Precision grip control, sensory impairments and their interactions in children with hemiplegic cerebral palsy: a systematic review

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.

Investigation of the Relationship between Sensory-Processing Skills and Motor Functions in Children with Cerebral Palsy

The main purpose of this study is to examine the relationship between sensory-processing skills and gross motor functions, bimanual motor functions, and balance in children with cerebral palsy (CP). A total of 47 patients between the ages of 3 and 10, diagnosed with CP, who received or applied for treatment in our physical therapy and rehabilitation unit were included in the study. Sensory profiling (SP), assisting hand assessment (AHA), the Gross Motor Function Measure-66 (GMFM-66), and the Pediatric Berg Balance Scale (PBBS) were used in the evaluation of the children with CP who participated in the study. The Gross Motor Function Classification System (GMFCS) was used to classify the children based on functional abilities and limitations, and the Manual Ability Classification System (MACS) was used to classify the children based on manual dexterity. The SP parameters were compared with AHA, GMFM-66, and PBBS results, and with GMFCS and MACS levels. Statistically significant relationships were found between AHA and SP, PBBS, and SP and between GMFM-66 and SP (p < 0.05). Our study shows that there are some disorders in sensory processing in children with CP. We think that sensory evaluations should be included in the CP rehabilitation program.

Correlation between scapular alignment and upper extremity function in children with hemiparetic cerebral palsy

OBJECTIVES

To investigate the relationship between scapular alignment and upper extremity function.

METHODS

Eighty-five children (63 boys and 22 girls) with spastic hemiplegic cerebral palsy aged 3 to 6 years were included in the study. Scapular upward rotation was assessed using Postural Zone software, and upper extremity function was assessed using the Pediatric Arm Function Test.

RESULTS

There was a significant difference (p = .0001) in the degree of upward scapular rotation between less affected and affected sides (-41.78 ± 4.87 and -26.42 ± 6.34, respectively). There was a significant difference (p = .0001) between the function of the upper extremity of the affected side and the less affected sides (48.15 ± 14.37, 62.1 ± 6.62, respectively). Pearson Correlation Coefficient (r) was calculated, and there was a strong negative significant correlation between the degree of scapular upward rotation of the affected side, a unilateral score of the affected side, and the total score of the Pediatric Arm Function Test (r = -0.976, p = .0001 and r = -0.973, p = .0001, respectively). The correlation between symmetry index and total score of the Pediatric Arm Function Test was a strong positive significant correlation (r = 0.946, p = .0001).

CONCLUSION

The degree of upward scapular rotation was less on the affected side. Scapular alignment and symmetry may contribute to upper extremity function in children with hemiplegic cerebral palsy. Clinically, correction of scapular deviations may be considered in the rehabilitation program for children with hemiplegic cerebral palsy. This study suggests further experimental studies to find the cause and effect.

Somatosensation and motor performance in the less-affected and more-affected hand of unilateral cerebral palsy children: a cross-sectional study

PURPOSE

This study aimed to examine motor performance and somatosensory processing of unilateral cerebral palsy (UCP) children in both the less-affected hand and the more-affected hand. This study is also aimed at analysing the somatosensory proccessing in the more-affected hand in relation to age and damaged hemisphere.

MATERIALS AND METHODS

Forty-seven children aged from 6 to 15 years (UCP = 23; TD = 24) were recruited. Grip strength, pinch strength, Box and Block Test and Jebsen Taylor Hand Function Test were used to analyse motor performance. A comprehensive somatosensory assessment battery was included: tactile registration, unilateral, bilateral and spatio-temporal perception, haptic recognition, texture perception, proprioception, pressure pain threshold and functional sensitivity.

RESULTS

UCP children exhibited lower performance in all aspects of motor performance measured in both the less-affected hand and the more-affected hand, except grip strength in the less-affected hand. Significant differences were found for all tests included in the somatosensory assessment in both the less-affected hand and the more-affected hand, except unilateral perception tests in the less-affected hand.

CONCLUSIONS

UCP children present difficulties in motor performance and somatosensory processing not only in the more-affected hand, but also in the less-affected hand. Somatosensation may be a critical driver of functional performance.Implications for rehabilitationThe less-affected hand of children with unilateral cerebral palsy should be included in both assessment and intervention programmes.Somatosensory processing should be assessed through a comprehensive battery, both in the less-affected hand and in the more-affected hand of unilateral cerebral palsy children.Somatosensory treatment must be taken into account if functional performance in the activities of daily living of unilateral cerebral palsy children is to be improved.

Motor control differs for increasing and decreasing force production during ankle Isometric exercises in children

BACKGROUND

Performance of the central nervous system (CNS) in increased and decreasing muscle force around the ankle joint is essential for upright tasks of daily living. Previous studies have shown altered CNS control when they decrease force compared with when they increase force in young and older adults. But whether such alteration exists during childhood with incomplete maturation of CNS systems remain unclear. Therefore, this study aimed to evaluate the disparities in intramuscular EMG-EMG coherence, which serve as indicators of corticospinal drive to muscles during ankle isometric increasing and decreasing force generation in children.

METHODS

We measured intramuscular EMG-EMG coherence activity of the tibialis anterior (TA) and the associated ability to perform isometric efforts at the ankle in 12 typically developing children (mean ± SD age = 5.91±1.37 years) and 12 healthy young adults (mean ± SD age = 23.16±1.52 years). The participants maintained isometric contractions at 20% of their maximal voluntary contractions (MVC) during ankle dorsiflexion to match a triangle trajectory for 7 s, including ramping up in 3.5 s (increasing force phase) and then linearly ramping down to rest in 3.5 s (decreasing force phase). The variability of force control was characterized by the coefficient of variance (CoV) of force output. Intramuscular EMG-EMG coherence from TA in two frequency bands, the beta band (15-30 Hz) and gamma band (30-45) that could reflect the corticospinal drive, were calculated for the comparison. A repeated measures ANOVA with the within-subjects factor of force generation phase (increasing force vs. decreasing force)x between-subjects factor of the group (children and young adults) was used for statistical analysis.

RESULTS

Regarding the within-subjects difference, our results exhibited significantly higher CoV of force (p < 0.01) and lower EMG-EMG coherence of TA when they decrease force compared with when they increase force in both children and young adult groups. Regarding the between-subjects difference, the CoV of force was significantly higher (p < 0.01) in children compared to young adults, while the EMG-EMG coherence in children showed a significantly lower (p < 0.01) coherence compared with young adults. Furthermore, the EMG-EMG coherence measures were negatively correlated with the CoV of force.

CONCLUSIONS

The findings suggest that the age-related development would increase the corticospinal drive to TA muscle to deal with ankle isometric dorsiflexion during childhood, which could be also modulated with the force production phases, including increasing and decreasing force.

Neural Correlates of Impaired Grasp Function in Children with Unilateral Spastic Cerebral Palsy

Unilateral spastic cerebral palsy (USCP) is caused by damage to the developing brain and affects motor function, mainly lateralized to one side of the body. Children with USCP have difficulties grasping objects, which can affect their ability to perform daily activities. Although cerebral palsy is typically classified according to motor function, sensory abnormalities are often present as well and may contribute to motor impairments, including grasping. In this review, we show that the integrity and connectivity pattern of the corticospinal tract (CST) is related to execution and anticipatory control of grasping. However, as this may not explain all the variance of impairments in grasping function, we also describe the potential roles of sensory and sensorimotor integration deficits that contribute to grasp impairments. We highlight studies measuring fingertip forces during object manipulation tasks, as this approach allows for the dissection of the close association of sensory and motor function and can detect the discriminant use of sensory information during a complex, functional task (i.e., grasping). In addition, we discuss the importance of examining the interactions of the sensory and motor systems together, rather than in isolation. Finally, we suggest future directions for research to understand the underlying mechanisms of grasp impairments.

Neuro-imaging characteristics of sensory impairment in cerebral palsy; a systematic review

Background

Objective: To identify and examine neural reorganization of the sensory network in terms of lesion type, somatotopic organization of the primary somatosensory area, and functional connectivity in relation to sensory function in children and young adults with cerebral palsy (CP).

Methods

Design: systematic review, Prospero registration ID 342570. Data sources: PubMed; Cochrane; Web of Science; Embase; CINAHL and PEDro from inception to March 13, 2021. Eligibility criteria: All types of original studies, concerning sensory connectivity in relation to sensory outcome in patients with spastic CP, &lt;30 years of age. No publication status or date restrictions were applied. Data extraction and synthesis: Two authors independently determined the eligibility of studies. Quality assessment was performed by a third author. Neuro-imaging/neurophysiological techniques, sensory outcomes and patient characteristics were extracted.

Results

Children and young adults with periventricular leucomalacia (PVL) lesions have significantly better hand function and sensation scores than patients with cortical-subcortical/middle cerebral artery (MCA) lesions. Ipsilesional reorganization of the S1 (primary somatosensory cortex) area appears to be the primary compensation mechanism after a unilateral early brain lesion, regardless of the timing of the lesion. Interhemispheric reorganization of the sensory system after early brain lesions is rare and, when it occurs, poorly effective. Diffusion tractography shows a positive correlation between the ascending sensory tract (AST) diffusivity metrics of the more affected hemisphere and sensory test outcomes.

Discussion and conclusions

Because of the large variability in study design, patient characteristics, neuroimaging/neurophysiological techniques and parameters as well as sensory assessment methods used, it is difficult to draw definite inferences on the relationship between the reorganization of the sensory network following early brain damage and sensory function in children and young adults with CP. In general, sensory function seems to be worse in cortical as opposed to white matter tract (PVL) lesions. International consensus on a clinically relevant sensory test battery is needed to enhance understanding of the intriguing compensatory mechanisms of sensory network following early brain damage and potential consequences for rehabilitation strategies.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/.

Effects of stochastic resonance stimulation on manual function in children with hemiplegic cerebral palsy: A pilot clinical trial

OBJECTIVE

To investigate the effect of stochastic resonance stimulation (SRS) on manual abilities in children with hemiplegic cerebral palsy.

DESIGN

This pilot study is a randomized, sham-controlled, one-period, crossover trial.

SETTING

A neuroscience clinic with specialty therapy programs at an urban, university-based children's hospital.

PARTICIPANTS

Sixteen children ages 3 to 16 years who were diagnosed with hemiplegic cerebral palsy and had hand Manual Abilities Classification scale score of I to III with sufficient cognitive abilities to follow instructions.

INTERVENTIONS

Children donned wrist and arm bands that delivered SRS via embedded piezoelectric actuators in two randomly assigned conditions: sham (devices powered off) and subthreshold stimulation (SBT-SRS). Following the randomized protocol, a subset of participants also completed an open-label, above-threshold stimulation (AT-SRS) condition. Children carried out the same uni-manual and bimanual tasks during the randomized and open-label protocols; all data were collected in a single session.

MAIN OUTCOME MEASURE(S)

Box and Blocks (B&B) test, a uni-manual function test, and the Shriners Hospital Upper Extremity Evaluation (SHUEE). The SHUEE was video recorded and scored by two raters who were blinded to the experimental condition.

RESULTS

Thirteen children completed the B&B task and 14 children completed the SHUEE. Children in the SBT-SRS condition relative to sham condition moved an average of 1.8 more blocks in 1 minute (p = .08); scored an average of 3 points higher on SHUEE spontaneous functional analysis (p < .002); and scored an average of 2.7 points higher on SHUEE dynamic positional analysis (p = .20). In the open-label protocol, children in the AT-SRS condition relative to sham moved 3.9 more blocks than in the sham condition (n = 8, p < .001); scored an average of 4.5 points higher on SHUEE spontaneous functional analysis (n = 6, p = .08); and scored an average of 10.5 points higher on SHUEE dynamic positional analysis (n = 6, p = .01).

CONCLUSION(S)

In this pilot study, we found preliminary evidence that children with hemiplegic cerebral palsy demonstrated improved uni-manual abilities and increased function of the impaired hand on bimanual tasks when receiving a single session of SBT-SRS. Preliminary evidence also suggests that some children with hemiplegic cerebral palsy may improve more when receiving a single session of AT-SRS. Future research using larger, controlled studies should evaluate the optimal intensity, duration, and long-term effect of SRS for improving impaired manual abilities.

The Effect of Bimanual Intensive Functional Training on Somatosensory Hand Function in Children with Unilateral Spastic Cerebral Palsy: An Observational Study

(1) Background: Next to motor impairments, children with unilateral spastic cerebral palsy (CP) often experience sensory impairments. Intensive bimanual training is well known for improving motor abilities, though its effect on sensory impairments is less known. (2) Objective: To investigate whether bimanual intensive functional therapy without using enriched sensory materials improves somatosensory hand function. (3) Methods: A total of twenty-four participants with CP (12-17 years of age) received 80-90 h of intensive functional training aimed at improving bimanual performance in daily life. Somatosensory hand function was measured before training, directly after training, and at six months follow-up. Outcome measures were: proprioception, measured by thumb and wrist position tasks and thumb localization tasks; vibration sensation; tactile perception; and stereognosis. (4) Results: Next to improving on their individual treatment goals, after training, participants also showed significant improvements in the perception of thumb and wrist position, vibration sensation, tactile perception, and stereognosis of the more affected hand. Improvements were retained at six months follow-up. Conversely, proprioception measured by the thumb localization tasks did not improve after training. (5) Conclusions: Intensive functional bimanual training without environmental tactile enrichment may improve the somatosensory function of the more affected hand in children with unilateral spastic CP.

Feasibility of Using Joystick-Operated Ride-on-Toys to Promote Upper Extremity Function in Children With Cerebral Palsy: A Pilot Study

PURPOSE

To evaluate the feasibility of implementation, acceptance, and perceived efficacy of a joystick-operated ride-on-toy intervention to promote upper extremity (UE) function in 3- to 14-year-old children with hemiplegic cerebral palsy.

METHODS

Exit questionnaires were collected from children, caregivers, and clinicians/camp staff following a 3-week ride-on-toy training program incorporated within a summer camp for children with hemiplegic cerebral palsy. Training encouraged children to use their affected UE to maneuver the ride-on-toy. Questionnaires included Likert scale and open-ended questions to assess enjoyment, acceptance, feasibility, and perceived efficacy of the training.

RESULTS

All stakeholder groups indicated that the training was enjoyable. Clinicians/staff and caregivers indicated that the training increased children's motivation to use their affected UE and reported perceived improvements in UE movement control and function following training.

CONCLUSIONS

Our promising preliminary findings call for future research to systematically assess the efficacy of ride-on-toys to promote UE control and function in children with hemiplegic cerebral palsy.Supplemental Digital Content 1 video abstract, available at: http://links.lww.com/PPT/A404.

Reliable and Valid Robotic Assessments of Hand Active and Passive Position Sense in Children With Unilateral Cerebral Palsy

Impaired hand proprioception can lead to difficulties in performing fine motor tasks, thereby affecting activities of daily living. The majority of children with unilateral cerebral palsy (uCP) experience proprioceptive deficits, but accurately quantifying these deficits is challenging due to the lack of sensitive measurement methods. Robot-assisted assessments provide a promising alternative, however, there is a need for solutions that specifically target children and their needs. We propose two novel robotics-based assessments to sensitively evaluate active and passive position sense of the index finger metacarpophalangeal joint in children. We then investigate test-retest reliability and discriminant validity of these assessments in uCP and typically developing children (TDC), and further use the robotic platform to gain first insights into fundamentals of hand proprioception. Both robotic assessments were performed in two sessions with 1-h break in between. In the passive position sense assessment, participant's finger is passively moved by the robot to a randomly selected position, and she/he needs to indicate the perceived finger position on a tablet screen located directly above the hand, so that the vision of the hand is blocked. Active position sense is assessed by asking participants to accurately move their finger to a target position shown on the tablet screen, without visual feedback of the finger position. Ten children with uCP and 10 age-matched TDC were recruited in this study. Test-retest reliability in both populations was good (intraclass correlation coefficients (ICC) >0.79). Proprioceptive error was larger for children with uCP than TDC (passive: 11.49° ± 5.57° vs. 7.46° ± 4.43°, p = 0.046; active: 10.17° ± 5.62° vs. 5.34° ± 2.03°, p < 0.001), indicating discriminant validity. The active position sense was more accurate than passive, and the scores were not correlated, underlining the need for targeted assessments to comprehensively evaluate proprioception. There was a significant effect of age on passive position sense in TDC but not uCP, possibly linked to disturbed development of proprioceptive acuity in uCP. Overall, the proposed robot-assisted assessments are reliable, valid and a promising alternative to commonly used clinical methods, which could help gain a better understanding of proprioceptive impairments in uCP, facilitating the design of novel therapies.

Psychometric Properties of Lower Limb Somatosensory Function and Body Awareness Outcome Measures in Children with Upper Motor Neuron Lesions: A Systematic Review

PURPOSE

A systematic review of the psychometric properties and feasibility of outcome measures assessing lower limb somatosensory function and body awareness in children with upper motor neuron lesion.

METHODS

We followed the COnsensus-based Standards for the selection of health Measurement INstruments guidelines. Two raters independently judged the quality and risk of bias of each study. Data synthesis was performed, and aspects of feasibility were extracted.

RESULTS

Twelve studies investigated eleven somatosensory function measures quantifying four modalities and eight body awareness measures quantifying two modalities. The best evidence synthesis was very low to low for somatosensory function modalities and low for body awareness modalities. Few feasibility aspects were reported (e.g., the percentage or minimum age of participants able to perform the tests).

CONCLUSION

Current evidence on the psychometric characteristics of somatosensory function and body awareness outcome measures are relatively sparse. Further research on psychometric properties and practical application is needed.

The Effectiveness of Proprioceptive Training for Improving Motor Performance and Motor Dysfunction: A Systematic Review

Objective

Proprioceptive training is any intervention aiming to improve proprioceptive function with the ultimate goal to enhance motor function and performance. It has been promoted as an approach to enhance athletic performance and as a tool for sensorimotor rehabilitation. Numerous studies sought to provide evidence on the effectiveness of the approach. However, many different training regimes claiming to train proprioception report a variety of sensorimotor measures that are not directly comparable. This, in turn, makes it difficult to assess effectiveness across approaches. It is the objective of this study to systematically review recent empirical evidence to gain an understanding of which outcome measures are most sensitive, which populations may benefit most from proprioceptive training, and what are the effects on proprioceptive and motor systems.

Methods

Four major databases were searched. The following inclusion criteria were applied: (1) A quantified pre- and post-treatment measure of proprioceptive function. (2) An intervention or training program believed to influence or enhance proprioceptive function. (3) Contained at least one form of treatment or outcome measure that is indicative of somatosensory function and not confounded by information from other sensory modalities. 4) The study reported of at least one quantified measure of motor performance.

Results

Of the 3,297 articles identified by the database search, 70 studies met the inclusion criteria and were included for further review. Across studies, proprioceptive training led to comparable gains in both proprioceptive (+46%) and motor performance (+45%). The majority of studies (50/70) applied active movement interventions. Interventions applying somatosensory stimulation were most successful in clinical populations. Joint position sense error (JPSE) was the most commonly used proprioceptive measure and presents a reliable and feasible measure for clinical use.

Conclusion

Proprioceptive training can lead to significant improvements in proprioceptive and motor function across a range healthy and clinical populations. Regimens requiring active movement of the trainee tended to be most successful in improving sensorimotor performance. Conclusive evidence on how long training gains are retained is still lacking. There is no solid evidence about the underlying long-term neuroplastic changes associated proprioceptive training.

The Effects of Ayres Sensory Integration and Related Sensory Based Interventions in Children with Cerebral Palsy: A Scoping Review

The theory of Ayres Sensory Integration^® was formulated in the 1960s, and is also known as sensory integration (SI). It has been used in people with cerebral palsy (CP), though the research evidence for its effects in this population is contradictory and inconclusive. To fill in this knowledge gap, we conducted a scoping review of the body of literature on the topic, including any type of quantitative or qualitative research of SI in people with CP without any restrictions of age, language, geography, professionals involved, etc. In September 2020, we searched Scopus, ProQuest Central, MEDLINE (via PubMed), CINAHL Plus and the Academic Search Ultimate and Web of Science, as well as the grey literature sources OpenGrey and MedNar. Two reviewers independently screened the texts and the references lists of the included papers. We finally included seven relevant papers (four randomized controlled trials, two quasi-experimental studies and one case series), though not all fidelity measures required for Ayres SI were reported in the papers. The age of participants ranged from 3 months to 15 years; no studies were identified on adults. There is some evidence that SI or related sensory-based interventions (SBI) may be useful for movement development and other outcomes (attention span, therapy of sensory processing disorders, body perception and therapy of strabismus), but there is only scarce and low-quality evidence comparing interventions. We recommend to conduct well-designed randomized controlled trials (RCTs) with an optimal sample size on the effectiveness of formal Ayres SI for the motor development or other outcomes (as attention span or self-care abilities) using standardized measurement tools.

PROPENSIX: pressure garment therapy using compressive dynamic Lycra® sleeve to improve bi-manual performance in unilateral cerebral palsy: a multicenter randomized controlled trial protocol

Background

Upper limb impairment affects activity and participation in children with unilateral cerebral palsy (UCP). Pressure garment therapy (PGT) using compressive dynamic Lycra^® garments is an innovative intervention proposed for the management of cerebral palsy consequences. The PROPENSIX study aims to evaluate the efficacy of a therapy using a Lycra^® sleeve as compared to a placebo sleeve to improve bi-manual performance measured by the Assisting Hand Assessment (AHA) in children with unilateral cerebral palsy.

Methods

The PROPENSIX trial is a multicenter, prospective, placebo-controlled, double-blinded, randomized study. One hundred children with UCP, aged from 5 to 10, are randomly assigned as soon as they are recruited in a 1:1 ratio to perform usual daily activities, especially activities involving bimanual performances, with Lycra^® sleeve or placebo sleeve during 6 months. The primary endpoint is the change in bimanual performance from inclusion to 6 months, evaluated by AHA. The secondary endpoints evaluate changes from inclusion to 6 months in other dimensions of the International Classification of Functioning (ICF), upper limb movement capacity assessed by Quality of Upper Extremity Skill Test (QUEST), and health-related quality of life evaluated by Pediatric Quality of Life Inventory 3.0 Cerebral Palsy Module (PedsQLTM 3.0 CP Module) and in body structures and functions domain assessed by neuro-orthopedic examination and somatosensory evoked potentials (SEP).

Discussion

The PROPENSIX study is the largest randomized controlled trial (RCT) aiming to evaluate the efficacy of a PGT using compressive dynamic Lycra^® sleeve in UCP. Enhancement of children’s bimanual performance at the end of the 6 months wear of the Lycra^® sleeve should improve evidence regarding this type of treatment and expand discussion about their recommendation in clinical practice. Data from secondary outcomes assessments should bring interesting arguments to discuss the Lycra^® sleeve action on mobility, tonus, and sensory impairments in children with unilateral cerebral palsy.

Trial registration

ClinicalTrials.govNCT02086214. Retrospectively registered on March 13, 2014

Trial status

Study start data: December 2012. Recruitment status: completed. Primary completion date: April 2021. Estimated study completion date: December 2022. Protocol version 10 (date: February 2018).

Assessing spino-cortical proprioceptive processing in childhood unilateral cerebral palsy with corticokinematic coherence

OBJECTIVE

To develop an electrophysiological marker of proprioceptive spino-cortical tracts integrity based on corticokinematic coherence (CKC) in young children with unilateral cerebral palsy (UCP), in whom behavioral measures are not applicable.

METHODS

Electroencephalography (EEG) signals from 12 children with UCP aged 19 to 57 months were recorded using 128-channel EEG caps while their fingers were moved at 2 Hz by an experimenter, in separate sessions for the affected and non-affected hands. The coherence between movement kinematics and EEG signals (i.e., CKC) was computed at the sensor and source (using a realistic head model) levels. Peaks of CKC obtained for the affected and non-affected hands were compared for location and strength. The relation between CKC strength on the lesion-side, the lesion-type (cortico-subcortical vs. subcortical) and the level of manual ability were studied with 2-way repeated-measures ANOVA.

RESULTS

At the individual level, a significant CKC peak at the central area contralateral to the moved hand was found in all young children with their non-affected hand and in 8 out of 12 children with their affected hand. At the group level, CKC to the affected hand movements was weaker than CKC to the non-affected hand movements. This difference was influenced by the type of lesion, the effect being predominant in the subgroup (n = 5) with cortico-subcortical lesions.

CONCLUSION

CKC is measurable with EEG in young children with UCP and provides electrophysiological evidence for altered proprioceptive spino-cortical tracts on the lesioned brain hemisphere, particularly in children with cortico-subcortical lesions.

Somatosensory deficits and neural correlates in cerebral palsy: a scoping review

AIM

To synthetize studies assessing somatosensory deficits and alterations in cerebral responses evoked by somatosensory stimulation in individuals with cerebral palsy (CP) compared to typically developing individuals.

METHOD

A scoping review of the literature was performed in the MEDLINE, Embase, PsycInfo, CINAHL, Evidence-Based Medicine Reviews, and Web of Science databases (last search carried out on 6th and 7th August 2020) with a combination of keywords related to CP and somatosensory functions. Somatosensory deficits were measured with clinical tests and alterations in cerebral responses were measured with functional magnetic resonance imaging, electroencephalography, and magnetoencephalography.

RESULTS

Forty-eight articles were included. Overall, 1463 participants with CP (mean [SD] age 13y 1mo [4y 11mo], range 1-55y; 416 males, 319 females, sex not identified for the remaining participants) and 1478 controls (mean [SD] age 13y 1mo [5y 8mo], range 1-42y; 362 males, 334 females, sex not identified for the remaining participants) were included in the scoping review. For tactile function, most studies reported registration (8 out of 13) or perception (21 out of 21) deficits in participants with CP. For proprioception, most studies also reported registration (6 out of 8) or perception (10 out of 15) deficits. Pain function has not been studied as much, but most studies reported registration (2 out of 3) or perception (3 out of 3) alterations. Neuroimaging findings (18 studies) showed alterations in the somatotopy, morphology, latency, or amplitude of cortical responses evoked by somatosensory stimuli.

INTERPRETATION

Despite the heterogeneity in the methods employed, most studies reported somatosensory deficits. The focus has been mainly on tactile and proprioceptive function, whereas pain has received little attention. Future research should rigorously define the methods employed and include a sample that is more representative of the population with CP. What this paper adds Most of the papers reviewed found tactile registration and perception deficits in the upper limbs. Proprioceptive deficits were generally observed in cerebral palsy but results were heterogeneous. Pain has received little attention compared to tactile and proprioceptive functions. Neuroimaging studies supported behavioral observations. Alterations were observed for both the most and least affected limb.

Upper Limb Motor Planning in Individuals with Cerebral Palsy Aged between 3 and 21 Years Old: A Systematic Review

Individuals with cerebral palsy have difficulties performing activities of daily living. Beyond motor execution impairments, they exhibit motor planning deficits contributing to their difficulties. The objective of this review is to synthesize the behavioral evidence of motor planning deficits during an upper limb motor task in children, adolescents and young adults with cerebral palsy aged between 3 and 21 years. Methods: The inclusion criteria were: (1) including individuals with cerebral palsy from 3 to 21 years old; (2) assessing upper limb motor planning. Six databases were screened. The quality assessment of the studies was performed. Results: Forty-six studies and 686 participants were included. Five articles have been identified as very high quality, 12 as high, 20 as moderate, six as low, three as very low. Force planning studies reported a deficit for the more affected hand but adequate performances for the less affected hand. Object-manipulation studies reported hand posture planning deficits irrespectively of the hand assessed. Conclusions: Motor planning deficits has been shown in the more affected hand for force scaling, while the results for other variables showed overall deficits. Hence, variables affected by motor planning deficits in both hands should be considered in children with cerebral palsy to optimize intervention.

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.

Relative independence of upper limb position sense and reaching in children with hemiparetic perinatal stroke

BACKGROUND

Studies using clinical measures have suggested that proprioceptive dysfunction is related to motor impairment of the upper extremity following adult stroke. We used robotic technology and clinical measures to assess the relationship between position sense and reaching with the hemiparetic upper limb in children with perinatal stroke.

METHODS

Prospective term-born children with magnetic resonance imaging-confirmed perinatal ischemic stroke and upper extremity deficits were recruited from a population-based cohort. Neurotypical controls were recruited from the community. Participants completed two tasks in the Kinarm robot: arm position-matching (three parameters: variability [Var_xy], contraction/expansion [Area_xy], systematic spatial shift [Shift_xy]) and visually guided reaching (five parameters: posture speed [PS], reaction time [RT], initial direction error [IDE], speed maxima count [SMC], movement time [MT]). Additional clinical assessments of sensory (thumb localization test) and motor impairment (Assisting Hand Assessment, Chedoke-McMaster Stroke Assessment) were completed and compared to robotic measures.

RESULTS

Forty-eight children with stroke (26 arterial, 22 venous, mean age: 12.0 ± 4.0 years) and 145 controls (mean age: 12.8 ± 3.9 years) completed both tasks. Position-matching performance in children with stroke did not correlate with performance on the visually guided reaching task. Robotic sensory and motor measures correlated with only some clinical tests. For example, AHA scores correlated with reaction time (R = - 0.61, p < 0.001), initial direction error (R = - 0.64, p < 0.001), and movement time (R = - 0.62, p < 0.001).

CONCLUSIONS

Robotic technology can quantify complex, discrete aspects of upper limb sensory and motor function in hemiparetic children. Robot-measured deficits in position sense and reaching with the contralesional limb appear to be relatively independent of each other and correlations for both with clinical measures are modest. Knowledge of the relationship between sensory and motor impairment may inform future rehabilitation strategies and improve outcomes for children with hemiparetic cerebral palsy.

Bimanual motor performance in everyday life activities of children with hemiplegic cerebral palsy

BACKGROUND

Motor impairments in children with cerebral palsy significantly reduce their ability to learn and adapt bimanual actions into their life roles. The current evidence on bimanual coordination performance in children with hemiplegic cerebral palsy were mostly drawn from kinematic studies. Whether these kinematic findings on bimanual motor performance can be observed when performing daily life activities in a natural environment is not clear. Further, there is no evidence what and how the verbal prompting influences bilateral motor performance. We intend to explore its role on bimanual motor performance as well.

AIM

This study aimed to investigate the bimanual motor performance in everyday life activities of children with hemiplegic cerebral palsy and the role of verbal prompts in facilitating affected hand use.

DESIGN

Observational study.

SETTING

Local medical center and community.

POPULATION

Twenty-five children with hemiplegic cerebral palsy and 25 age-matched typically developing children.

METHODS

The Observation-based Test of Capacity, Performance, and Developmental Disregard and Melbourne Assessment 2 were used to assess the quantitative and qualitative use of hands in everyday activities.

RESULTS

Children with hemiplegic cerebral palsy, demonstrated different motor coordination patterns in daily bimanual activities compared with their counterparts. With verbal prompts, children with hemiplegic cerebral palsy significantly increased the use of their affected hands in bimanual activities. However, the increases were observed only in basic motor components, such as reaching and grasping, and not in complex motor components such as manipulation.

CONCLUSIONS

These findings will assist researchers and clinicians to develop and refine intervention programs that maximize rehabilitation benefits in improving bimanual hand coordination performance for children with hemiplegic cerebral palsy.

CLINICAL REHABILITATION IMPACT

This study increased our understanding of bimanual motor performance of children with hemiplegic cerebral palsy in everyday life activities. The results demonstrated children with cerebral palsy rely more on their less-affected hand to perform bimanual activities with or without verbal prompts. Incorporating bimanual activities and verbal prompts during intervention may only be effective on facilitating basic hand movements but not on improving complex movements of affected hands. Further research is needed to explore other intervention strategies to facilitate complex bilateral hand movements.

Mirror Therapy and Action Observation Therapy to Increase the Affected Upper Limb Functionality in Children with Hemiplegia: A Randomized Controlled Trial Protocol

The movements of the affected upper limb in infantile hemiplegia are slower and clumsy. This leads to a decrease in the use of the affected hand. The visual effect obtained using the mirror box and the observation of actions in another individual can activate the same structural neuronal cells responsible for the execution of these actions. This research will study the affected upper limb functionality in hemiplegia infantile from 6 to 12 years old after the application of two intervention protocols: observation action therapy and mirror therapy combined with observation action therapy. Children with a diagnose of congenital infantile hemiplegia will be recruited to participate in a randomized controlled trial with two intervention protocols during four weeks (1 h per/day; 5 sessions per/week): Mirror Therapy Action Observation (MTAO) or Action Observation Therapy (AOT). The study variables will be: spontaneous use, measured with the Assisting Hand Assessment (AHA); manual ability measured with the Jebsen Taylor Hand Function Test (JTHFT); surface electromyography of the flexors and extensors muscles of the wrist and grasp strength through a grip dynamometer. Four assessments will be performed: At baseline situation, at the end of treatment, 3 and 6 months after treatment (follow-up assessments). This study will study the effects of these therapies on the use of the affected upper limb in children with hemiplegia.

Impact of somatosensory interventions on upper limb function in children with hemiplegic cerebral palsy: a single-subject design study

Background/aims

Hemiplegia is one of the most common types of cerebral palsy. Upper limb dysfunction in these children can affect their quality of life. The aim of this study was to investigate the effects of somatosensory interventions on upper extremity sensory and motor functions in spastic hemiplegic children.

Methods

This single-subject study was performed in the occupational therapy clinic of Tehran University of Medical Sciences. Three participants (two boys and one girl) aged 8–12 years with spastic hemiplegia were assessed during baseline, treatment and follow-up phases. During the treatment phase, the children received 12 tactile and proprioceptive stimulation (active, passive and playful) sessions over 4 weeks. Four sensory measures (tactile localisation, stereognosis, two-point discrimination, proprioception) and one motor measure (Box and Block Test) were assessed during each phase.

Results

Improvement in function was seen in all three children based on visual analysis, with significant differences between the baseline and treatment scores in the majority of measures for all participants. Changes were sustained at follow up for most tests. The effect size was large for all three children.

Conclusions

Despite the small number of participants, sensory intervention with a focus on sensory deficits could help to improve upper extremity sensory and motor function in children with spastic hemiplegia.

Foot and ankle somatosensory deficits in children with cerebral palsy: A pilot study

PURPOSE

To investigate foot and ankle somatosensory function in children with cerebral palsy (CP).

METHODS

Ten children with spastic diplegia (age 15 ± 5 y; GMFCS I-III) and 11 typically developing (TD) peers (age 15 ± 10 y) participated in the study. Light touch pressure and two-point discrimination were assessed on the plantar side of the foot by using a monofilament kit and an aesthesiometer, respectively. The duration of vibration sensation at the first metatarsal head and medial malleolus was tested by a 128 Hz tuning fork. Joint position sense and kinesthesia in the ankle joint were also assessed.

RESULTS

Children with CP demonstrated significantly higher light touch pressure and two-point discrimination thresholds compared to their TD peers. Individuals with CP perceived the vibration stimulus for a longer period compared to the TD participants. Finally, the CP group demonstrated significant impairments in joint position sense but not in kinesthesia of the ankle joints.

CONCLUSIONS

These findings suggest that children with CP have foot and ankle tactile and proprioceptive deficits. Assessment of lower extremity somatosensory function should be included in clinical practice as it can guide clinicians in designing more effective treatment protocols to improve functional performance in CP.

Cognitive-Motor Interference Heightens the Prefrontal Cortical Activation and Deteriorates the Task Performance in Children With Hemiplegic Cerebral Palsy

OBJECTIVE

To compare the prefrontal cortex (PFC) activation and task performance during single- and dual-task conditions between typically developing (TD) children and children with hemiplegic cerebral palsy (HCP).

DESIGN

A prospective, comparative design.

SETTING

Research laboratory.

PARTICIPANTS

Participants (N=21) included 12 TD children (age, 6.0±1.1y) and 9 children with HCP (age, 7.2±3.1).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

PFC activation was assessed by measuring the concentration of oxygenated hemoglobin while the children performed a shape-matching task with their more affected arm while sitting on a stable (single task) vs dynamic surface (dual task). The task performance was assessed with the total number of shapes matched, dual-task cost, and reaction time (RT).

RESULTS

For both conditions, the children with HCP exhibited greater PFC activation, matched a fewer shapes, and had slower RT than the TD children. These differences were accentuated during the dual-task condition and the dual-task cost was greater. An increase in the PFC activation during the dual-task condition was tightly correlated with a higher dual-task cost in children with HCP (r=0.77, P=.01).

CONCLUSIONS

Children with HCP appear to have a heightened amount of PFC activity while performing a dual task. The greater cortical activity may be a result of the finite attentional resources that are shared between both the motor as well as cognitive demands of the task. The cognitive-motor interference is likely exacerbated in children with HCP because of the structural and functional brain changes as a result of an insult to the developing brain.

Methodological Considerations to Investigate Dosage Parameters of Intensive Upper Limb Rehabilitation in Children with Unilateral Spastic Cerebral Palsy: A Scoping Review of RCTs

PURPOSES

To identify and synthesize RCTs on the isolated effect of dosage parameters of upper limb Intensive Motor Rehabilitation Treatments (IMRT) of children with Unilateral Spastic Cerebral Palsy (USCP); to identify the most frequent methodological weaknesses.

METHODS

Searches were conducted until September 2018 in gray and published literature databases and supplemented by exploring the identified studies' references. Inclusion criteria applied: RCT; children aged 1.5 to 19 years with USCP; upper limb IMRT differing only from ≥1/4 dosage parameters between groups. Literature analyses conducted: qualitative and descriptive.

RESULTS

We identified 461 studies. Seventeen were included: three presented a rehabilitation dosage distinction between groups in Frequency-Time, four in Intensity-Progressivity, three in Intensity-Restraint, two in Intensity-Environment and five presented ≥3 distinctions above.

CONCLUSIONS

Inconsistencies were noted between USCP lifelong issues, and the short follow-ups and lack of participation assessments. Confounding factors and misstatements in Intent To Treat (ITT) analyses were identified. A meta-analysis was considered irrelevant.

ABBREVIATIONS

USCP, CP: Unilateral Spastic Cerebral Palsy, Cerebral Palsy; RCT: Randomized Controlled Trial; IMRT: Intensive Motor Rehabilitation Treatment.

A perspective on the development of hemispheric specialization, infant handedness, and cerebral palsy

Cerebral Palsy (CP), a common form of neurological pediatric disability, results from pre- or perinatal brain injury. Although there is growing evidence of the efficacy of motor learning-based therapies, several factors interact to produce variability in impairment and limit the effectiveness of these therapies. The variability of hand function present in children with CP indicates that a range of developmental pathways must contribute to the manifestation of individually unique characteristics of impairment. Despite two decades of progress using therapies derived from understanding the mechanisms controlling hand function, very little is known about the sensorimotor experiences occurring during development that likely shape later functional problems for children with CP. In this "perspective" paper, we propose that the study of the development of motor skills in typically developing infants may reveal experiential factors potentially important for creating remedial therapies for children with CP. Specifically, we use the development of infant handedness, a model of hemispheric specialization of function, as an example of how self-generated experiences and sensorimotor feedback can shape the development of limb control and hemispheric specialization. We illustrate how early sensorimotor asymmetries concatenate into pronounced differences in skill between the two hands. We suggest that this model of infant handedness provides a framework for studying the individual differences manifested in children with CP. These differences likely arise from aberrant sensorimotor experiences created by sensorimotor circuits disrupted by the early brain injury. We conclude that knowledge of the developmental events, including subtle motor behaviors, that shape sensorimotor pathways, can improve treatment options for children with CP.

Foot and Ankle Somatosensory Deficits Affect Balance and Motor Function in Children With Cerebral Palsy

Sensory dysfunction is prevalent in cerebral palsy (CP). Evidence suggests that sensory deficits can contribute to manual ability impairments in children with CP, yet it is still unclear how they contribute to balance and motor performance. Therefore, the objective of this study was to investigate the relationship between lower extremity (LE) somatosensation and functional performance in children with CP. Ten participants with spastic diplegia (Gross Motor Function Classification Scale: I-III) and who were able to stand independently completed the study. Threshold of light touch pressure, two-point discriminatory ability of the plantar side of the foot, duration of cutaneous vibration sensation, and error in the joint position sense of the ankle were assessed to quantify somatosensory function. The balance was tested by the Balance Evaluation System Test (BESTest) and postural sway measures during a standing task. Motor performance was evaluated by using a battery of clinical assessments: (1) Gross Motor Function Measure (GMFM-66-IS) to test gross motor ability; (2) spatiotemporal gait characteristics (velocity, step length) to evaluate walking ability; (3) Timed Up and Go (TUG) and 6 Min Walk (6MWT) tests to assess functional mobility; and (4) an isokinetic dynamometer was used to test the Maximum Volitional Isometric Contraction (MVIC) of the plantar flexor muscles. The results showed that the light touch pressure measure was strongly associated only with the 6MWT. Vibration and two-point discrimination were strongly related to balance performance. Further, the vibration sensation of the first metatarsal head demonstrated a significantly strong relationship with motor performance as measured by GMFM-66-IS, spatiotemporal gait parameters, TUG, and ankle plantar flexors strength test. The joint position sense of the ankle was only related to one subdomain of the BESTest (Postural Responses). This study provides preliminary evidence that LE sensory deficits can possibly contribute to the pronounced balance and motor impairments in CP. The findings emphasize the importance of developing a thorough LE sensory test battery that can guide traditional treatment protocols toward a more holistic therapeutic approach by combining both motor and sensory rehabilitative strategies to improve motor function in CP.

Impairments of Visuospatial Attention in Children with Unilateral Spastic Cerebral Palsy

Aim

This observational study aimed at assessing the prevalence of visuospatial attention deficits in children with unilateral spastic cerebral palsy (USCP), taking into consideration the affected hemibody and the localization of the brain lesion.

Method

Seventy-five children with USCP were assessed with four visuospatial attention tests: star cancellation, Ogden figure copy, line bisection, and proprioceptive pointing.

Results

A majority (64%) of children with USCP presented a deficit in at least one test compared to the reference values. The alterations observed in children with left or right USCP were related to egocentric or allocentric neglect, respectively. Children with cortico/subcortical lesion presented more often visuospatial attention deficits than children with periventricular lesion. Visuospatial attention deficits were not associated with brain lesion locations.

Interpretation

Visuospatial attention deficits are prevalent in children with USCP and should be taken into account during their rehabilitation process. The present results shed new light on the interpretation of motor impairments in children with USCP as they may be influenced by the frequent presence of visuospatial deficits.

Stochastic resonance stimulation improves balance in children with cerebral palsy: a case control study

Background

Stochastic Resonance (SR) Stimulation has been used to enhance balance in populations with sensory deficits by improving the detection and transmission of afferent information. Despite the potential promise of SR in improving postural control, its use in individuals with cerebral palsy (CP) is novel. The objective of this study was to investigate the immediate effects of electrical SR stimulation when applied in the ankle muscles and ligaments on postural stability in children with CP and their typically developing (TD) peers.

Methods

Ten children with spastic diplegia (GMFCS level I- III) and ten age-matched TD children participated in this study. For each participant the SR sensory threshold was determined. Then, five different SR intensity levels (no stimulation, 25, 50, 75, and 90% of sensory threshold) were used to identify the optimal SR intensity for each subject. The optimal SR and no stimulation condition were tested while children stood on top of 2 force plates with their eyes open and closed. To assess balance, the center of pressure velocity (COPV) in anteroposterior (A/P) and medial-lateral (M/L) direction, 95% COP confidence ellipse area (COPA), and A/P and M/L root mean square (RMS) measures were computed and compared.

Results

For the CP group, SR significantly decreased COPV in A/P direction, and COPA measures compared to the no stimulation condition for the eyes open condition. In the eyes closed condition, SR significantly decreased COPV only in M/L direction. Children with CP demonstrated greater reduction in all the COP measures but the RMS in M/L direction during the eyes open condition compared to their TD peers. The only significant difference between groups in the eyes closed condition was in the COPV in M/L direction.

Conclusions

SR electrical stimulation may be an effective stimulation approach for decreasing postural sway and has the potential to be used as a therapeutic tool to improve balance. Applying subject-specific SR stimulation intensities is recommended to maximize balance improvements. Overall, balance rehabilitation interventions in CP might be more effective if sensory facilitation methods, like SR, are utilized by the clinicians.

Trial registration

ClinicalTrials.gov identifier NCT02456376; 28 May 2015 (Retrospectively registered); https://clinicaltrials.gov/ct2/show/NCT02456376.

Potentials of Ultrahigh-Field MRI for the Study of Somatosensory Reorganization in Congenital Hemiplegia

Reorganization of somatosensory function influences the clinical recovery of subjects with congenital unilateral brain lesions. Ultrahigh-field (UHF) functional MRI (fMRI) with the use of a 7 T magnet has the potential to contribute fundamentally to the current knowledge of such plasticity mechanisms. The purpose of this study was to obtain preliminary information on the possible advantages of the study of somatosensory reorganization at UHF fMRI. We enrolled 6 young adults (mean age 25 ± 6 years) with congenital unilateral brain lesions (4 in the left hemisphere and 2 in the right hemisphere; 4 with perilesional motor reorganization and 2 with contralesional motor reorganization) and 7 healthy age-matched controls. Nondominant hand sensory assessment included stereognosis and 2-point discrimination. Task-dependent fMRI was performed to elicit a somatosensory activation by using a safe and quantitative device developed ad hoc to deliver a reproducible gentle tactile stimulus to the distal phalanx of thumb and index fingers. Group analysis was performed in the control group. Individual analyses in the native space were performed with data of hemiplegic subjects. The gentle tactile stimulus showed great accuracy in determining somatosensory cortex activation. Single-subject gentle tactile stimulus showed an S1 activation in the postcentral gyrus and an S2 activation in the inferior parietal insular cortex. A correlation emerged between an index of S1 reorganization (distance between expected and reorganized S1) and sensory deficit (p < 0.05) in subjects with hemiplegia, with higher distance related to a more severe sensory deficit. Increase in spatial resolution at 7 T allows a better localization of reorganized tactile function validated by its correlation with clinical measures. Our results support the S1 early-determination hypothesis and support the central role of topography of reorganized S1 compared to a less relevant S1-M1 integration.

Dexterity and Finger Sense: A Possible Dissociation in Children With Cerebral Palsy

Both hand and finger sensory perception and motor abilities are essential for the development of skilled gestures and efficient bimanual coordination. While finger dexterity and finger sensory perception can be impaired in children with cerebral palsy (CP), the relationship between these two functions in this population is not clearly established. The common assumption that CP children with better sensory function also demonstrate better motor outcomes has been recently challenged. To study these questions further, we assessed both finger dexterity and finger gnosia, the ability to perceive one’s own fingers by touch, in groups of 11 children with unilateral (i.e., hemiplegic CP) and 11 children with bilateral spastic CP (i.e., diplegic CP) and compared them with typical children. In our sample, children with hemiplegia exhibited finger dexterity deficit in both hands and finger gnosia deficit only in their paretic hand. In contrast, children with diplegia exhibited finger gnosia deficits in both hands and finger dexterity deficit only in their dominant hand. Thus, our results indicated that children with spastic hemiplegia and diplegia present different sensory and motor profiles and suggest that these two subgroups of CP should be considered separately in future experimental and clinical research. We discuss the implications of our results for rehabilitation.

Changes in Tactile Function During Intensive Bimanual Training in Children With Unilateral Spastic Cerebral Palsy

Recently, an intensive bimanual intervention using sensory enriched materials resulted in improved tactile function in children with unilateral spastic cerebral palsy (USCP), raising the question of whether the observed tactile function improvement was due to the sensory enriched environment or the bimanual intervention per se. The present study investigates whether a bimanual intensive intervention improves tactile function. Nineteen children with USCP received 90 hours of bimanual training without enriched environment. Primary outcomes: Manual Form Perception Test/MFPT, Grating Orientation Task/GOT. Children were assessed before, after the training, and at the 4-month follow-up. Significant improvements were observed in MFPT for the more affected hand ( P = .015). Larger stereognosis/MFPT improvements correlated with poorer baseline motor function. Intensive bimanual training alone was sufficient to improve stereognosis, though no improvement in GOT was observed. Present and previously published findings suggest that environmental tactile enrichment incorporated into a bimanual motor training may be needed to improve spatial discrimination/GOT in children with USCP.

Effect of sensory and motor connectivity on hand function in pediatric hemiplegia

OBJECTIVE

We tested the hypothesis that somatosensory system injury would more strongly affect movement than motor system injury in children with unilateral cerebral palsy (USCP). This hypothesis was based on how somatosensory and corticospinal circuits adapt to injury during development; whereas the motor system can maintain connections to the impaired hand from the uninjured hemisphere, this does not occur in the somatosensory system. As a corollary, cortical injury strongly impairs sensory function, so we hypothesized that cortical lesions would impair hand function more than subcortical lesions.

METHODS

Twenty-four children with unilateral cerebral palsy had physiological and anatomical measures of the motor and somatosensory systems and lesion classification. Motor physiology was performed with transcranial magnetic stimulation and somatosensory physiology with vibration-evoked electroencephalographic potentials. Tractography of the corticospinal tract and the medial lemniscus was performed with diffusion tensor imaging, and lesions were classified by magnetic resonance imaging. Anatomical and physiological results were correlated with measures of hand function using 2 independent statistical methods.

RESULTS

Children with disruptions in the somatosensory connectivity and cortical lesions had the most severe upper extremity impairments, particularly somatosensory function. Motor system connectivity was significantly correlated with bimanual function, but not unimanual function or somatosensory function.

INTERPRETATION

Both sensory and motor connectivity impact hand function in children with USCP. Somatosensory connectivity could be an important target for recovery of hand function in children with USCP. Ann Neurol 2017;82:766-780.

Including a Lower-Extremity Component during Hand-Arm Bimanual Intensive Training does not Attenuate Improvements of the Upper Extremities: A Retrospective Study of Randomized Trials

Hand-Arm Bimanual Intensive Therapy (HABIT) promotes hand function using intensive practice of bimanual functional and play tasks. This intervention has shown to be efficacious to improve upper-extremity (UE) function in children with unilateral spastic cerebral palsy (USCP). In addition to UE function deficits, lower-extremity (LE) function and UE-LE coordination are also impaired in children with USCP. Recently, a new intervention has been introduced in which the LE is simultaneously engaged during HABIT (Hand-Arm Bimanual Intensive Therapy Including Lower Extremities; HABIT-ILE). Positive effects of this therapy have been demonstrated for both the UE and LE function in children with USCP. However, it is unknown whether the addition of this constant LE component during a bimanual intensive therapy attenuates UE improvements observed in children with USCP. This retrospective study, based on multiple randomized protocols, aims to compare the UE function improvements in children with USCP after HABIT or HABIT-ILE. This study included 86 children with USCP who received 90 h of either HABIT (n = 42) or HABIT-ILE (n = 44) as participants in previous studies. Children were assessed before, after, and 4-6 months after intervention. Primary outcomes were the ABILHAND-Kids and the Assisting Hand Assessment. Secondary measures included the Jebsen-Taylor Test of Hand Function, the Pediatric Evaluation of Disability Inventory [(PEDI); only the self-care functional ability domain] and the Canadian Occupational Performance Measure (COPM). Data analysis was performed using two-way repeated-measures analysis of variance with repeated measures on test sessions. Both groups showed similar, significant improvements for all tests (test session effect p < 0.001; group × test session interaction p > 0.05) except the PEDI and COPM. Larger improvements on these tests were found for the HABIT-ILE group (test session effect p < 0.001; group × test session interaction p < 0.05). These larger improvements may be explained by the constant simultaneous UE-LE engagement observed during the HABIT-ILE intervention since many daily living activities included in the PEDI and the COPM goals involve the LE and, more specifically, UE-LE coordination. We conclude that UE improvements in children with USCP are not attenuated by simultaneous UE-LE engagement during intensive intervention. In addition, systematic LE engagement during bimanual intensive intervention (HABIT-ILE) leads to larger functional improvements in activities of daily living involving the LE.

Impacts of Sensation, Perception, and Motor Abilities of the Ipsilesional Upper Limb on Hand Functions in Unilateral Stroke: Quantifications From Biomechanical and Functional Perspectives

BACKGROUND

The presence of subtle losses in hand dexterity after stroke affects the regaining of independence with regard to activities of daily living. Therefore, awareness of ipsilesional upper extremity (UE) function may be of importance when developing a comprehensive rehabilitation program. However, current hand function tests seem to be unable to identify asymptomatic UE impairments.

OBJECTIVES

To assess the motor coordination as well as the sensory perception of an ipsilesional UE using biomechanical analysis of performance-oriented tasks and conducting a Manual Tactile Test (MTT).

DESIGN

Case-controlled study.

SETTING

A university hospital.

PARTICIPANTS

A total of 21 patients with unilateral stroke, along with 21 matched healthy control subjects, were recruited.

METHODS

Each participant was requested to perform a pinch-holding-up activity (PHUA) test, object-transport task, and reach-to-grasp task via motion capture, as well as the MTT.

MAIN OUTCOME MEASUREMENTS

The kinetic data of the PHUA test, kinematics analysis of functional movements, and time requirement of MTT were analyzed.

RESULTS

Patients with ipsilesional UE had an inferior ability to scale and produce pinch force precisely when conducting the PHUA test compared to the healthy controls (P < .05). The movement time was statistically longer and peak velocity was significantly lower (P < .05) in the performance-oriented tasks for the ipsilesional UE patients. The longer time requirement in 3 MTT subtests showed that the ipsilesional UE patients experienced degradation in sensory perception (P < .001).

CONCLUSION

Comprehensive sensorimotor assessments based on functional perspectives are valid tools to determine deficits in the sensation-perception-motor system in the ipsilesional UE. Integration of sensorimotor training programs for ipsilesional UE in future neuro-rehabilitation strategies may provide more beneficial effects to regain patients' motor recovery and to promote daily living activity independence than focusing on paretic arm motor training alone.

LEVEL OF EVIDENCE

III.

Hands Support and Postural Oscillation During Sit-to-Stand Movement in Children With Cerebral Palsy and Typical Children

The authors aimed to compare the weight bearing on hands during sit-to-stand (STS) movement in children with cerebral palsy (CP) and typical children (TC), verify its effect on postural oscillation, and analyze the relationship between weight bearing on hands and postural oscillation. Twenty children with CP (Gross Motor Function Classification System levels I and II) and 35 TC performed STS with and without anterior hands support. Mann-Whitney test compared weight bearing between groups. Wilcoxon test investigated differences in postural oscillation between the conditions with and without anterior hand support for both groups. The Spearman correlation tested the relationship between weight-bearing and postural oscillation during the hand support condition. Children with CP bore more weight on hands than TC to perform STS. The hand support reduced postural oscillation during the second phase of STS in both groups. In the CP group, greater weight bearing was related with lower postural oscillation in the beginning of STS. Although children with CP were able to perform STS without support, they bore more weight on their hands to perform the task than TC. Moreover, children with CP and TC use mechanical and somatosensory information to modulate their postural control during STS in different ways.

The Effectiveness of a Computer Game-Based Rehabilitation Platform for Children With Cerebral Palsy: Protocol for a Randomized Clinical Trial

BACKGROUND

It is difficult to engage young children with cerebral palsy (CP) in repetitive, tedious therapy. As such, there is a need for innovative approaches and tools to motivate these children. We developed the low-cost, computer game-based rehabilitation platform CGR that combines fine manipulation and gross movement exercises with attention and planning game activities appropriate for young children with CP.

OBJECTIVE

The objective of this study is to provide evidence of the therapeutic value of CGR to improve upper extremity (UE) motor function for children with CP.

METHODS

This randomized controlled, single-blind, clinical trial with an active control arm will be conducted at 4 sites. Children diagnosed with CP between the ages of 4 and 10 years old with moderate UE impairments and fine motor control abnormalities will be recruited.

RESULTS

We will test the difference between experimental and control groups using the Quality of Upper Extremity Skills Test (QUEST) and Peabody Developmental Motor Scales, Second Edition (PDMS-2) outcome measures. The parents of the children and the therapist experiences with the interventions and tools will be explored using semi-structured interviews using the qualitative description approach.

CONCLUSIONS

This research protocol, if effective, will provide evidence for the therapeutic value and feasibility of CGR in the pediatric rehabilitation of UE function.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02728375; http:https://clinicaltrials.gov/ct2/show/NCT02728375 (Archived by WebCite at http://www.webcitation.org/6qDjvszvh).

Kinesthetic deficits after perinatal stroke: robotic measurement in hemiparetic children

Background

While sensory dysfunction is common in children with hemiparetic cerebral palsy (CP) secondary to perinatal stroke, it is an understudied contributor to disability with limited objective measurement tools. Robotic technology offers the potential to objectively measure complex sensorimotor function but has been understudied in perinatal stroke. The present study aimed to quantify kinesthetic deficits in hemiparetic children with perinatal stroke and determine their association with clinical function.

Methods

Case–control study. Participants were 6–19 years of age. Stroke participants had MRI confirmed unilateral perinatal arterial ischemic stroke or periventricular venous infarction, and symptomatic hemiparetic cerebral palsy. Participants completed a robotic assessment of upper extremity kinesthesia using a robotic exoskeleton (KINARM). Four kinesthetic parameters (response latency, initial direction error, peak speed ratio, and path length ratio) and their variabilities were measured with and without vision. Robotic outcomes were compared across stroke groups and controls and to clinical measures of sensorimotor function.

Results

Forty-three stroke participants (23 arterial, 20 venous, median age 12 years, 42% female) were compared to 106 healthy controls. Stroke cases displayed significantly impaired kinesthesia that remained when vision was restored. Kinesthesia was more impaired in arterial versus venous lesions and correlated with clinical measures.

Conclusions

Robotic assessment of kinesthesia is feasible in children with perinatal stroke. Kinesthetic impairment is common and associated with stroke type. Failure to correct with vision suggests sensory network dysfunction.

Sensory tractography and robot-quantified proprioception in hemiparetic children with perinatal stroke

Perinatal stroke causes most hemiparetic cerebral palsy, resulting in lifelong disability. We have demonstrated the ability of robots to quantify sensory dysfunction in hemiparetic children but the relationship between such deficits and sensory tract structural connectivity has not been explored. It was aimed to characterize the relationship between the dorsal column medial lemniscus (DCML) pathway connectivity and proprioceptive dysfunction in children with perinatal stroke. Twenty-nine participants (6-19 years old) with MRI-classified, unilateral perinatal ischemic stroke (14 arterial, 15 venous), and upper extremity deficits were recruited from a population-based cohort and compared with 21 healthy controls. Diffusion tensor imaging (DTI) defined DCML tracts and five diffusion properties were quantified: fractional anisotropy (FA), mean, radial, and axial diffusivities (MD, RD, AD), and fiber count. A robotic exoskeleton (KINARM) tested upper limb proprioception in an augmented reality environment. Correlations between robotic measures and sensory tract diffusion parameters were evaluated. Lesioned hemisphere sensory tracts demonstrated lower FA and higher MD, RD, and AD compared with the non-dominant hemisphere of controls. Dominant (contralesional) hemisphere tracts were not different from controls. Both arterial and venous stroke groups demonstrated impairments in proprioception that correlated with lesioned hemisphere DCML tract diffusion properties. Sensory tract connectivity is altered in the lesioned hemisphere of hemiparetic children with perinatal stroke. A correlation between lesioned DCML tract diffusion properties and robotic proprioceptive measures suggests clinical relevance and a possible target for therapeutic intervention. Hum Brain Mapp 38:2424-2440, 2017. © 2017 Wiley Periodicals, Inc.

Mirror therapy in children with hemiparesis: a randomized observer-blinded trial

AIM

To determine the efficacy of mirror therapy in children with hemiparesis.

METHOD

The design was an observer-blinded parallel-group randomized controlled trial (International Standard Randomised Controlled Trial Number 48748291). Randomization was computer-generated, 1:1 allocation to mirror therapy or comparison groups. The settings were home-based intervention and tertiary centre assessments. Participants were 90 children with hemiparesis aged 7 to 17 years. Intervention was 15 minutes per day of simultaneous arm training, 5 days a week, for 5 weeks. The mirror therapy group used a mirror; those in the comparison group looked at their paretic limb. Assessments comprised measures of upper limb strength, function (Melbourne Assessment 2), daily performance (ABILHAND-Kids), and sensory function at weeks 0 (T0 ), 5 (T1 ), and 10 (T2 ).

RESULTS

There were no significant differences in outcomes and their progression over time between the mirror therapy and comparison groups. Post-hoc intention-to-treat analyses showed significant improvements in both groups for grasp strength (T0 -T1 +12.6%), pinch strength (T0 -T2 +9.1%), upper limb function in terms of accuracy (T0 -T2 +2.7%) and fluency (T0 -T2 +5.0%), as well as daily performance (T0 -T2 +16.6%). Per protocol analyses showed additional improvements in dexterity (T0 -T2 +4.0%).

INTERPRETATION

The use of the mirror illusion during therapy had no significant effect on treatment outcomes. However, 5 weeks of daily simultaneous arm training significantly improved paretic upper limb strength, function, and daily use.

Assessing postural stability via the correlation patterns of vertical ground reaction force components

Background

Many methods have been proposed to assess the stability of human postural balance by using a force plate. While most of these approaches characterize postural stability by extracting features from the trajectory of the center of pressure (COP), this work develops stability measures derived from components of the ground reaction force (GRF).

Methods

In comparison with previous GRF-based approaches that extract stability features from the GRF resultant force, this study proposes three feature sets derived from the correlation patterns among the vertical GRF (VGRF) components. The first and second feature sets quantitatively assess the strength and changing speed of the correlation patterns, respectively. The third feature set is used to quantify the stabilizing effect of the GRF coordination patterns on the COP.

Results

In addition to experimentally demonstrating the reliability of the proposed features, the efficacy of the proposed features has also been tested by using them to classify two age groups (18–24 and 65–73 years) in quiet standing. The experimental results show that the proposed features are considerably more sensitive to aging than one of the most effective conventional COP features and two recently proposed COM features.

Conclusions

By extracting information from the correlation patterns of the VGRF components, this study proposes three sets of features to assess human postural stability during quiet standing. As demonstrated by the experimental results, the proposed features are not only robust to inter-trial variability but also more accurate than the tested COP and COM features in classifying the older and younger age groups. An additional advantage of the proposed approach is that it reduces the force sensing requirement from 3D to 1D, substantially reducing the cost of the force plate measurement system.

Relationship between somatosensory deficit and brain somatosensory system after early brain lesion: A morphometric study

Cerebral Palsy (CP) is a group of permanent motor disorders due to non-progressive damage to the developing brain. Poor tactile discrimination is common in children with unilateral CP. Previous findings suggest the crucial role of structural integrity of the primary (S1) and secondary (S2) somatosensory areas located in the ipsilesional hemisphere for somatosensory function processing. However, no focus on the relationship between structural characteristics of ipsilesional S1 and S2 and tactile discrimination function in paretic hands has been proposed. Using structural MRI and a two-point discrimination assessment (2 PD), we explore this potential link in a group of 21 children (mean age 13 years and 7 months) with unilateral CP secondary to a periventricular white matter injury (PWMI) or middle cerebral artery infarct (MCA). For our whole sample there was a significant negative correlation between the 2 PD and the gray matter volume in the ipsilesional S2 (rho = -0.50 95% confidence interval [-0.76, -0.08], one-tailed p-value = 0.0109) and in the ipsilesional S1 (rho = -0.57, 95% confidence interval [-0.81, -0.19], one-tailed p-value = 0.0032). When studying these relationships with regard to the lesion types, we found these correlations were non-significant in the patients with PWMI but stronger in patients with MCA. According to our results, the degree of sensory impairment is related to the spared gray matter volume in ipsilesional S1 and S2 and is marked after an MCA stroke. Our work contributes to a better understanding of why some patients with CP have variable somatosensory deficit following an early brain lesion.

The effects of intensive bimanual training with and without tactile training on tactile function in children with unilateral spastic cerebral palsy: A pilot study

Children with unilateral spastic cerebral palsy (USCP) often have tactile impairments. Intensive bimanual training improves the motor abilities, but the effects on the sensory system have not been studied. Here we compare the effects of bimanual training with and without tactile training on tactile impairments. Twenty children with USCP (6-15.5 years; MACS: I-III) were randomized to receive either bimanual therapy (HABIT) or HABIT+tactile training (HABIT+T). All participants received 82 h of standardized HABIT. In addition 8 sessions of 1h were provided to both groups. The HABIT+T group received tactile training (without vision) using materials of varied shapes and textures. The HABIT group received training with the same materials without tactile directed training (full vision). Primary outcomes included grating orientation task/GOT and stereognosis. Secondary outcomes included two-point discrimination/TPD, Semmes-Weinstein monofilaments/SWM. The GOT improved in both groups after training, while stereognosis of the more-affected hand tended to improve (but p=0.063). No changes were found in the TPD and the SWM. There were no group×test interactions for any measure. We conclude tactile spatial resolution can improve after bimanual training. Either intensive bimanual training alone or incorporation of materials with a diversity of shapes/textures may drive these changes.

Early childhood constraint therapy for sensory/motor impairment in cerebral palsy: a randomised clinical trial protocol

INTRODUCTION

Cerebral palsy (CP) is the most common physical disability in childhood. It is a disorder resulting from sensory and motor impairments due to perinatal brain injury, with lifetime consequences that range from poor adaptive and social function to communication and emotional disturbances. Infants with CP have a fundamental disadvantage in recovering motor function: they do not receive accurate sensory feedback from their movements, leading to developmental disregard. Constraint-induced movement therapy (CIMT) is one of the few effective neurorehabilitative strategies shown to improve upper extremity motor function in adults and older children with CP, potentially overcoming developmental disregard.

METHODS AND ANALYSIS

This study is a randomised controlled trial of children 12-24 months corrected age studying the effectiveness of CIMT combined with motor and sensory-motor interventions. The study population will comprise 72 children with CP and 144 typically developing children for a total of N=216 children. All children with CP, regardless of group allocation will continue with their standard of care occupational and physical therapy throughout the study. The research material collected will be in the form of data from high-density array event-related potential scan, standardised assessment scores and motion analysis scores.

ETHICS AND DISSEMINATION

The study protocol was approved by the Institutional Review Board. The findings of the trial will be disseminated through peer-reviewed journals and scientific conferences.

TRIAL REGISTRATION NUMBER

NCT02567630.