Reliability of the Melbourne assessment of unilateral upper limb function

Changes Induced by Early Hand-Arm Bimanual Intensive Therapy Including Lower Extremities in Young Children With Unilateral Cerebral Palsy: A Randomized Clinical Trial

Importance

Intensive interventions are provided to young children with unilateral cerebral palsy (UCP), classically focused on the upper extremity despite the frequent impairment of gross motor function. Hand-Arm Bimanual Intensive Therapy Including Lower Extremities (HABIT-ILE) effectively improves manual dexterity and gross motor function in school-aged children.

Objective

To verify if HABIT-ILE would improve manual abilities in young children with UCP more than usual motor activity.

Design, Setting, and Participants

This prospective randomized clinical trial (November 2018 to December 2021), including 2 parallel groups and a 1:1 allocation, recruitment took place at European university hospitals, cerebral palsy specialized centers, and spontaneous applications at 3 sites: Brussels, Belgium; Brest, France; and Pisa, Italy. Matched (age at inclusion, lesion type, cause of cerebral palsy, and affected side) pairs randomization was performed. Young children were assessed at baseline (T0), 2 weeks after baseline (T1), and 3 months after baseline (T2). Health care professionals and assessors of main outcomes were blinded to group allocation. At least 23 young children (in each group) aged 12 to 59 months with spastic/dyskinetic UCP and able to follow instructions were needed. Exclusion criteria included uncontrolled seizures, scheduled botulinum toxin injections, orthopedic surgery scheduled during the 6 months before or during the study period, severe visual/cognitive impairments, or contraindications to magnetic resonance imaging.

Interventions

Two weeks of usual motor activity including usual rehabilitation (control group) vs 2 weeks (50 hours) of HABIT-ILE (HABIT-ILE group).

Main Outcomes and Measures

Primary outcome: Assisting Hand Assessment (AHA); secondary outcomes: Gross Motor Function Measure-66 (GMFM-66), Pediatric Evaluation of Disability Inventory-Computer Adaptive Test (PEDI-CAT), and Canadian Occupational Performance Measure (COPM).

Results

Of 50 recruited young children (26 girls [52%], median age; 35.3 months for HABIT-ILE group; median age, 32.8 months for control group), 49 were included in the final analyses. Change in AHA score from T0 to T2 was significantly greater in the HABIT-ILE group (adjusted mean score difference [MD], 5.19; 95% CI, 2.84-7.55; P < .001). Changes in GMFM-66 (MD, 4.72; 95% CI, 2.66-6.78), PEDI-CAT daily activities (MD, 1.40; 95% CI, 0.29-2.51), COPM performance (MD, 3.62; 95% CI, 2.91-4.32), and satisfaction (MD, 3.53; 95% CI, 2.70-4.36) scores were greater in the HABIT ILE group.

Conclusions and Relevance

In this clinical trial, early HABIT-ILE was shown to be an effective treatment to improve motor performance in young children with UCP. Moreover, the improvements had an impact on daily life activities of these children.

Trial registration

ClinicalTrials.gov Identifier: NCT04020354.

Adaptation and Validation of a Serious Game for Motor Learning Training in Children with Cerebral Palsy

Objective: Children with cerebral palsy (CP) present motor learning disorders and somatosensory dysfunction. Although many protocols use videogames in children with CP, few apply or examine motor learning principles. This study aims at (1) implementing therapist-user-designer collaboration in adapting a videogame to the principles of motor learning and the characteristics of users with CP, and (2) piloting the effectiveness of these adaptations by analyzing the achievement of motor learning parameters (learning rate acquisition, retention, and transfer to motor and somatosensory function). Materials and Methods: Periodical interprofessional meetings conducted to the adaptation of a videogame, requiring the control of a joystick for traveling through a maze, to motor learning principles. In a pilot validation, effects in unilateral upper limb function, gross manual dexterity, and somatosensory thresholds were assessed before and after 10-week training in 13 children with CP. Results: After 10-week training with the adapted serious game, children showed learning rates above 90% and improvement in motor learning parameters along the sessions. Manual dexterity and pronation-supination of the dominant hand improved after training. No significant effects were found on somatosensory thresholds. Conclusion: Serious games are useful as motor learning tools for improving motor function in children with PC. Cooperative work among professionals and users is advisable for designing efficient videogames according to rehabilitation best practices.

Does the Level of Focus in Serious Games in Immersive VR Correlate with the Quality of Movement? Preliminary Results from an Ongoing Study on Rehabilitation of Children with Cerebral Palsy

Cerebral palsy (CP), one of the diseases that cause motor deficiency, is a childhood condition characterized by a motor disability (palsy) caused by a non-progressive static lesion in the brain (cerebral) [1], [2]. Rehabilitation of patients with CP is typically accomplished through exercises performed by a team of several specialists so that the patient can act independently or with as little reliance on third parties as possible. In CP, motor disorders are often present together with sensory, perceptual, cognitive, behavioural and communication disorders. Regarding motor disorders, the most frequent outcome is hemiplegia, although diplegic and paraplegic patients are also present [1].

Design and Use of a 3D-Printed Dynamic Upper Extremity Orthosis for Children With Cerebral Palsy and Severe Upper Extremity Involvement: A Pilot Study

IMPORTANCE

Children with cerebral palsy (CP) and severe hand impairment have limited options for upper extremity (UE) orthoses.

OBJECTIVE

To (1) design and fabricate a customized low-cost, functional, three-dimensional (3D) printed dynamic upper extremity orthosis (DUEO) and (2) examine, using a comprehensive evaluation, the effect of the orthosis on the UE function of children with unilateral UE CP, Manual Ability Classification System (MACS) Levels III to V.

DESIGN

Pilot study. Assessments were performed pretreatment and immediately posttreatment.

SETTING

Hospital-based outpatient occupational therapy department.

PARTICIPANTS

Five patients, ages 13 to 17 yr, with CP and unilateral UE involvement MACS Levels III to V.

INTERVENTION

Custom forearm thumb opponens orthosis and the DUEO were designed and fabricated by a multidisciplinary team for use during eight 1-hr occupational therapy sessions targeting bimanual UE training.

OUTCOMES AND MEASURES

Pretreatment and posttreatment assessments included the Assisting Hand Assessment (AHA), Melbourne Assessment 2 (MA-2), Pediatric Motor Activity Log-Revised (PMAL-R), and the Pediatric Quality of Life Inventory: CP Module (PedsQL:CP).

RESULTS

All participants had higher posttreatment scores on at least one measure. Four had minimal clinically important differences (MCID) on the AHA. Three met MCID criteria on MA-2 subtests (one negative change). Four demonstrated improvement on the PMAL-R (one participant achieved an MCID score), and three reported improvements in more than one PedsQL:CP domain.

CONCLUSIONS AND RELEVANCE

This novel 3D-printed device, in combination with occupational therapy, shows promising evidence that children who score in lower MACS levels can show gains in UE function. What This Article Adds: This study demonstrates that a customized, 3D-printed dynamic orthosis, in combination with occupational therapy intervention, can facilitate UE function in children with severe hand impairment.

Robotic Rehabilitation and Transcranial Direct Current Stimulation in Children With Bilateral Cerebral Palsy

Aim

To identify challenges of combining robotic upper extremity rehabilitation with tDCS in children with upper extremity bilateral cerebral palsy (CP) by assessing feasibility, tolerability and safety.

Methods

This was an unblinded, open-label, pilot clinical trial. Participants completed 10 × 1 h sessions of robotic rehabilitation combined with motor cortex anodal tDCS. Feasibility, acceptability and practicality, were assessed including the number of participants completing the protocol, factors limiting participation, time required for sessions, and completion of functional assessments and tolerability scales. To assess safety, standardized clinical and robotic measures of sensorimotor function were performed. The trial was registered at clinicaltrials.gov (NCT04233710).

Results

Eight children were recruited (mean age 8y ± 1.8y, range 6–11 years) and 5 completed the intervention. There were no serious adverse events. One child developed focal seizures 6 weeks after the trial that were deemed to be unrelated. Barriers to completion included time and scheduling demands and patient factors, specifically cognitive/behavioral impairments and dyskinesia. No decline in clinical function was appreciated.

Conclusions

Robotic upper extremity rehabilitation combined with tDCS may be feasible in children with bilateral CP. Careful participant selection, family engagement, and protocol adaptations are recommended to better understand the feasibility and tolerability of future trials.

Activity of Mirror Neurons and Its Effect on Various Diseases

Ayna nöronların nöroanatomik yapılanması ve işlevselliğinin araştırılması son yıllarda oldukça artmıştır. Özellikle nörolojik ve ortopedik hasta gruplarında uygulanan tedavi yaklaşımlarında pasif uygulamalar yerine hastanın katılımının olduğu aktif uygulamalar tercih edilmektedir. Bunun temel sebeplerinden birisi ayna nöronları ve birincil motor korteksi dâhil ederek tedaviyi kalıcı hale getirmeyi amaçlamaktır. Ayna nöronların fonksiyonel ve disfonksiyonel durumlarını ortaya koymak, tedavi seanslarında hastaların semptomlarını anlamada çok büyük katkı sağlamaktadır. Özellikle ayna nöronları aktive ederek planlanan ayna terapisi ile hastalar nöronal bağlantılarını yeniden yapılandırarak nöroplastik aktivite sağlarlar ve böylece iyileşme süreçlerine katkıda bulunmuş olurlar. Literatür taramalarında ayna nöronların aktivasyonlarının yer aldığı hastalıkların yapısal özellikleri birbirinden farklı olsa da ortak özellik olarak ayna nöronların aktive edilerek tedaviye katkı sağladığını söylemek mümkündür. Yapılan tedavi uygulamalarında, ilgili fonksiyonel hareketin hasta tarafından fiziksel olarak yapılmadığı durumlarda dahi bilişsel olarak hareketin yapıldığının imgelenmesi, ayna nöronları aktive ederek hastanın iyilik halini arttırdığı belirlenmiştir. 

Toward a More Comprehensive Assessment of School Age Children with Hemiplegic Cerebral Palsy

Background:

Cerebral palsy (CP) is the leading cause of disability in children. While motor deficits define CP, many patients experience behavioral and cognitive deficits which limit participation. The purpose of this study was to contribute to our understanding of developmental delay and how to measure these deficits among children with CP.

Methods:

Children 5 to 15 years with hemiplegic CP were recruited. Cognition and motor ability were assessed. The brain injury associated with observed motor deficits was identified. Accelerometers measured real-world bilateral upper extremity movement and caregivers completed behavioral assessments.

Results:

Eleven children participated, 6 with presumed perinatal stroke. Four children scored below average intelligence quotient while other measures of cognition were within normal limits (except processing speed). Motor scores confirmed asymmetrical deficits. Approximately one third of scores indicated deficits in attention, behavior, or depression.

Conclusions:

Our findings corroborate that children with CP experience challenges that are broader than motor impairment alone. Despite the variation in brain injury, all participants completed study procedures.

Implications:

Our findings suggest that measuring behavior in children with CP may require a more comprehensive approach and that caregivers are amenable to using online collection tools which may assist in addressing the therapeutic needs of children with CP.

Relationship between motor abilities and executive functions in patients after pediatric stroke

Patients after pediatric stroke typically experience varying extent of motor and cognitive impairments. During rehabilitation, these impairments are often treated as separate entities. While there is a notion claiming that motor and cognitive functions are interrelated to some degree in healthy children, a minimal amount of evidence exists regarding this issue in patients after pediatric stroke. The purpose of this study was to investigate the association between motor abilities and executive functions in patients after pediatric arterial ischemic stroke. Twenty-seven patients (6 - 23 years) diagnosed with pediatric arterial ischemic stroke in the chronic phase (≥ 2 years after diagnosis, diagnosed < 16 years) and 49 healthy controls (6 - 26 years) were included in this study. Participants completed six tasks from standardized neuropsychological tests assessing the dimensions of executive functions, namely working memory, inhibition, and shifting. Additionally, we assessed hand strength and upper limb performance with two tasks each. In the patient group, the association between upper limb performance and executive functions was stronger than between hand strength and executive functions. Our results point toward the idea of a close interrelation between upper limb performance and executive functions. Training more complex and cognitively engaging motor abilities involving upper limb performance rather than basic motor abilities such as hand strength during a rehabilitation program may have the power to foster executive function development and vice versa in patients after stroke.

The role of mirror mechanism in the recovery, maintenance, and acquisition of motor abilities

While it is well documented that the motor system is more than a mere implementer of motor actions, the possible applications of its cognitive side are still under-exploited, often remaining as poorly organized evidence. Here, we will collect evidence showing the value of action observation treatment (AOT) in the recovery of impaired motor abilities for a vast number of clinical conditions, spanning from traumatological patients to brain injuries and neurodegenerative diseases. Alongside, we will discuss the use of AOT in the maintenance of appropriate motor behavior in subjects at risk for events with dramatic physical consequences, like fall prevention in elderly people or injury prevention in sports. Finally, we will report that AOT can help to tune existing motor competencies in fields requiring precise motor control. We will connect all these diverse dots into the neurophysiological scenario offered by decades of research on the human mirror mechanism, discussing the potentialities for individualization. Empowered by modern technologies, AOT can impact individuals' safety and quality of life across the whole lifespan.

Functional connectivity and upper limb function in patients after pediatric arterial ischemic stroke with contralateral corticospinal tract wiring

To develop individualized motor rehabilitation, knowledge of the relationship between neuroplastic reorganization and motor recovery after pediatric arterial ischemic stroke (AIS) is crucial. Thus, we investigated functional connectivity in patients after AIS with good motor outcome and in patients with hemiparesis compared with typically developing peers. We included 18 patients (n = 9 with hemiparesis, n = 9 with good motor outcome) with pediatric AIS in the chronic phase (≥ 2 years after diagnosis, diagnosed > 16 years) and 18 peers matched by age and gender. Participants underwent a standardized motor assessment, single-pulse transcranial magnetic stimulation to determine the type of corticospinal tract wiring, and resting-state functional magnetic resonance imaging to examine motor network connectivity. Corticospinal tract wiring was contralateral in all participants. Patients with hemiparesis had lower interhemispheric connectivity strength compared with patients with good clinical outcome and peers. Patients with good clinical outcome had higher intrahemispheric connectivity strength compared with peers. Further, higher intrahemispheric connectivity was related to better motor outcome in patients. Our findings suggest that better motor outcome after pediatric AIS is related to higher motor network connectivity strength. Thus, resting-state functional connectivity might be predictive for motor recovery after pediatric AIS.

Functional outcomes of botulinum neurotoxin-A injection followed by reciprocal electrical stimulation in children with cerebral palsy: A randomized controlled trial

BACKGROUND

The integration of therapeutic approaches is increasingly recommended for children with cerebral palsy, to enhance outcomes. Nevertheless, clinicians still opt for separate or combined therapies based on little credible knowledge.

OBJECTIVE

This study endeavored to evaluate the effect of botulinum neurotoxin-A (BoNT-A) injection and reciprocal neuromuscular electrical stimulation (rNMES) and their combination on the upper extremity function in children with spastic hemiplegia.

METHODS

Sixty-four children with spastic hemiplegia (aged 6- 10 years) were randomly assigned to four treatment-based groups [group I (BoNT-A), group II (rNMES), group III (combined BoNT-A and rNMES), and group IV (Control)]. All children received a physical rehabilitation program, thrice/week over three months. Unilateral upper-limb function, bimanual hand function, and real-time arm-hand function were assessed using Melbourne Assessment (MA), Assisting Hand Assessment (AHA), and Pediatric Motor Activity Log (PMAL) scales respectively pre-treatment, post-treatment, and at 6 months follow-up.

RESULTS

Post-treatment, group III achieved greater improvement in MA, AHA, and PMAL compared to other groups (all P < 0.05), and the difference remained in favor of group III at the follow-up (all P < 0.05).

CONCLUSIONS

This study suggests that BoNT-A and rNMES combined are more effective than either of them alone to enhance upper-extremity function in children with spastic hemiplegia.

Developmental Remodelling of the Motor Cortex in Hemiparetic Children With Perinatal Stroke

BACKGROUND

Perinatal stroke often leads to lifelong motor impairment. Two common subtypes differ in timing, location, and mechanism of injury: periventricular venous infarcts (PVI) are fetal white matter lesions while most arterial ischemic strokes (AIS) are cortical injuries acquired near term birth. Both alter motor system development and primary motor cortex (M1) plasticity, often with retained ipsilateral corticospinal fibers from the non-lesioned motor cortex (M1').

METHODS

Task-based functional magnetic resonance imaging was used to define patterns of motor cortex activity during paretic and unaffected hand movement. Peak coordinates of M1, M1', and the supplementary motor area in the lesioned and intact hemispheres were compared to age-matched controls. Correlations between displacements and clinical motor function were explored.

RESULTS

Forty-nine participants included 14 PVI (12.59 ± 3.7 years), 13 AIS (14.91 ± 3.9 years), and 22 controls (13.91 ± 3.4 years). AIS displayed the greatest M1 displacement from controls in the lesioned hemisphere while PVI locations approximated controls. Peak M1' activations were displaced from the canonical hand knob in both PVI and AIS. Extent of M1 and M1' displacement were correlated (r = 0.50, P = 0.025) but were not associated with motor function. Supplementary motor area activity elicited by paretic tapping was displaced in AIS compared to controls (P = 0.003).

CONCLUSION

Motor network components may be displaced in both hemispheres after perinatal stroke, particularly in AIS and those with ipsilateral control of the affected limb. Modest correlations with clinical function may support that more complex models of developmental plasticity are needed to inform targets for individualized neuromodulatory therapies in children with perinatal stroke.

A Framework for User Adaptation and Profiling for Social Robotics in Rehabilitation

Physical rehabilitation therapies for children present a challenge, and its success-the improvement of the patient's condition-depends on many factors, such as the patient's attitude and motivation, the correct execution of the exercises prescribed by the specialist or his progressive recovery during the therapy. With the aim to increase the benefits of these therapies, social humanoid robots with a friendly aspect represent a promising tool not only to boost the interaction with the pediatric patient, but also to assist physicians in their work. To achieve both goals, it is essential to monitor in detail the patient's condition, trying to generate user profile models which enhance the feedback with both the system and the specialist. This paper describes how the project NAOTherapist-a robotic architecture for rehabilitation with social robots-has been upgraded in order to include a monitoring system able to generate user profile models through the interaction with the patient, performing user-adapted therapies. Furthermore, the system has been improved by integrating a machine learning algorithm which recognizes the pose adopted by the patient and by adding a clinical reports generation system based on the QUEST metric.

Deep Brain Stimulation of the Internal Pallidum in Lesch-Nyhan Syndrome: Clinical Outcomes and Connectivity Analysis

BACKGROUND

Lesch-Nyhan syndrome (LNS) is a rare genetic disorder characterized by a deficiency of hypoxanthine-guanine phosphoribosyltransferase enzyme. It manifests during infancy with compulsive self-mutilation behavior associated with disabling generalized dystonia and dyskinesia. Clinical management of these patients poses an enormous challenge for medical teams and carers.

OBJECTIVES

We report our experience with bilateral deep brain stimulation (DBS) of the globus pallidus internus (GPi) in the management of this complex disorder.

MATERIALS AND METHODS

Preoperative and postoperative functional assessment data prospectively collected by a multidisciplinary pediatric complex motor disorders team, including imaging, neuropsychology, and neurophysiology evaluations were analyzed with regards to motor and behavioral control, goal achievement, and patient and caregivers' expectations.

RESULTS

Four male patients (mean age 13 years) underwent DBS implantation between 2011 and 2018. Three patients received double bilateral DBS electrodes within the posteroventral GPi and the anteromedial GPi, whereas one patient had bilateral electrodes placed in the posteroventral GPi only. Median follow-up was 47.5 months (range 22-98 months). Functional improvement was observed in all patients and discussed in relation to previous reports. Analysis of structural connectivity revealed significant correlation between the involvement of specific cortical regions and clinical outcome.

CONCLUSION

Combined bilateral stimulation of the anteromedial and posteroventral GPi may be considered as an option for managing refractory dystonia and self-harm behavior in LNS patients. A multidisciplinary team-based approach is essential for patient selection and management, to support children and families, to achieve functional improvement and alleviate the overall disease burden for patients and caregivers.

Understanding the impact of bilateral brain injury in children with unilateral cerebral palsy

The presence of bilateral brain injury in patients with unilateral cerebral palsy (CP) may impact neuroplasticity in the ipsilateral hemisphere; however, this pattern of injury is typically under‐analyzed due to the lack of methods robust to severe injury. In this study, injury‐robust methods have been applied to structural brain magnetic resonance imaging (MRI) data of a cohort of 91 children with unilateral CP (37 with unilateral and 54 with bilateral brain injury, 4–17 years) and 44 typically developing controls (5–17 years), to determine how brain structure is associated with concurrent motor function, and if these associations differ between patients with unilateral or bilateral injury. Regression models were used to associate these measures with two clinical scores of hand function, with patient age, gender, brain injury laterality, and interaction effects included. Significant associations with brain structure and motor function were observed (Pearson's r = .494–.716), implicating several regions of the motor pathway, and demonstrating an accurate prediction of hand function from MRI, regardless of the extent of brain injury. Reduced brain volumes were observed in patients with bilateral injury, including volumes of the thalamus and corpus callosum splenium, compared to those with unilateral injury, and the healthy controls. Increases in cortical thickness in several cortical regions were observed in cohorts with unilateral and bilateral injury compared to controls, potentially suggesting neuroplasticity might be occurring in the inferior frontal gyrus and the precuneus. These findings identify prospective useful target regions for transcranial magnetic stimulation intervention.

Using accelerometry for measurement of motor behavior in children: Relationship of real-world movement to standardized evaluation

BACKGROUND

When detected, children with asymmetrical motor impairment are referred for therapeutic interventions to maximize the child's ability to reach their health and developmental potential. Referal is dependent on standardized evaluation, which rarely examines upper extremity (UE) function within the context of real-world activity. Accelerometry provides an efficient method to objectively measure movement in children. The purpose of this study was to compare accelerometry to clinical assessment, specifically the Melbourne Assessment of Unilateral Upper Limb Function-2 (MA-2).

METHODS

A total of 52 children between 1-17 years of age with asymmetrical motor deficits and age matched controls participated in this study. Participants wore bilateral accelerometers for 4 x 25 h. The use ratio (UR) and mono-arm use index (MAUI) were calculated to quantify asymmetrical impairment. The Melbourne Assessment of Unilateral Upper Limb Function-2 (MA-2) was administered and compared to accelerometry variables.

RESULTS

The UR and MAUI were significantly different in children with and without deficits. The MAUI was significantly correlated with all domains of the MA-2: accuracy (r = 0.44, p = 0.026); fluency (r = 0.52, p = 0.006); dexterity (r = 0.53, p = 0.005); and range of motion (r = 0.49, p = 0.011).

CONCLUSIONS

Our findings suggest a relationship between real-world movement and clinical evaluation.

Perspectives and Challenges in Robotic Neurorehabilitation

The development of robotic devices for rehabilitation is a fast-growing field. Nowadays, thanks to novel technologies that have improved robots’ capabilities and offered more cost-effective solutions, robotic devices are increasingly being employed during clinical practice, with the goal of boosting patients’ recovery. Robotic rehabilitation is also widely used in the context of neurological disorders, where it is often provided in a variety of different fashions, depending on the specific function to be restored. Indeed, the effect of robot-aided neurorehabilitation can be maximized when used in combination with a proper training regimen (based on motor control paradigms) or with non-invasive brain machine interfaces. Therapy-induced changes in neural activity and behavioral performance, which may suggest underlying changes in neural plasticity, can be quantified by multimodal assessments of both sensorimotor performance and brain/muscular activity pre/post or during intervention. Here, we provide an overview of the most common robotic devices for upper and lower limb rehabilitation and we describe the aforementioned neurorehabilitation scenarios. We also review assessment techniques for the evaluation of robotic therapy. Additional exploitation of these research areas will highlight the crucial contribution of rehabilitation robotics for promoting recovery and answering questions about reorganization of brain functions in response to disease.

Motor and non-motor determinants of health-related quality of life in young dystonia patients

OBJECTIVES

To systematically investigate the relationship between motor and non-motor symptoms, and health-related quality of life (HR-QoL) in children and young adults with dystonia.

METHODS

In this prospective observational cross-sectional study, 60 patients (6-25 years) with childhood-onset dystonia underwent a multidisciplinary assessment of dystonia severity (Burke-Fahn-Marsden Dystonia Rating Scale, Global Clinical Impression), motor function (Gross Motor Function Measure, Melbourne Assessment of Unilateral Upper Limb Function), pain (visual analogue scale), intelligence (Wechsler Intelligence Scale), executive functioning (Behavior Rating Inventory of Executive Function) and anxiety/depression (Child/Adult Behavior Checklist). Measures were analyzed using a principal component analysis and subsequent multiple regression to evaluate which components were associated with HR-QoL (Pediatric Quality of life Inventory) for total group, and non-lesional (primary) and lesional (secondary) subgroups.

RESULTS

Patients (29 non-lesional, 31 lesional dystonia) had a mean age of 13.6 ± 5.9 years. The principal component analysis revealed three components: 1) motor symptoms; 2) psychiatric and behavioral symptoms; and 3) pain. HR-QoL was associated with motor symptoms and psychiatric and behavioral symptoms (R2 = 0.66) for the total sample and lesional dystonia, but in the non-lesional dystonia subgroup only with psychiatric and behavioral symptoms (R2 = 0.51).

CONCLUSIONS

Non-motor symptoms are important for HR-QoL in childhood-onset dystonia. We suggest a multidisciplinary assessment of motor and non-motor symptoms to optimize individual patient management.

Time Course of Upper Limb Function in Children with Unilateral Cerebral Palsy: A Five-Year Follow-Up Study

Knowledge on long-term evolution of upper limb function in children with unilateral cerebral palsy (CP) is scarce. The objective was to report the five-year evolution in upper limb function and identify factors influencing time trends. Eighty-one children (mean age 9 y and 11 mo, SD 3 y and 3 mo) were assessed at baseline with follow-up after 6 months, 1, and 5 years. Passive range of motion (PROM), tone, muscle, and grip strength were assessed. Activity measurements included Melbourne Assessment, Jebsen-Taylor test, Assisting Hand Assessment (AHA), and ABILHAND-Kids. At 5-year follow-up, PROM (p < 0.001) and AHA scores (p < 0.001) decreased, whereas an improvement was seen for grip strength (p < 0.001), Melbourne Assessment (p = 0.003), Jebsen-Taylor test (p < 0.001), and ABILHAND-Kids (p < 0.001). Age influenced the evolution of AHA scores (p = 0.003), with younger children being stable over time, but from 9 years onward, children experienced a decrease in bimanual performance. Manual Ability Classification System (MACS) levels also affected the evolution of AHA scores (p = 0.02), with stable scores in MACS I and deterioration in MACS II and III. In conclusion, over 5 years, children with unilateral CP develop more limitations in PROM, and although capacity measures improve, the spontaneous use of the impaired limb in bimanual tasks becomes less effective after the age of 9 years.

Assessment of upper limb use in children with typical development and neurodevelopmental disorders by inertial sensors: a systematic review

Understanding development of bimanual upper limb (UL) activities in both typical and atypical conditions in children is important for: i) tailoring rehabilitation programs, ii) monitoring progress, iii) determining outcomes and iv) evaluating effectiveness of treatment/rehabilitation. Recent technological advances, such as wearable sensors, offer possibilities to perform standard medical monitoring. Body-worn motion sensors, mainly accelerometers, have shown very promising results but, so far, these studies have mainly focused on adults. The main aim of this review was to report the evidence of UL activity of both typically developing (TD) children and children with neurodevelopmental disorders (NDDs) that are reliably reported and comparable, using a combination of multiple wearable inertial sensors, both in laboratory and natural settings. Articles were selected from three research databases (PubMed, Web of Science and EBSCO). Included studies reported data on children aged 0-20 years old simultaneously wearing at least two inertial sensors on upper extremities. The collected and reported data were relevant in order to describe the amount of physical activity performed by the two ULs separately. A total of 21 articles were selected: 11 including TD, and 10 regarding NDDs. For each article, a review of both clinical and technical data was performed. We considered inertial sensors used for following aims: (i) to establish activity intensity cut-points; (ii) to investigate validity and reliability of specified markers, placement and/or number of inertial sensors; (iii) to evaluate duration and intensity of natural UL movements, defined motor tasks and tremor; and (iv) to assess efficacy of certain rehabilitation protocols. Our conclusions were that inertial sensors are able to detect differences in use between both hands and that all reviewed studies support use of accelerometers as an objective outcome measure, appropriate in assessing UL activity in young children with NDDs and determining intervention effectiveness. Further research on responsiveness to interventions and consistency with use in real-world settings is needed. This information could be useful in planning UL rehabilitation strategies.

Developing a Suite of Motion-Controlled Games for Upper Extremity Training in Children with Cerebral Palsy: A Proof-of-Concept Study

Aim: The Scratch programming language allows learner developers to write games. The Kinect2Scratch extension makes Scratch games with bodily motion control possible by connecting to Microsoft's Kinect sensor. This study examined the feasibility and possible efficacy of a suite of motion-controlled games designed for upper extremity (UE) training in children with cerebral palsy (CP) using Kinect2Scratch.

Materials and Methods: This is a proof-of-concept study. We developed three games, requiring three UE movement patterns (shoulder holding, reaching, and handclap), for use in children with CP. The primary outcome was feasibility, addressed by adherence, engagement, satisfaction, and safety. The secondary outcome was efficacy, which was evaluated by Quality of Upper Extremities Skills Test (QUEST), Box and Block Test (BBT), Melbourne Assessment 2 (MA2) test, and ABILHAND-kids score.

Results: Thirteen children with CP (mean age 6.9 years) received 24 sessions of training (30 minutes per session). The adherence rate was 100%. During the first 2 weeks of training, children had a significantly higher level of participation in Kinect2Scratch training than in conventional rehabilitation [Pittsburgh Participation Scale, median (interquartile range [IQR]), 6 (3–6) vs. 4 (3–6) P = 0.04]. However, during the last 2 weeks of training, there was no significant difference in participation between the Kinect2Scratch and conventional training [Pittsburgh Rehabilitation Participation Scale, median (IQR), 4 (3–5) vs. 4 (3–6) P = 0.55]. Most children enjoyed playing the games. The mean score of enjoyment was 4.54 ± 0.66. There were no adverse events during the training periods. The children had significant improvement in total score of QUEST and MA2. There were no significant improvements in BBT and ABILHAND-kids score.

Conclusion: Using Kinect2Scratch games for UE training is a feasible adjunctive program for children with CP.

Reorganization of the Action Observation Network and Sensory-Motor System in Children with Unilateral Cerebral Palsy: An fMRI Study

Little is known about the action observation network (AON) in children with unilateral cerebral palsy (UCP). Using fMRI, we aimed to explore AON and sensory-motor network (SMN) in UCP children and compare them to typically developed (TD) children and analyse the relationship between AON (re-)organization and several neurophysiological and clinical measures. Twelve UCP children were assessed with clinical scales and transcranial magnetic stimulation (TMS). For the fMRI study, they underwent a paradigm based on observation of complex and simple object-manipulation tasks executed by dominant and nondominant hand. Moreover, UCP and TD children carried out a further fMRI session to explore SMN in both an active motor and passive sensory task. AON in the UCP group showed higher lateralization, negatively related to performances on clinical scales, and had greater activation of unaffected hemisphere as compared to the bilateral representation in the TD group. In addition, a good congruence was found between bilateral or contralateral activation of AON and activation of SMN and TMS data. These findings indicate that our paradigm might be useful in exploring AON and the response to therapy in UCP subjects.

Action Observation Treatment Improves Upper Limb Motor Functions in Children with Cerebral Palsy: A Combined Clinical and Brain Imaging Study

The aim of the present study was to assess the role of action observation treatment (AOT) in the rehabilitation of upper limb motor functions in children with cerebral palsy. We carried out a two-group, parallel randomized controlled trial. Eighteen children (aged 5–11 yr) entered the study: 11 were treated children, and 7 served as controls. Outcome measures were scores on two functional scales: Melbourne Assessment of Unilateral Upper Limb Function Scale (MUUL) and the Assisting Hand Assessment (AHA). We collected functional scores before treatment (T1), at the end of treatment (T2), and at two months of follow-up (T3). As compared to controls, treated children improved significantly in both scales at T2 and this improvement persisted at T3. AOT has therefore the potential to become a routine rehabilitation practice in children with CP. Twelve out of 18 enrolled children also underwent a functional magnetic resonance study at T1 and T2. As compared to controls, at T2, treated children showed stronger activation in a parieto-premotor circuit for hand-object interactions. These findings support the notion that AOT contributes to reorganize brain circuits subserving the impaired function rather than activating supplementary or vicariating ones.

Rehabilitation of Upper Limb in Children with Acquired Brain Injury: A Preliminary Comparative Study

Acquired brain injuries (ABIs) can lead to a wide range of impairments, including weakness or paralysis on one side of the body known as hemiplegia. In hemiplegic patients, the rehabilitation of the upper limb skills is crucial, because the recovery has an immediate impact on patient quality of life. For this reason, several treatments were developed to flank physical therapy (PT) and improve functional recovery of the upper limbs. Among them, Constraint-Induced Movement Therapy (CIMT) and robot-aided therapy have shown interesting potentialities in the rehabilitation of the hemiplegic upper limb. Nevertheless, there is a lack of quantitative evaluations of effectiveness in a standard clinical setting, especially in children, as well as a lack of direct comparative studies between these therapeutic techniques. In this study, a group of 18 children and adolescents with hemiplegia was enrolled and underwent intensive rehabilitation treatment including PT and CIMT or Armeo®Spring therapy. The effects of the treatments were assessed using clinical functional scales and upper limb kinematic analysis during horizontal and vertical motor tasks. Results showed CIMT to be the most effective in terms of improved functional scales, while PT seemed to be the most significant in terms of kinematic variations. Specifically, PT resulted to have positive influence on distal movements while CIMT conveyed more changes in the proximal kinematics. Armeo treatment delivered improvements mainly in the vertical motor task, showing trends of progresses of the movement efficiency and reduction of compensatory movements of the shoulder with respect to other treatments. Therefore, every treatment gave advantages in a specific and different upper limb district. Therefore, results of this preliminary study may be of help to define the best rehabilitation treatment for each patient, depending on the goal, and may thus support clinical decision.

Impaired mobility associated with an increased likelihood of death in children: A systematic review

Improved identification of children with an increased likelihood of death can support appropriate provision of integrated palliative care. This systematic review aims to consider immobility and the associated likelihood of death in children with disabilities, living in high-income countries. Two reviewers independently searched MEDLINE, Embase, Cochrane Library, OpenGrey and Science Citation Index (1990-2016) for studies that reported hazard ratios (HRs) and relative risk for the likelihood of death related to impaired mobility. Nine papers were included. Three studies reported functioning using the Gross Motor Function Classification Scale (GMFCS) and the remaining studies reported measures of functioning unique to the study. The strongest single prognostic factor for the likelihood of death was 'lack of sitting ability at 24 months', HR 44.4 (confidence interval (CI) 6.1-320.8) followed by GMFCS V HR 16.3 (CI 5.6-47.2) and 11.4 (CI 3.76-35.57) and 'not able to cruise by 24 months', HR 14.4 (CI 3.5-59.2). Immobility is associated with an increased risk of dying over study periods, but different referent groups make clinical interpretation challenging. Overall, the quality of evidence is moderate. The findings suggest that immobility can support identification of children who may benefit from integrated palliative care.

Efficacy of oral pharmacological treatments in dyskinetic cerebral palsy: a systematic review

AIM

To evaluate the actual evidence of efficacy of oral pharmacological treatments in the management of dyskinetic cerebral palsy (CP).

METHOD

A systematic review was performed according to the American Academy for Cerebral Palsy and Developmental Medicine (AACPDM) and Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology. Articles were searched for in PubMed/MEDLINE, Scopus, Web of Science, Cochrane Library, Database of Reviews of Effectiveness, OTSeeker, Physiotherapy Evidence Database, REHABDATA, and ClinicalTrials.gov.

RESULTS

Sixteen articles met the eligibility criteria. Eight studies on trihexyphenidyl and two on levodopa showed contradictory results. Low efficacy was reported for diazepam, dantrolene sodium, perphenazine, and etybenzatropine. Tetrabenazine, gabapentin and levetiracetam should be studied in more detail. The updated available evidence does not support any therapeutic algorithm for the management of dyskinetic CP.

INTERPRETATION

This lack of evidence is partially owing to the inconsistency of classifications of patients and of outcome measures used in the reviewed studies. Further randomized, double-blind, placebo-controlled pharmacological trials, optimized for different age groups, based on valid, reliable, and disease-specific rating scales are strongly needed. Outcome measures should be selected within the framework of the International Classification of Functioning, Disability and Health.

WHAT THIS PAPER ADDS

Evidence to prove (or disprove) the efficacy of oral drugs in dyskinetic cerebral palsy is low. The most investigated drugs, trihexyphenidyl and levodopa, show contradictory results. Tetrabenazine, levetiracetam, and gabapentin efficacy should be studied in more detail. Lack of evidence is partially due to the inconsistency of classifications and outcome measures used. Outcome measures should be selected within the framework of the International Classification of Functioning, Disability and Health in next clinical trials.

Interhemispheric motor interactions in hemiparetic children with perinatal stroke: Clinical correlates and effects of neuromodulation therapy

OBJECTIVE

Brain stimulation and constraint therapy may enhance function after perinatal stroke but mechanisms are unknown. We characterized interhemispheric interactions (IHI) in hemiparetic children and explored their relationship to motor function and neuromodulation.

METHODS

Forty-five hemiparetic perinatal stroke subjects aged 6-19 years completed a clinical trial of repetitive-transcranial magnetic stimulation (rTMS) and constraint therapy. Paired-pulse TMS measured IHI in cases and normal controls. Suprathreshold conditioning stimuli preceded contralateral test stimuli bidirectionally: stroke to non-stroke (SNS) and non-stroke to stroke (NSS). Primary outcome was the interhemispheric ratio (IHR) between conditioned and test only MEP amplitudes X100 (<100 implied inhibition). Motor outcomes at baseline and post-intervention were compared to IHR.

RESULTS

Procedures were well tolerated. IHI occurred bidirectionally in controls. Eighteen stroke participants had complete data. IHR were increased in stroke participants in both directions. SNS IHR was >100 (facilitation) in 39% of measurements and correlated with better motor function. NSS IHR correlated with poorer motor function. Intervention-induced clinical change was not associated with IHR.

CONCLUSIONS

Interhemispheric interactions are altered and related to clinical function, but not necessarily neuromodulation, in children with perinatal stroke.

SIGNIFICANCE

Adding interhemispheric interactions to evolving models of developmental plasticity following early injury may advance neuromodulation strategies.

How does the interaction of presumed timing, location and extent of the underlying brain lesion relate to upper limb function in children with unilateral cerebral palsy?

BACKGROUND

Upper limb (UL) function in children with unilateral cerebral palsy (CP) vary largely depending on presumed timing, location and extent of brain lesions. These factors might exhibit a complex interaction and the combined prognostic value warrants further investigation. This study aimed to map lesion location and extent and assessed whether these differ according to presumed lesion timing and to determine the impact of structural brain damage on UL function within different lesion timing groups.

MATERIALS AND METHODS

Seventy-three children with unilateral CP (mean age 10 years 2 months) were classified according to lesion timing: malformations (N = 2), periventricular white matter (PWM, N = 42) and cortical and deep grey matter (CDGM, N = 29) lesions. Neuroanatomical damage was scored using a semi-quantitative MRI scale. UL function was assessed at body function and activity level.

RESULTS

CDGM lesions were more pronounced compared to PWM lesions (p = 0.0003). Neuroanatomical scores were correlated with a higher degree to UL function in the CDGM group (r_s = -0.39 to r_s = -0.84) compared to the PWM group (r_rb = -0.42 to r_s = -0.61). Regression analysis found lesion location and extent to explain 75% and 65% (p < 0.02) respectively, of the variance in AHA performance in the CDGM group, but only 24% and 12% (p < 0.03) in the PWM group.

CONCLUSIONS

In the CDGM group, lesion location and extent seems to impact more on UL function compared to the PWM group. In children with PWM lesions, other factors like corticospinal tract (re)organization and structural connectivity may play an additional role.

Weight-supported training of the upper extremity in children with cerebral palsy: a motor learning study

Background

Novel neurorehabilitation technologies build upon treatment principles derived from motor learning studies. However, few studies have investigated motor learning with assistive devices in children and adolescents with Cerebral Palsy (CP). The aim of this study was to investigate whether children with CP who trained with weight support in a playful, virtual environment would improve upper extremity task performance (i.e. skill acquisition), transfer, and retention, three aspects that indicate whether motor learning might have occurred or not.

Methods

Eleven children with CP (mean age 13.3 years, standard deviation 3.4 years), who were mildly to moderately impaired, participated. They played in the Armeo® Spring the exergame Moorhuhn with their more affected arm during 3 days (70 min pure play time). For this within-subject design, kinematic assessments, the Box and Block Test, and five items of the Melbourne Assessment were administered twice during a baseline week (one week before the intervention), directly before and after the intervention, and one day after the training phase (retention).

Results

The average exergame score improved from 209.55 to 339.73 (p < 0.001, Cohen’s d = 1.80), indicating skill acquisition. The change in the Box and Block test improved from 0.45 (baseline week) to 3.95 (intervention week; p = 0.008, d = 1.59) indicating skill transfer. The kinematic assessments and the Melbourne items did not change. Improvement in game score and Box and Bock Test persisted one day later (retention).

Conclusions

We found evidence indicating the successful acquisition, transfer, and retention of upper extremity skills in children with CP. We therefore infer that motor learning occurred when children with CP trained their more affected arm with weight-support in a playful, virtual environment.

Adductor Tenotomy Combined with Palmar Capsulodesis for Spastic Thumb-in-Palm Deformity in Cerebral Palsy: Description of a Surgical Technique and Clinical Results

BACKGROUND

Spastic thumb deformity in cerebral palsy significantly impedes hand function. Flexion-adduction forces across the first ray is the result from imbalance between intrinsic and extrinsic muscles. Multiples surgeries have been devised for the treatment of this condition such as contracture release and by tendon transfers for balancing the muscles forces. We report the results of a less demanding surgical technique, intended to avoid hyperextension of the metacarpophalangeal joint previously described in other series.

METHODS

Five patients with cerebral palsy who underwent a surgical correction for their thumb-in-palm deformity between January 2013 and August 2014 were included. All patients were assessed postoperatively with a minimum follow up of six months. Three criteria were chosen to evaluate functional ability: capacity to perform pinch, volitional muscle control and usefulness of the hand in daily life activities.

RESULTS

Patients who had surgery for spastic thumb deformity were reviewed. The thumb was maintained out of the palm in all patients. Three patients were able to perform correct pinch, achieved volitional muscle control and a more functional hand. One patient had limitation to achieve one of the evaluated daily life activities and one patient lacked active thumb movement for pinch, motor control and achieved no daily life activities. No postoperative complications were recorded.

CONCLUSIONS

We present a less challenging technique that should be taken into account for the treatment of thumb-in-palm deformity. Appearance and functional improvement can be achieved with this surgical procedure avoiding disadvantages of secondary deformities.

Feasibility of Motor Imagery Training for Children with Developmental Coordination Disorder - A Pilot Study

Children with Developmental Coordination Disorder (DCD) experience movement difficulties that may be linked to processes involved in motor imagery (MI). This paper discusses recent advances in theory that underpin the use of MI training for children with DCD. This knowledge is translated in a new MI training protocol which is compared with the cognitive orientation to daily occupational performance (CO-OP). Children meeting DSM-5 criteria for DCD were assigned to MI (n = 4) or CO-OP (n = 4) interventions and completed nine treatment sessions, including homework exercises. Results were positive, with two children in the MI group and three in the CO-OP group improving their m-ABC-2 score by ≥ 2 standard scores, interpreted as a clinically meaningful change. Moreover, all children and parents noticed improvements in motor skills after training. This is the first study to demonstrate the feasibility of a theoretically principled treatment protocol for MI training in children with DCD, and extends earlier work.

Trial registration: The complete trial is registered at the Dutch trial register, www.trialregister.nl (NTR5471). http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5471

Orthopedic surgery in cerebral palsy: Instructional course lecture

Orthopedic surgery (OS) plays an important role in the management of cerebral palsy (CP). The objectives of OS are to optimize functions and prevent deformity. Newer developments in OS for CP include emphasis on hip surveillance, minimally invasive procedures, use of external fixators instead of plates and screws, better understanding of lever arm dysfunctions (that can only be corrected by bony OS), orthopedic selective spasticity-control surgery, and single-event multilevel lever arm restoration and anti spasticity surgery, which have led to significant improvements in gross motor function and ambulation, especially in spastic quadriplegia, athetosis, and dystonia. The results of OS can be dramatic and life altering for the person with CP and their caregivers if it is performed meticulously by a specialized surgical team, at the appropriate age, for the correct indications, employing sound biomechanical principles and is followed by physician-led, protocol based, intensive, multidisciplinary, institutional rehabilitation, and long term followup. However, OS can be a double-edged sword, and if performed less than optimally, and without the supporting multidisciplinary medical and rehabilitation team, expertise and infrastructure, it often leads to significant functional worsening of the person with CP, including irretrievable loss of previous ambulatory capacity. OS must be integrated into the long term management of the person with CP and should be anticipated and planned at the optimal time and not viewed as a "last resort" intervention or failure of rehabilitation. This instructional course lecture reviews the relevant contemporary principles and techniques of OS in CP.

The International Classification of Functioning (ICF) to evaluate deep brain stimulation neuromodulation in childhood dystonia-hyperkinesia informs future clinical & research priorities in a multidisciplinary model of care

The multidisciplinary team (MDT) approach illustrates how motor classification systems, assessments and outcome measures currently available have been applied to a national cohort of children and young people with dystonia and other hyperkinetic movement disorders (HMD) particularly with a focus on dyskinetic cerebral palsy (CP). The paper is divided in 3 sections. Firstly, we describe the service model adopted by the Complex Motor Disorders Service (CMDS) at Evelina London Children's Hospital and King's College Hospital (ELCH-KCH) for deep brain stimulation. We describe lessons learnt from available dystonia studies and discuss/propose ways to measure DBS and other dystonia-related intervention outcomes. We aim to report on current available functional outcome measures as well as some impairment-based assessments that can encourage and generate discussion among movement disorders specialists of different backgrounds regarding choice of the most important areas to be measured after DBS and other interventions for dystonia management. Finally, some recommendations for multi-centre collaboration in regards to functional clinical outcomes and research methodologies for dystonia-related interventions are proposed.

Effect of parent-delivered action observation therapy on upper limb function in unilateral cerebral palsy: a randomized controlled trial

AIM

To determine whether home-based, parent-delivered therapy comprising action observation (AO) and repeated practice (RP) improves upper limb function more than RP alone in children with unilateral cerebral palsy (UCP).

DESIGN

single-blinded parallel-group randomized controlled trial with 1:1 allocation comparing AO+RP (intervention) with RP alone (control).

RANDOMIZATION

computer-generated, with allocation concealment by opaque sequentially-numbered envelopes.

SETTING

northern England, August 2011 to September 2013.

PARTICIPANTS

70 children with UCP; mean age 5.6 years (SD 2.1), 31 female.

INTERVENTION

home-based activities were provided, tailored to interests and abilities.

DURATION

15 minutes/day, 5 days/week for 3 months.

ASSESSMENTS

Assisting Hand Assessment (AHA; primary outcome measure), Melbourne Assessment 2 (MA2), and ABILHAND-Kids at baseline, 3 months, and 6 months.

RESULTS

Outcome data was available at 3 months for 28 children in the AO+RP group and 31 controls, and at 6 months for 26 and 28 children respectively. There were no between-group differences in AHA, MA2, or ABILHAND-Kids at 3 or 6 months versus baseline (all p>0.05). Combined-group improvements (p<0.001), observed in AHA and MA2 at 3 months, were maintained at 6 months. ABILHAND-Kids also showed improvement at 3 months (p=0.003), maintained at 6 months.

INTERPRETATION

Parent-delivered RP (with or without AO) improves upper limb function and could supplement therapist input.

The Symptomatic Treatment of Acquired Dystonia: A Systematic Review

Background

Acquired dystonia is caused by an acquired or exogenous event. Although the therapeutic armamentarium used in clinical practice is more or less similar to that used for inherited or idiopathic dystonia, formal proof of the efficacy of these interventions in acquired dystonia is lacking.

Methods

The authors attempt to provide a comprehensive and systematic review of the current evidence for medical and allied health care treatment strategies in acquired dystonias. The PubMed, Cochrane Library, MEDLINE, Web of Science, PiCarta, and PsycINFO databases were searched up to December 2015, including randomized controlled trials, patient-control studies, and case series or single case reports containing a report on clinical outcome.

Results

There are level 3 practice recommendations for botulinum toxin injections and globus pallidus pars interna deep brain stimulation for tardive dystonia and dystonic cerebral palsy as well as intrathecal baclofen for dystonic cerebral palsy. There are insufficient and conflicting data on the effect (vs. the hazard) of other pharmacological interventions, and limited work has been done on other forms of neurostimulation and allied health care. Because no class A1 or A2 studies were identified, level 1 or 2 practice recommendations could not be deducted for a specific treatment intervention.

Conclusions

To improve the current medical and allied health care treatment options for patients with acquired dystonia, high-quality trials that examine the efficacy of therapies need to be performed.

Do mirror movements relate to hand function and timing of the brain lesion in children with unilateral cerebral palsy?

AIM

This study aimed to systematically map the severity of mirror movements in both hands in a prospective cohort of children with unilateral cerebral palsy, and to explore the relationship with hand function and brain lesion type.

METHOD

Seventy-eight children were included (41 males, 37 females; age 9y 4mo, SD 3y 1mo, range 5-15y). Mirror movements were scored during three repetitive tasks following Woods and Teuber criteria. Strength, tone, Melbourne Assessment, Jebsen-Taylor test, and Assisting Hand Assessment were evaluated. Lesions were classified into malformations (n=5), periventricular (n=43), cortico-subcortical (n=22), and postnatally acquired lesions (n=8).

RESULTS

Significantly more mirror movements were observed in the non-paretic versus the paretic hand (p≤0.003). Higher mirror movement scores in the non-paretic hand significantly correlated with lower distal strength and lower scores on unimanual and bimanual assessments (r=0.29-0.41). In the paretic hand, significant differences were found between lesion types (p=0.03).

INTERPRETATION

The occurrence of mirror movements in the non-paretic hand seems related to hand function while mirror movements in the paretic hand seem more related to the lesion timing, whereby children with earlier lesions present with more mirror movements.

Outcome measures evaluating hand function in children with bilateral cerebral palsy: a systematic review

AIM

To review outcome measures used to evaluate hand function, with emphasis on manual capacity and performance, in children with bilateral cerebral palsy (CP), to describe the content and measurement properties of such measures, and to investigate the quality of the studies that have examined these properties.

METHOD

Embase, MEDLINE, PubMed, and CINAHL were searched. The COSMIN-criteria (COnsensus-based Standards for the selection of health Measurement INstruments) were used to assess the quality of studies and the Terwee criteria were used to assess the result of the studies.

RESULTS

Five hand function measures were identified from 16 papers. The strongest level of evidence for aspects of validity and reliability was found for the Melbourne Assessment 2, assessing unimanual capacity, and for the questionnaire ABILHAND-Kids, assessing perceived manual ability in daily activities. However, evidence for the responsiveness of these measures is missing.

INTERPRETATION

Further high-quality studies providing evidence for responsiveness, as well as for additional aspects of validity and reliability of the Melbourne Assessment 2 and the ABILHAND-Kids, are needed. Furthermore, there is a need to develop appropriate outcome measures evaluating how children with bilateral CP use their hands when handling objects in bimanual tasks.

Effects of botulinum toxin type A on upper limb function in children with cerebral palsy: a systematic review

Objective: To evaluate whether botulinum toxin type A injections improve upper limb function in children with cerebral palsy.

Methods: An extensive search was carried out in PUBMED, CINAHL, PICARTA, EMBASE, PEDRO and the Cochrane Controlled Trials Register. Controlled and uncontrolled studies were included and evaluated on the basis of a best evidence synthesis.

Results: Twelve out of 645 identified studies were included: three randomized controlled trials (RCTs) ( n = 64) of high methodological quality, and nine uncontrolled studies ( n = 107) of sufficient methodological quality. In one of the three RCTs a short-term, significant decrease of spasticity was found in favour of the botulinum toxin type A group, which was supported by five of the seven uncontrolled studies that also measured spasticity. In one RCT significant changes in range of motion were reported for wrist and thumb extension. This finding was supported by two out of seven uncontrolled studies. One RCT reported a significant improvement in activities after one month, according to the Quality of Upper Extremity Skills Test and the Pediatric Evaluation Disability Inventory, whereas five out of the nine uncontrolled studies reported an improvement in functional activities.

Conclusion: Insufficient evidence is found for the effects of botulinum toxin type A injections to reduce spasticity or to increase range of motion and upper limb function in children with cerebral palsy. Besides differences in treatment goals, the lack of evidence is mainly due to the use of invalid assessment instruments and insufficient statistical power to demonstrate treatment effects.

Development of a set of activities to evaluate the arm and hand function in children with obstetric brachial plexus lesion

Objective: To develop an observational instrument that can be used to evaluate the quality of arm and hand skills in daily functional activities in children with obstetric brachial plexus lesion (OBPL). A set of functional activities was constructed and standardized, and the intra-observer reliability of the assessment of this set of activities was studied.

Setting: Department of Occupational Therapy and Department of Rehabilitation Medicine, VU University Medical Centre.

Subjects: Twenty-six children with OBPL in the age range of 4 -6 years.

Interventions: The children were asked to perform 47 bimanual activities, which were recorded on videotape.

Main measures: The videotapes were scored twice by the same occupational therapist.

Results: The percentage of agreement in scoring ‘hand-use’, ‘speed’ and ‘assistance’ was over 80% for a substantial number of activities, indicating a strong agreement. However, in scoring ‘deviations in movements and body posture’ the percentage of agreement was insufficient in most activities.

Conclusions: This set of activities has good potential for assessment of the performance of functional activities in children with OBPL. This study, however, showed a number of difficulties in observing and scoring the activities that have to be considered when developing a standardized video observation.

A Novel Device for Grasping Assessment during Functional Tasks: Preliminary Results

This paper presents a methodology and first results obtained in a study with a novel device that allows the analysis of grasping quality. Such a device is able to acquire motion information of upper limbs allowing kinetic of manipulation analysis as well. A pilot experiment was carried out with six groups of typically developing children aged between 5 and 10 years, with seven to eight children in each one. The device, designed to emulate a glass, has an optical system composed by one digital camera and a special convex mirror that together allow image acquisition of grasping hand posture when it is grasped and manipulated. It also carries an Inertial Measurement Unit that captures motion data as acceleration, orientation, and angular velocities. The novel instrumented object is used in our approach to evaluate functional tasks performance in quantitative terms. During tests, each child was invited to grasp the cylindrical part of the device that was placed on the top of a table, simulating the task of drinking a glass of water. In the sequence, the child was oriented to transport the device back to the starting position and release it. The task was repeated three times for each child. A grasping hand posture evaluation is presented as an example to evaluate grasping quality. Additionally, motion patterns obtained with the trials performed with the different groups are presented and discussed. This device is attractive due to its portable characteristics, the small size, and its ability to evaluate grasping form. The results may be also useful to analyze the evolution of the rehabilitation process through reach-to-grasping movement and the grasping images analysis.

Quantitative Evaluation of Performance during Robot-assisted Treatment

INTRODUCTION

This article is part of the Focus Theme of Methods of Information in Medicine on "Methodologies, Models and Algorithms for Patients Rehabilitation".

OBJECTIVES

The great potential of robots in extracting quantitative and meaningful data is not always exploited in clinical practice. The aim of the present work is to describe a simple parameter to assess the performance of subjects during upper limb robotic training exploiting data automatically recorded by the robot, with no additional effort for patients and clinicians.

METHODS

Fourteen children affected by cerebral palsy (CP) performed a training with Armeo®Spring. Each session was evaluated with P, a simple parameter that depends on the overall performance recorded, and median and interquartile values were computed to perform a group analysis.

RESULTS

Median (interquartile) values of P significantly increased from 0.27 (0.21) at T0 to 0.55 (0.27) at T1 . This improvement was functionally validated by a significant increase of the Melbourne Assessment of Unilateral Upper Limb Function.

CONCLUSIONS

The parameter described here was able to show variations in performance over time and enabled a quantitative evaluation of motion abilities in a way that is reliable with respect to a well-known clinical scale.

Effects of botulinum toxin A and/or bimanual task-oriented therapy on upper extremity activities in unilateral Cerebral Palsy: a clinical trial

BACKGROUND

This study reports on the effects of botulinum toxin A (BoNT-A) injections in the upper extremity (UE) in children with unilateral Cerebral Palsy (uCP) combined with bimanual task-oriented therapy (BITT) or either treatment modality performed separately. Bimanual activities were measured with the Assisting Hand Assessment (AHA), the ABILHand-Kids questionnaire (AK), the Observational Skills Assessment Score (OSAS). Goal achievement was measured with Goal Attainment Scaling (GAS), using blind video assessment, and the Canadian Occupational Performance Measure (COPM).

METHODS

Thirty-five children, mean age 7.14 years (SD 2.63), 11 Manual Ability Classification Score (MACS) I, 15 MACS II and 9 MACS III, participated. The trial started with four study groups: BoNT-A-only (n = 5), BITT-only (n = 11), BoNT-A + BITT (n = 13), and control (n = 6). Twenty-two children were randomised, 13 children received their parents' preferred treatment: BoNT-A + BITT or BITT-only. Three comparisons were analysed: BITT (BoNT-A + BITT and BITT-only; n = 24) versus no BITT (BoNT-A-only and control; n = 11), BoNT-A (BoNT-A-only and BoNT-A + BITT; n = 18) versus no BoNT-A (BITT-only and control; n = 17), and the additional effect of BoNT-A (BoNT-A + BITT versus BITT-only). Follow-up time: 24 weeks.

RESULTS

No significant differences between the groups were found on the AHA. The amount of use of both hands on the OSAS was significantly better in the BoNT-A group in the beading and sandwich-making task. The BoNT-A group also showed significant improvement in the quality scores of the OSAS: the wrist position during grasping and holding, especially in the younger children. The BITT group improved significantly on the AK and significantly more on the performance and satisfaction scores of the COPM at 12 and 24 weeks regarding several goals. BoNT-A showed a significant negative effect at 12 and 24 weeks in the most important goal. BITT, more than BoNT-A + BITT, showed positive effects on the GAS score at 12 (significant), 18 and 24 weeks.

CONCLUSIONS

BoNT-A has a positive effect on quality of movement and amount of use of the affected UE during the 3 months' working time. BoNT-A has no additional effect on bimanual performance and goal achievement. BITT has a positive effect on goal achievement and bimanual performance, even up to 6 weeks after therapy had stopped.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN69541857.

The results of surgical treatment for pronation deformities of the forearm in cerebral palsy after a mean follow-up of 17.5 years

Aim

This study evaluates the effects of three surgical procedures in the treatment of pronation deformities of the forearm in cerebral palsy patients; namely the transposition of pronator teres to extensor carpi radialis brevis muscle; and rerouting of the pronator teres muscle with or without pronator quadratus muscle myotomy.

Methods

Sixty-one patients, 48 male/13 female, with a mean age of 17 years (5–41 years) were treated between 1971 and 2011. Pronator teres transposition was performed in 10, pronator rerouting in 35, and pronator rereouting with pronator quadratus myotomy in 16 patients. Ranges of motion, and assessments using the Quick Dash, Mayo Scoring, and Functional Classification system of upper extremity, were made before and after surgery. Mean follow-up was 17.5 years (3–41 years).

Results

All three procedures led to significantly improved ranges of motion and upper limb function, with good/excellent results in 80 % of patients. Mean active supination improved from 10 ° (0–60 °) to 85 ° (30–90 °) (p < 0.001). There were significant improvements in Functional Classification system for the upper extremity scores (p < 0.003), Mean Quick Dash Scores improved from 58.41 (38.63–79.54) to 44.59 (27.27–68.18), and mean MEPS improved from 68 (30–85) to 84 (60–100) following surgery. All three techniques had statistically improved MEPS following surgery (p < 0.001); only the pronator teres muscle rerouting with pronator quadratus myotomy showed an improved Functional Classification system for the upper extremity score (p < 0.05); and only the pronator teres rerouting procedure showed an improved Quick Dash score (p < 0.05). There were no statistically significant differences in outcomes between different ages groups, and no significant differences between isolated pronator teres muscle rerouting were compared with those undergoing simultaneous treatment of carpal flexion and thumb adduction deformities (p > 0.05).

Conclusion

Surgery is very effective in the management of pronation deformities of the forearm in patients with cerebral palsy. Isolated pronator teres rerouting is probably the most effective and simple technique. Adjunctive pronator quadratus myotomy does not lead to an improvement in the results and requires an additional surgical approach. There should be no age restriction to surgery, as all age groups appear to benefit from similar improvements in range of motion and upper limb function.

Cortical reorganisation of cerebral networks after childhood stroke: impact on outcome

BACKGROUND

Recovery after arterial ischaemic stroke is known to largely depend on the plastic properties of the brain. The present study examines changes in the network topography of the developing brain after stroke. Effects of brain damage are best assessed by examining entire networks rather than single sites of structural lesions. Relating these changes to post-stroke neuropsychological variables and motor abilities will improve understanding of functional plasticity after stroke. Inclusion of healthy controls will provide additional insight into children's normal brain development. Resting state functional magnetic resonance imaging is a valid approach to topographically investigate the reorganisation of functional networks after a brain lesion. Transcranial magnetic stimulation provides complementary output information. This study will investigate functional reorganisation after paediatric arterial ischaemic stroke by means of resting state functional magnetic resonance imaging and transcranial magnetic stimulation in a cross-sectional plus longitudinal study design. The general aim of this study is to better understand neuroplasticity of the developing brain after stroke in order to develop more efficacious therapy and to improve the post-stroke functional outcome.

METHODS

The cross-sectional part of the study will investigate the functional cerebral networks of 35 children with chronic arterial ischaemic stroke (time of the lesion >2 years). In the longitudinal part, 15 children with acute arterial ischaemic stroke (shortly after the acute phase of the stroke) will be included and investigations will be performed 3 times within the subsequent 9 months. We will also recruit 50 healthy controls, matched for age and sex. The neuroimaging and neurophysiological data will be correlated with neuropsychological and neurological variables.

DISCUSSION

This study is the first to combine resting state functional magnetic resonance imaging and transcranial magnetic stimulation in a paediatric population diagnosed with arterial ischaemic stroke. Thus, this study has the potential to uniquely contribute to the understanding of neuronal plasticity in the brains of healthy children and those with acute or chronic brain injury. It is expected that the results will lead to the development of optimal interventions after arterial ischaemic stroke.

Randomized controlled trial of web-based multimodal therapy for unilateral cerebral palsy to improve occupational performance

AIM

The study aimed to investigate the effectiveness of a web-based therapy programme, 'Move it to improve it' (Mitii(™)), in children with unilateral cerebral palsy (UCP) on occupational performance, upper limb function, and visual perception.

METHOD

Participants (n=102) were matched in pairs and randomized to intervention (Mitii for 20wks; 26 males, mean age 11y 8mo [2y 4mo], Manual Ability Classification System level I=11, II=39, III=1) or control (standard care; 25 males, mean age 11y 10mo [2y 5mo], Manual Ability Classification System level I=13, II=37). Outcomes were the Assessment of Motor and Process Skills (AMPS), Assisting Hand Assessment, Jebsen-Taylor Test of Hand Function (JTTHF), Melbourne Assessment of Unilateral Upper Limb Function (MUUL), Canadian Occupational Performance Measure (COPM), and Test of Visual Perceptual Skills (TVPS-3).

RESULTS

Participants completed on average 32.4 hours of Mitii (range 3.7-74.7h). The Mitii group demonstrated significantly greater post-intervention scores than the comparison group on the AMPS, JTTHF dominant upper limb, COPM, and TVPS-3. The differences between groups were not clinically significant. There were no differences between groups on measures of impaired upper limb function.

INTERPRETATION

Mitii delivers individualized, web-based therapy at home and has potential to increase therapy dose. Mitii can be considered as an option to enhance occupational performance and visual perception for children with UCP.