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

Interventions to Promote Bimanual Activities and Participation in Daily Life Activities in Children with Cerebral Palsy: A Scoping Review

AIMS

To identify rehabilitation interventions and outcome measures that target bimanual activities and autonomy in activities of daily living (ADLs) in children with cerebral palsy.

METHODS

This scoping review followed the Arksey and O'Malley framework. The literature search was conducted in five medical databases. Inclusion criteria were studies of children with cerebral palsy that delivered rehabilitation interventions targeting upper limb function and used valid outcome measures assessing bimanual activities or ADLs. The exclusion criteria were pharmacological or surgical interventions, reviews, expert opinions, protocols and qualitative studies. Two independent researchers screened titles/abstracts and full texts. Data related to the study participants, interventions, outcome measures and results were extracted.

RESULTS

Eighty-nine publications were included in this review. Out of the 17 interventions identified, the most frequent were constraint-induced movement therapy (n = 29), virtual reality (n = 22), hand-arm bimanual intensive training (n = 12), bimanual intensive training (n = 11) and action observation (n = 6). All five interventions showed significant improvements on bimanual function, whereas all but action observation showed improvements in autonomy in ADLs. We identified 15 outcome measures capturing bimanual activities and 6 capturing autonomy in ADLs.

CONCLUSION

This scoping review provides essential information for the improvement of rehabilitation interventions for children with cerebral palsy.

Bridging the Gap: A Novel Approach to Pediatric Rehabilitation Training in Low Resource Settings

PURPOSE

Approximately 250 million children younger than 5 years in low- and middle-income countries are at risk of not reaching their developmental potential, often without access to rehabilitation. A training program was developed to provide physical therapists in Myanmar with the knowledge and skills to deliver family-centered early rehabilitation.

METHODS

Participants completed online coursework, discussions, synchronous mentoring sessions, and onsite training for 7 weeks. To assess the effectiveness of the training, participants completed surveys on their self-perception of knowledge and skills related to early rehabilitation at 4 intervals. Focus group interviews were also conducted to allow the participants to discuss their experiences.

RESULTS

There were significant improvements in knowledge and discussed implementation of the new skills in practice with a focus on family education and innovative use of home materials.

CONCLUSION

The training program effectively enhanced participants' confidence in their ability to implement family-centered interventions using available resources.

Evaluation of a Game-Based Mechatronic Device for Rehabilitation of Hand-Arm Function in Children With Cerebral Palsy: Feasibility Randomized Controlled Trial

BACKGROUND

Children with neurodevelopmental disorders, such as cerebral palsy (CP), often experience motor impairments in manual dexterity, which hinder daily tasks and social interactions. Traditional rehabilitation methods require repetitive task practice, which can be difficult for children to sustain due to low engagement. Game-based rehabilitation devices and robots offer a promising alternative by combining therapy with digital play, improving motivation and compliance. However, many systems fail to incorporate actual object manipulation, which is essential for motor learning through sensory feedback. To address this limitation, a low-cost, easy-to-use robotic manipulandum device (RMD) was developed. The RMD enables real-time object manipulation during gameplay while providing assistive force, allowing the practice of a wide range of manual dexterity skills beyond gross reaching. This system offers an engaging and effective rehabilitation approach to enhance hand function in children with CP.

OBJECTIVE

This study aimed to provide evidence for the feasibility and therapeutic value of the RMD game-based exercise program for children with CP.

METHODS

In total, 34 children with CP, aged 4 to 10 years, were randomly assigned to the experimental group (XG) or the control group (CG). The XG received a computer game-based exercise program using the RMD, focusing on object manipulation tasks, while the CG received task-specific training similar to constraint-induced movement therapy. Both groups received their respective therapy programs 3 times per week for 8 weeks. Semistructured interviews with parents and children, along with qualitative analysis, were conducted to evaluate their experiences with the exercise program. The following outcome measures were used: (1) the Peabody Developmental Motor Scale-2 (PDMS-2) grasping and visual-motor integration subtests and (2) the computer game-based upper extremity (CUE) assessment of manual dexterity.

RESULTS

No dropouts occurred during the 8-week program. Both groups showed significant improvements in the PDMS-2 subtests (P<.001) and the CUE assessment of manual dexterity, including success rates (tennis ball: P=.001; cone: P<.001; medicine ball: P=.001; and peanut ball: P<.001) and movement errors (tennis ball: P=.01; cone: P<.001; medicine ball: P=.04; and peanut ball: P<.001). The XG outperformed the CG, showing greater improvements in PDMS-2 grasping (P=.002) and visual-motor integration (P=.01). In the CUE assessment, the XG demonstrated higher success rates (medicine ball: P=.001 and peanut ball: P=.02) and fewer movement errors (cone: P<.001). Parents reported an increase in the children's independence in daily tasks.

CONCLUSIONS

This study demonstrates the feasibility, acceptability, and positive outcomes of the RMD game-based exercise program for improving hand function in children with CP. The findings support further research and development of computer game-assisted rehabilitation technologies.

TRIAL REGISTRATION

Clinical Trials Registry - India CTRI/2021/07/034903; https://ctri.nic.in/Clinicaltrials/pmaindet2.php?EncHid=NTc4ODU.

Robotic assessment of bilateral and unilateral upper limb functions in adults with cerebral palsy

BACKGROUND

Children with unilateral cerebral palsy (CP) exhibit motor impairments predominantly on one side of the body, while also having ipsilesional and bilateral impairments. These impairments are known to persist through adulthood, but their extent have not been described in adults with CP. This study's aim is to characterize bilateral and unilateral upper limbs impairments in adults with CP.

METHODS

Nineteen adults with CP (34.3 years old ± 11.5) performed three robotic assessments in the Kinarm Exoskeleton Lab, including two bilateral tasks (Object Hit [asymmetric independent goals task] and Ball on Bar [symmetric common goal task]) and one unilateral task (Visually Guided Reaching, performed with the more affected arm [MA] and less affected arm [LA]). Individual results were compared to sex, age and handedness matched normative data, describing the proportion of participants exhibiting impairments in each task-specific variable (e.g., Hand speed), each performance category (e.g., Feedforward control) and in global task performance. Associations were assessed using Spearman correlation coefficients between: 1: the results of the MA and LA of each limb in the unilateral task; and 2: the results of each limb in the unilateral vs. the bilateral tasks.

RESULTS

The majority of participants exhibited impairments in bilateral tasks (84%). The bilateral performance categories (i.e., Bimanual) identifying bilateral coordination impairments were impaired in the majority of participants (Object Hit: 57.8%; Ball on Bar: 31.6%). Most of the participants were impaired when performing a unilateral task with their MA arm (63%) and a smaller proportion with their LA arm (31%). The Feedforward control was the unilateral performance category showing the highest proportion of impaired participants while displaying the strongest relationship between the MA and LA arms impairments (rs = 0.93). Feedback control was the unilateral performance category most often associated with impairments in bilateral tasks (6 out of 8 performance categories).

CONCLUSIONS

Adults with CP experienced more impairment in bilateral tasks while still having substantial impairments in unilateral tasks. They frequently display Feedforward control impairments combined with a higher reliance on Feedback control during both bilateral and unilateral tasks, leading to poorer motor performance.

Relationship between somatosensory and visuo-perceptual impairments and motor functions in adults with hemiparetic cerebral palsy

Introduction

Children with cerebral palsy (CP) exhibit a variety of sensory impairments that can interfere with motor performance, but how these impairments persist into adulthood needs further investigation. The objective of this study was to describe the sensory impairments in adults having CP and how they relate to motor impairments.

Methods

Nineteen adults having CP performed a set of robotic and clinical assessments. These assessments were targeting different sensory functions and motor functions (bilateral and unilateral tasks). Frequency of each type of impairments was determined by comparing individual results to normative data. Association between the sensory and motor impairments was assessed with Spearman correlation coefficient.

Results

Impairment in stereognosis was the most frequent, affecting 57.9% of participants. Although less frequently impaired (26.3%), tactile discrimination was associated with all the motor tasks (unilateral and bilateral, either robotic or clinical). Performance in robotic motor assessments was more frequently associated with sensory impairments than with clinical assessments. Finally, sensory impairments were not more closely associated with bilateral tasks than with unilateral tasks.

Discussion

Somatosensory and visuo-perceptual impairments are frequent among adults with CP, with 84.2% showing impairments in at least one sensory function. These sensory impairments show a moderate association with motor impairments.

Enhanced EEG power density during painful stretching in individuals with cerebral palsy

BACKGROUND

Pain perception mechanisms in cerebral palsy remain largely unclear.

AIMS

This study investigates brain activity in adults with cerebral palsy during painful and non-painful stretching to elucidate their pain processing characteristics.

METHODS AND PROCEDURES

Twenty adults with cerebral palsy and 20 controls underwent EEG in three conditions: rest, non-painful stretching, and painful stretching. Time-frequency power density of theta, alpha, and beta waves in somatosensory and frontal cortices was analyzed, alongside baseline pressure pain thresholds.

OUTCOMES AND RESULTS

Cerebral palsy individuals exhibited higher theta, alpha, and beta power density in both cortices during painful stretching compared to rest, and lower during non-painful stretching. Controls showed higher power density during non-painful stretching but lower during painful stretching. Cerebral palsy individuals had higher pain sensitivity, with those more sensitive experiencing greater alpha power density.

CONCLUSIONS AND IMPLICATIONS

These findings confirm alterations in the cerebral processing of pain in individuals with cerebral palsy. This knowledge could enhance future approaches to the diagnosis and treatment of pain in this vulnerable population.

Test-retest reliability of corticokinematic coherence in young children with cerebral palsy: An observational longitudinal study

OBJECTIVES

To assess the test-retest reliability of the corticokinematic coherence (CKC), an electrophysiological marker of proprioception, in children with cerebral palsy (CP).

METHODS

Electroencephalography (EEG) signals from 15 children with unilateral or bilateral CP aged 23 to 53 months were recorded in two sessions 3 months apart using 128-channel EEG caps. During each session, children's fingers were moved at 2 Hz by an experimenter, in separate recordings for the more-affected (MA) and less-affected (LA) hands. The CKC was computed at the electrode and source levels, at movement frequency F0 (2 Hz) and its first harmonic F1 (4 Hz). A two-way mixed-effects model intraclass-correlation coefficient (ICC) was computed for the maximum CKC strength across electrodes at F0 and F1 obtained during the two sessions.

RESULTS

ICC of the CKC strength acquired from LA and MA hands pooled together were respectively 0.51 (95% CI: 0.30-0.68) at F0 and 0.96 (95% CI: 0.93-0.98) at F1. The mean distances separating the CKC peaks in the source space at the two evaluation times were in the order of a centimeter.

CONCLUSION

CKC is a robust electrophysiologic marker to study the longitudinal changes in cortical processing of proprioceptive afferences in young children with CP.

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.

Altered excitation-inhibition balance in the primary sensorimotor cortex to proprioceptive hand stimulation in cerebral palsy

OBJECTIVE

Our objective was to clarify the primary sensorimotor (SM1) cortex excitatory and inhibitory alterations in hemiplegic (HP) and diplegic (DP) cerebral palsy (CP) by quantifying SM1 cortex beta power suppression and rebound with magnetoencephalography (MEG).

METHODS

MEG was recorded from 16 HP and 12 DP adolescents, and their 32 healthy controls during proprioceptive stimulation of the index fingers evoked by a movement actuator. The related beta power changes were computed with Temporal Spectral Evolution (TSE). Peak strengths of beta suppression and rebound were determined from representative channels over the SM1 cortex.

RESULTS

Beta suppression was stronger contralateral to the stimulus and rebound was weaker ipsilateral to the stimulation in DP compared to controls. Beta modulation strengths did not differ significantly between HP and the control group.

CONCLUSIONS

The emphasized beta suppression in DP suggests less efficient proprioceptive processing in the SM1 contralateral to the stimulation. Their weak rebound further indicates reduced intra- and/or interhemispheric cortical inhibition, which is a potential neuronal mechanism for their bilateral motor impairments.

SIGNIFICANCE

The excitation-inhibition balance of the SM1 cortex related to proprioception is impaired in diplegic CP. Therefore, the cortical and behavioral proprioceptive deficits should be better diagnosed and considered to better target individualized effective rehabilitation in CP.

Biological and environmental factors may affect children's executive function through motor and sensorimotor development: Preterm birth and cerebral palsy

Disruptive biological and environmental factors may undermine the development of children's motor and sensorimotor skills. Since the development of cognitive skills, including executive function, is grounded in early motor and sensorimotor experiences, early delays or impairments in motor and sensorimotor processing often trigger dynamic developmental cascades that lead to suboptimal executive function outcomes. The purpose of this perspective paper is to link early differences in motor/sensorimotor processing to the development of executive function in children born preterm or with cerebral palsy. Uncovering such links in clinical populations would improve our understanding of developmental pathways and key motor and sensorimotor skills that are antecedent and foundational for the development of executive function. This knowledge will allow the refinement of early interventions targeting motor and sensorimotor skills with the goal of proactively improving executive function outcomes in at-risk populations.

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.

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/.

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.

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.