A Systematic Review of Training Methods That May Improve Selective Voluntary Motor Control in Children With Spastic Cerebral Palsy

Postural control telerehabilitation with a low-cost virtual reality protocol for children with cerebral palsy: Protocol for a clinical trial

OBJECTIVE

To establish the feasibility and effectiveness of a rehabilitation programme using low-cost virtual reality aimed at improving postural control in children with cerebral palsy-spastic hemiplegia. It also aims to compare the effectiveness of this programme under two delivery modalities, telerehabilitation (TR) and face-to-face (FtF).

METHODS

This is a registered randomized controlled clinical trial protocol (ACTRN12621000117819). Eighteen sessions of low-cost virtual reality therapy will be provided through both, FtF and TR modalities using a Nintendo Wii balance board. Each programme will last for 6 weeks and will consist of 3 sessions per week of 25 minutes each. Twenty patients diagnosed with cerebral palsy-spastic hemiplegia will be recruited for each group: FtF or TR (n = 40). Participants will be assessed at baseline, by the end of weeks 2, 4, and 6, and at weeks 8 and 10 (post-intervention follow-ups). The primary outcome will be the Center of Pressure sway area (CoParea); secondary outcomes will be standard deviation and velocity of the CoP in the mediolateral and anterior-posterior directions; tertiary outcomes will include the Modified-Modified Ashworth Scale for lower limbs, Modified Ashworth Scale for upper limbs, timed up-and-go tests, the timed one-leg standing and 6-minute walk test.

RESULTS

This study provides an assessment of the feasibility and effectiveness of an affordable rehabilitation programme using low-cost virtual reality aimed at improving postural control in children with cerebral palsy.

CONCLUSION

The designed rehabilitation programme using low-cost virtual reality may improve postural control in children with cerebral palsy-spastic hemiplegia. The TR modality is likely to be as effective as the FtF modality. The TR programme has been designed to overcome access barriers to physiotherapy services for children with cerebral palsy in low-resource settings, remote areas, and in restricted mobility contexts.

How does treadmill training contribute to botulinum toxin application plus routine physical therapy in ambulatory children with spastic bilateral cerebral palsy? A randomized controlled trial

BACKGROUND

In spite of treadmill training and multilevel botulinum toxin (BoNT-A) injection being the two most commonly used treatment methods in pediatric rehabilitation management, there was no study investigating the effect of treadmill training after BoNT-A injection in children with cerebral palsy (CP).

AIM

The aim of this study was to investigate the effect of treadmill training in addition to routine physical therapy after BoNT-A injection in ambulatory children with spastic bilateral CP on lower extremity muscle strength, selective motor control, and mobility.

METHODS

A total of 30 spastic bilateral children with CP classified level II-III by the Gross Motor Function Classification System were randomly assigned the study and control groups. Both groups continued routine physical therapy treatments after multilevel BoNT-A injection into lower extremities, while the study group additionally underwent 8 weeks of treadmill training (20 min, two sessions per week). Handheld dynamometer, selective control assessment of lower extremity, temporospatial evaluation of gait, and Pediatric Evaluation of Disability Inventory were assessed before and after 8 weeks.

RESULTS

In both groups, hip, knee, and ankle muscle strength increased at the end of 8 weeks (p < 0.05); however, in the study group, hip flexor/extensor muscle strength (p < 0.05, ES ≥ 0.50), selective motor control of ankle (p < 0.01, ES = 1.17), walking speed (p < 0.01, ES = 2.60), step lengths (p < 0.01, ES = 1.32), and mobility (p < 0.01, ES = 1.37) increased significantly compared to those of the control group.

CONCLUSIONS

Treadmill training in addition to routine physical therapy after BoNT-A injection is beneficial for hip muscle strength, ankle selective motor control, walking quality, and functional mobility in the short term.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03580174.

Validity and reliability of an electromyography-based similarity index to quantify lower extremity selective voluntary motor control in children with cerebral palsy

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The SI_SCALE is a new electromyography-based measure to quantify selective voluntary motor control.

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There is a need for precise, interval-scaled measures of selective voluntary motor control in children with cerebral palsy.

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Concurrent and discriminative validity of the new measure was affirmed and test–retest reliability was acceptable.

Objective

To quantify selective voluntary motor control (SVMC) objectively and more precisely, we combined the “Selective Control Assessment of the Lower Extremity” (SCALE) with surface electromyography. The resulting Similarity Index (SI) measures the similarity of muscle activation patterns. This study evaluated the preliminary validity and reliability of this novel SI_SCALE measure in children with cerebral palsy (CP).

Methods

We investigated concurrent validity by correlating the SI_SCALE of 24 children with CP (median age 10.6 years) with comparator assessments. For discriminative validity, the patients’ SI_SCALE scores were compared to 31 neurologically intact age-matched peers. Test-retest reliability was quantified using intraclass correlation coefficients (ICC) and minimal detectable change (MDC) values.

Results

The SI_SCALE correlated strongly with the SCALE (ρ = 0.90, p < .001) and the Gross Motor Function Classification System (ρ = −0.74, p < .001). SI_SCALE scores were significantly lower in children with CP compared to healthy peers. Test-retest reliability appeared good (for the more and less affected leg, ICC ≥ 0.84, and MDC ≤ 0.17).

Conclusions

Validity and reliability of the SI_SCALE leg and total scores lay within clinically acceptable ranges. Further clinimetric analyses should include responsiveness.

Significance

A neurophysiology-based assessment could contribute to a more refined assessment of SVMC impairments.

Game-based training of selective voluntary motor control in children and youth with upper motor neuron lesions: protocol for a multiple baseline design study

Background

Impairments of selective control of joint movements can have consequences for many activities of daily life, but there are only a few interventions to improve selective voluntary motor control (SVMC). We have developed a treatment option to specifically enhance SVMC exploiting the advantages of interactive computer play technology. It targets SVMC by training selective activation of a muscle or a selective joint movement while it provides immediate feedback about involuntary muscle activations/movements at an (unwanted) joint. This study aims to investigate the effectiveness of this game-based intervention to enhance SVMC in children and youth with upper motor neuron lesions.

Methods

We will conduct a randomized, non-concurrent, multiple baseline design study. Patients aged between 6 and 20 years with reduced SVMC due to an upper motor neuron lesion will be included. During the baseline phase of random length, participants will attend their regular intensive rehabilitation program, and in the intervention phase, they will additionally complete 10 therapy sessions (à 40 min) of the game-based SVMC training. The primary outcome will be a short SVMC assessment conducted repeatedly throughout both phases, which quantifies movement accuracy and involuntary movements. Changes in clinical SVMC measures, muscle strength, cortical excitability, motor control of the inhibited/unwanted movement, and functional independence will be assessed as secondary outcomes. We will use a mixed-effect model to determine the change in the course of the primary outcome when the intervention is introduced, and we will compare changes between phases for secondary outcomes with paired tests.

Discussion

This study will provide first evidence whether SVMC can be improved with our game-based training. The single-case design takes into account the individualization required for this intervention, and it can help to address the challenges of intervention trials in our setting.

Trial registration

German Clinical Trials Register: DRKS00025184, registered on 28.04.2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-021-02983-8.

Effects of Robotic-Assisted Gait Training in Children and Adolescents with Cerebral Palsy: A Network Meta-Analysis

Gait disturbances are common in children and adolescents with cerebral palsy (CP). Robotic-assisted gait training (RAGT) is becoming increasingly widespread, and hence it is important to examine its effectiveness. A network meta-analysis (NMA) of clinical trials comparing treatments with RAGT vs. other physical therapy treatments was carried out. This study was conducted according to the NMA version of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA-NMA) guidelines and following the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions. The outcome variables used were the D and E dimensions of the Gross Motor Function Measure (GMFM), gait speed, resistance, and stride length. Among 120 records, 8 trials were included. This NMA did not find statistically significant results for any of the comparisons examined in any of the outcomes studied and the magnitude of the effect size estimates was low or very low. Our NMA results should be interpreted with caution due to the high clinical heterogeneity of the studies included.

An Interactive Computer Game for Improving Selective Voluntary Motor Control in Children With Upper Motor Neuron Lesions: Development and Preliminary Feasibility Study

Background

Computer game–based interventions are emerging in pediatric neurorehabilitation, as they can provide two key elements for motor learning—motivating environments that enable long-term compliance, which is particularly relevant for children, and augmented feedback for improving movement performance.

Objective

The overall aim of this study is to develop an interactive computer play for children with upper motor neuron lesions to train selective voluntary motor control and give particular attention to motivation and feedback. We also aim to determine features that make games engaging, investigate which sensory feedback modality is noticed the fastest during play, develop an interactive game, and evaluate its feasibility.

Methods

We identified engaging game features by interviewing 19 children and adolescents undergoing rehabilitation. By using a test version of the game, we determined the response times of 10 patients who had to react to visual, auditory, or combined feedback signals. On the basis of the results of these two subprojects, we developed and designed a game environment. Feasibility was studied in terms of the practicability and acceptability of the intervention among 5 children with upper motor neuron lesions.

Results

The game features deemed the most important by pediatric patients were strategic gameplay (13/29, 45% of answers) and choice (6/29, 21%). While playing the game, an acoustic alarm signal (reaction time: median 2.8 seconds) was detected significantly faster (P=.01) than conditions with other feedback modalities (avatar velocity reduction: median 7.8 seconds; color desaturation: median 5.7 seconds). Most children enjoyed playing the game, despite some technical issues.

Conclusions

The careful identification of game features that increase motivation and feedback modalities that inform children quickly led to the development of an interactive computer play for training selective voluntary motor control in children and adolescents with upper motor neuron lesions.