed as a systematic review and meta-analysis, registered in PROSPERO (CRD42023403794). For the report and methodological definitions of this study, the recommendations of the PRISMA protocol and the Cochrane collaboration, were followed. A total of 3 electronic databases (PubMed, Scopus, and Web of Science) were searched for relevant Randomized Control Trials (RCT) using the combinations of terms "cerebral palsy" AND "action observation" OR "motor imagery" OR "mirror therapy" OR "cognitive therapy." A meta-analysis was carried out to compare cognitive and conventional approaches and combine direct and indirect effects. A random-effects meta-analysis model was used to derive pooled effect estimates.

EVIDENCE SYNTHESIS

Out of 328 records, 12 RCTs were analyzed in this systematic review published from 2012 to 2022, and included 375 children, of whom 195 received cognitive therapies, and 180 underwent conventional rehabilitation. AOT was the most investigated (RCTs N.=7), and showed significant results in the recovery of upper limb motor functions, albeit the meta-analysis demonstrated a non-significant difference in Melbourne Unilateral Upper limb Scale (MUUL) (95% CI: -7.34, 12); in Assisting Hand Assessment (AHA) (95% CI: -4.84, 10.74), and in AbilHand-Kids Questionnaire (95% CI: -1.12, 1.45). Five RCTs investigated MT showing significant improvements in grip and dexterity; none used MI as intervention therapy.

CONCLUSIONS

Cognitive therapies provided with encouraging results in the recovery of upper limb motor functions, although not a clinical effect in bimanual or unimanual performance; they could represent a valid therapeutic solution integrated to conventional rehabilitation in the treatment of upper limb motor impairment in children with CP.

Motor imagery for paediatric neurorehabilitation: how much do we know? Perspectives from a systematic review

Background

Motor Imagery (MI) is a cognitive process consisting in mental simulation of body movements without executing physical actions: its clinical use has been investigated prevalently in adults with neurological disorders.

Objectives

Review of the best-available evidence on the use and efficacy of MI interventions for neurorehabilitation purposes in common and rare childhood neurological disorders.

Methods

systematic literature search conducted according to PRISMA by using the Scopus, PsycArticles, Cinahl, PUBMED, Web of Science (Clarivate), EMBASE, PsychINFO, and COCHRANE databases, with levels of evidence scored by OCEBM and PEDro Scales.

Results

Twenty-two original studies were retrieved and included for the analysis; MI was the unique or complementary rehabilitative treatment in 476 individuals (aged 5 to 18 years) with 10 different neurological conditions including, cerebral palsies, stroke, coordination disorders, intellectual disabilities, brain and/or spinal cord injuries, autism, pain syndromes, and hyperactivity. The sample size ranged from single case reports to cohorts and control groups. Treatment lasted 2 days to 6 months with 1 to 24 sessions. MI tasks were conventional, graded or ad-hoc. MI measurement tools included movement assessment batteries, mental chronometry tests, scales, and questionnaires, EEG, and EMG. Overall, the use of MI was stated as effective in 19/22, and uncertain in the remnant studies.

Conclusion

MI could be a reliable supportive/add-on (home-based) rehabilitative tool for pediatric neurorehabilitation; its clinical use, in children, is highly dependent on the complexity of MI mechanisms, which are related to the underlying neurodevelopmental disorder.

Motor imagery therapy improved upper limb motor function in stroke patients with hemiplegia by increasing functional connectivity of sensorimotor and cognitive networks

Background

Motor imagery therapy (MIT) showed positive effects on upper limbs motor function. However, the mechanism by which MIT improves upper limb motor function is not fully understood. Therefore, our purpose was to investigate the changes in functional connectivity (FC) within and outside the sensorimotor network (SMN) induced by MIT associated with improvement in upper limb motor function in stroke patients.

Methods

A total of 26 hemiplegic stroke patients were randomly divided into MIT (n = 13) and control (n = 13) groups. Fugl-Meyer Assessment Upper Extremity Scale (FMA-UL), Modified Barthel Index (MBI) and resting-state functional magnetic resonance imaging (rs-fMRI) were evaluated in the two groups before treatment and 4 weeks after treatment. The efficacy of MIT on motor function improvement in stroke patients with hemiplegia was evaluated by comparing the FMA-UL and MBI scores before and after treatment in the two groups. Furthermore, the FC within the SMN and between the SMN and the whole brain was measured and compared before and after different treatment methods in stroke patients. The correlation analysis between the improvement of upper limbs motor function and changes in FC within the SMN and between the SMN and the whole brain was examined.

Results

The FCs between ipsilesional primary motor cortex (M1.I) and contralateral supplementary motor area (SMA.C), M1.I and ipsilesional SMA (SMA.I), and SMA.C and contralateral dorsolateral premotor cortex (DLPM.C) significantly increased in the control group but decreased in the MIT group; while the FC between SMA.C and contralateral primary somatosensory cortex (S1.C) significantly increased in the control group but showed no significant difference in the MIT group. The FCs between M1.I and the ipsilesional hippocampal gyrus and ipsilesional middle frontal gyrus significantly decreased in the control group but increased in the MIT group; while the FC in the contralateral anterior cingulate cortex significantly increased in the MIT group but there was no significant difference in the control group. The results of the correlation analysis showed that the differences in abnormal intra-FCs within the SMN negatively correlated with the differences in FMA and MBI, and the difference in abnormal inter-FCs of the SMN positively correlated with the differences in FMA and MBI.

Conclusions

MIT can improve upper limb motor function and daily activities of stroke patients, and the improvement effect of conventional rehabilitation therapy (CRT) combined with MIT is significantly higher than that of CRT alone. CRT may improve the upper limb motor function of stroke patients with hemiplegia mainly through the functional reorganization between SMN, while MIT may mainly increase the interaction between SMN and other brain networks.

Brain Activation Evoked by Motor Imagery in Pediatric Patients with Complete Spinal Cord Injury

BACKGROUND AND PURPOSE

Currently, there is no effective treatment for pediatric patients with complete spinal cord injury. Motor imagery has been proposed as an alternative to physical training for patients who are unable to move voluntarily. Our aim was to reveal the potential mechanism of motor imagery in the rehabilitation of pediatric complete spinal cord injury.

MATERIALS AND METHODS

Twenty-six pediatric patients with complete spinal cord injury and 26 age- and sex-matched healthy children as healthy controls were recruited. All participants underwent the motor imagery task-related fMRI scans, and additional motor execution scans were performed only on healthy controls. First, we compared the brain-activation patterns between motor imagery and motor execution in healthy controls. Then, we compared the brain activation of motor imagery between the 2 groups and compared the brain activation of motor imagery in pediatric patients with complete spinal cord injury and that of motor execution in healthy controls.

RESULTS

In healthy controls, compared with motor execution, motor imagery showed increased activation in the left inferior parietal lobule and decreased activation in the left supplementary motor area, paracentral lobule, middle cingulate cortex, and right insula. In addition, our results revealed that the 2 groups both activated the bilateral supplementary motor area, middle cingulate cortex and left inferior parietal lobule, and supramarginal gyrus during motor imagery. Compared with healthy controls, higher activation in the bilateral paracentral lobule, supplementary motor area, putamen, and cerebellar lobules III-V was detected in pediatric complete spinal cord injury during motor imagery, and the activation of these regions was even higher than that of healthy controls during motor execution.

CONCLUSIONS

Our study demonstrated that part of the motor imagery network was functionally preserved in pediatric complete spinal cord injury and could be activated through motor imagery. In addition, higher-level activation in sensorimotor-related regions was also found in pediatric complete spinal cord injury during motor imagery. Our findings may provide a theoretic basis for the application of motor imagery training in pediatric complete spinal cord injury.

Integrating Transcranial Direct Current Stimulation into an Existing Inpatient Physiotherapy Program to Enhance Motor Learning in an Adolescent with Traumatic Brain Injury: A Case Report

PURPOSE

Describe how transcranial direct current stimulation (tDCS) was incorporated into an inpatient physiotherapy program for an adolescent with severe traumatic brain injury (TBI), detail the motor learning focus of the physiotherapy sessions, and summarize gross motor progress.

METHOD

This case report describes an adolescent who received 20 minutes of anodal tDCS immediately prior to 16 physiotherapy sessions over four weeks. Potential side effects were tracked pre/post tDCS. Gross motor outcomes were measured pre-intervention, post-intervention, and three months post-intervention. Physiotherapy session content was analyzed using therapist documentation and the Motor Learning Strategies Rating Instrument.

RESULTS

The youth tolerated tDCS well. The primary side effect was itchiness under the electrodes during tDCS sessions. His mobility progressed from wheelchair use pre- 'tDCS + physiotherapy' to ambulation with a walker post-intervention. His Gross Motor Function Measure score increased 33.1% points pre/post intervention. Session tasks often had several foci (e.g., skill acquisition, strength, and balance) with task focus changing as the youth progressed. Various motor learning strategies were layered within tasks to support performance and learning.

CONCLUSIONS

tDCS was successfully integrated into an existing inpatient physiotherapy program for an adolescent with TBI. This protocol provides a structure for implementing, monitoring, and measuring tDCS + physiotherapy in pediatric rehabilitation.

Body experience influences lexical-semantic knowledge of body parts in children with hemiplegic cerebral palsy

Background

Disorders in different levels of body representation (i.e., body schema, body structural description, and body image) are present in hemiplegic cerebral palsy (HCP). However, it remains unclear whether the body image develops from aspects of body schema and body structural description, and how this occurs in children with HCP.

Objective and methods

In a cross-sectional study, we investigated 53 children with HCP (mean age about 10 years) and 204 typically developing (TD) control children to qualitatively evaluate whether and how body schema (related sensorimotor experiences) and body structural description (related visuospatial experiences) affect the development of children’s body image and whether this development is delayed through HCP. Graph analysis was used to create a lexical-semantic map of body representation from data of a semantic word fluency task.

Results

Results indicated a similar qualitative pattern of influences of sensorimotor and visuospatial experiences on lexical-semantic knowledge of body parts, with a delayed developmental course in children with HCP compared to TD children.

Conclusion

These findings suggest that children’s body image seemed to be influenced by body schema and body structural descriptions as indicated by poorer lexical-semantic knowledge of body parts in children with HCP due to missing physical experiences of the affected body parts. This might imply that “body talk” may beneficially complement physical therapy for children with HCP to promote body image development.

Children with Cerebral Palsy can imagine actions like their normally developed peers

The present study aimed at assessing whether children with Cerebral Palsy (CP) can imagine object directed actions similarly to their normally developed peers. We asked children with CP (n = 12) and paired healthy controls (n = 12) to imagine in first person perspective eight daily actions, after observing them through videoclips presented on a computer screen. During motor imagery (MI) children were interrupted at a specific timepoint (e.g., at 2.5 s) from the start. Two frames extracted from the videoclips were then presented on the screen. One of the two depicted the correct timepoint at which the imagined action was interrupted, while the other represented an earlier or later timepoint. Children had to respond by pressing the key associated to the correct frame. Children also underwent VMIQ-2 questionnaire. Both groups performed similarly in the questionnaire and in the requested task, where they showed the same error rate. Errors mainly concerned the later frame, suggesting a similar strategy to solve the task in the two groups. The results support the view that children with CP can imagine actions similarly to their normally developed peers. This encourages the use of MI as a rehabilitative tool in children with motor impairment.

Physical therapy in children with cerebral palsy in Brazil: a scoping review

AIM

To identify and assess published studies concerning physical therapy in Brazilian children and adolescents with cerebral palsy (CP) using the International Classification of Functioning, Disability and Health (ICF) framework.

METHOD

Articles in English and Portuguese published until October 2020, with no date restrictions, were searched in several different databases. Study characteristics, journal metrics, sample characteristics, and ICF domains explored intervention components and outcomes were extracted. Studies were classified according to the Oxford Centre for Evidence-Based Medicine hierarchy levels to characterize the evidence.

RESULTS

Ninety-four studies were included. Spastic CP with fewer limitations in gross motor abilities was the most reported; 67% of the studies had low levels of evidence and were published in journals without an impact factor. The three most frequent interventions were neurodevelopmental treatment, suit therapy, and transcranial direct current stimulation. Intervention components explored body functions and structures (73.4%), activity (59.6%), environment (2.1%). They did not explore participation (0%). The outcomes investigated addressed activity (79.8%), body functions and structures (67.0%), and participation (1.1%), but not environment (0%).

INTERPRETATION

Studies of physical therapy for Brazilian children and adolescents with CP focused on reducing impairments and activity limitations. Studies with higher levels of evidence and an expanded focus on participation and environmental factors are necessary.

Fisioterapia em crianças com paralisia cerebral no Brasil: uma revisão de escopo

OBJETIVO

Identificar e avaliar os estudos publicados sobre fisioterapia em crianças e adolescentes brasileiros com paralisia cerebral (PC), usando o modelo da Classificação Internacional de Funcionalidade, Incapacidade e Saúde (CIF). MÉTODO: Artigos em inglês e português publicados até outubro de 2020, sem restrição de data, foram pesquisados em diferentes bases bibliográficas. Foram extraídos dados sobre as características do estudo, métricas do periódico, características da amostra, domínios da CIF explorados a partir dos componentes e desfechos das intervenções. Para caracterizar as evidências, os estudos foram classificados de acordo com os níveis de evidência do Centro de Medicina Baseada em Evidência de Oxford.

RESULTADOS

Noventa e quatro estudos foram incluídos. Crianças com PC espástica e com menores limitações nas habilidades motoras grossas foram as mais reportadas; 67% dos estudos apresentaram baixos níveis de evidência e foram publicados em periódicos sem fator de impacto. As três intervenções mais frequentes foram o conceito neuroevolutivo Bobath/terapia do neurodesenvolvimento, a terapia com vestes e a estimulação transcraniana por corrente contínua. Os componentes das intervenções exploraram estruturas e funções do corpo (73,4%), atividade (59,6%) e ambiente (2,1%). Entretanto não exploraram a participação (0%). Os desfechos investigados abordaram atividade (79,8%), estruturas e funções do corpo (67,0%), participação (1%) e ambiente (0%). INTERPRETAÇÃO: Os estudos de intervenções fisioterapêuticas para crianças e adolescentes brasileiros com PC, apresentam maior foco em minimizar deficiências em estruturas e funções do corpo e limitações de atividades. São necessários mais estudos, com melhor nível de evidência e foco ampliado para a participação e os fatores ambientais.

The effect of motor imagery training on individuals with unilateral cerebral palsy on motor imagery ability, functional mobility and muscle activity

AIM

This study aims to examine the effect of motor imagery (MI) training on MI abilities, functional mobility, and lower extremity muscle activity in children with unilateral cerebral palsy (UCP).

METHOD

34 UCP and 17 typically developing participants were included. UCP was randomised into 2 groups as UCP MI and UCP control. Participants typically developing were included for baseline comparisons. UCP MI group received 8 weeks of physiotherapy and MI training, the UCP control group 8 weeks of physiotherapy training. The MI abilities, functional mobility, and lower extremity muscle activation were assessed in all groups.

RESULTS

It was found that MI training made a significant difference in favour of the UCP MI group in terms of Movement Imagery Questionnaire-For Children (MIQ-C), mental chronometry, functional mobility, and resting muscle activation (p < 0.05). There was no such significant change in the UCP control group.

CONCLUSION

This current approach in UCP is a feasible method, beneficial to include it in the rehabilitation process.

Neuromotor examination in unilateral cerebral palsy: Bilateral impairments in different levels of motor integration

Unilateral cerebral palsy (UCP) usually results in damage to the unilateral pyramidal system. However, the clinical presentation of neuromotor deficits also suggests lesions to the extrapyramidal and cerebellar systems bilaterally. In this study, we developed and tested a behavioral neuromotor examination protocol assessing impairments at three levels of motor integration for children with UCP, also considering impairments of the non-paretic upper limb as well as the influences of the laterality of the lesion. We included 30 children with UCP (10.79 ± 2.61 years) and 60 healthy children (8.27 ± 1.57 years) in the study. All children were assessed on general cognitive ability and classified according to the manual ability classification system (MACS). Our neuromotor examination protocol incorporated specific tasks for each level of motor integration: pyramidal, extrapyramidal and cerebellar. Children with UCP and controls did not differ with respect to general cognitive abilities and sex but children with UCP were significantly older. Controls performed significantly better than children with UCP on neuromotor tasks at all levels of motor integration. Additionally, performance of the non-plegine hand in children with UCP was significantly inferior to controls. With the exception of fine motor skills (pyramidal level), children with right and left UCP did not differ. Our behavioral neuromotor examination was sensitive to reveal impairments at all three levels of motor integration bilaterally in children with UCP-although more subtle for the non-paretic limb.

Motor imagery in children with unilateral cerebral palsy: a case-control study

AIM

To evaluate whether children with cerebral palsy (CP) are able to engage in a motor imagery task. Possible associations between motor imagery and functional performance, working memory, age, and intelligence were also investigated.

METHOD

This is a case-control study that assessed 57 children (25 females, 32 males) with unilateral CP, aged 6 to 14 years (mean age: 10y 4mo; SD 2y 8mo) and 175 typically developing (control) children, aged 6 to 13 years (87 females, 88 males; mean age: 9y 4mo; SD 1y 11mo). The hand laterality judgment task was used to measure motor imagery ability. Reaction time, accuracy, and the effect of the biomechanical constraints were assessed in this task.

RESULTS

Performance in both groups followed the biomechanical constraints of the task, that is, longer reaction times to recognize stimuli rotated laterally when compared to medial stimuli. Reaction time means did not differ significantly between groups (p>0.05). Significant differences between the unilateral CP and control groups were observed for accuracy (p<0.05). Functional performance and working memory were correlates of motor imagery tasks.

INTERPRETATION

Results suggest that children with unilateral CP can engage in motor imagery; however, they commit more errors than typically developing controls. In addition, their performance in tasks of motor imagery is influenced by functional performance and working memory.

Motor Imagery Development in Children: Changes in Speed and Accuracy With Increasing Age

Although motor imagery has been pointed as a promising strategy for the rehabilitation of children with neurological disorders, information on their development throughout childhood and adolescence is still scarce. For instance, it is still unclear at what age they reach a development comparable to the motor imagery performance observed in adults. Herein we used a mental rotation task to assess motor imagery in 164 typically developing children and adolescents, which were divided into four age groups (6-7, 8-9, 10-11, and 12-13 years) and 30 adults. The effects of biomechanical constraints, accuracy, and reaction time of the mental rotation task were considered. ANOVA showed that all groups had the effect of biomechanical restrictions of the mental rotation task. We found a group effect for accuracy [F (4, 180) = 17,560; p < 0.00; η2 = 3.79] and reaction time [F (4, 180) = 17.5; p < 0.001, η2 = 0.615], with the results of children groups 6-7 and 8-9 years being significantly lower than the other groups (p < 0.05). In all the analyses, there were no differences regarding accuracy and reaction time among the participants of the age groups 10-11 and 12-13 years and adults (p > 0.05). Concluding, children aged 6-7 years were able to perform motor imagery, motor imagery ability improved as the participants' ages increased, and children aged 10 and over-performed similarly to adults.